Physiotherapy as an alternative treatment for sixth cranial nerve palsy
SCIENTIFIC CONFERENCE XL ANNIVERSARY OF THE MEDICAL-SURGICAL RESEARCH CENTRE
Greta Valdés Lara (1) Yohyma de la Torre Chávez (2) Adianés Ross Montenegro (3) Alejandro Acanda de la Nuez (4)
1 http://orcid.org/0000-0002-4428-7811 First degree specialist in physical medicine and rehabilitation. Medical and Surgical Research Centre. University of Medical Sciences of Havana. Faculty of Medical Sciences Victoria de Girón. Havana. Cuba. e-mail: gretaval@infomed.sld.cu
2 http://orcid.org/0000-0003-3074-2147 First degree specialist in physical medicine and rehabilitation. Medical and Surgical Research Centre. University of Medical Sciences of Havana. Faculty of Medical Sciences Victoria de Girón. Havana. Cuba. e-mail: yohyma.chavez@infomed.sld.cu
3 Master of Science, B.Sc. in Physical Culture
4 B.Sc. in Physical Culture
Physiotherapy protocol with magnetotherapy, Hivamat (Deep Oscillation) and eye muscle exercises
Summary:
Objective: We present a case of paralysis of the sixth cranial nerve treated with regional magnet therapy, HIVAMAT (Deep Oscillation) and exercises of the ocular musculature with the aim of demonstrating the usefulness of physiotherapy in the management of this disease.
General details of the case: A 49-year-old male patient with a pathological history of arterial hypertension who on 27 February 2019 began to have difficulty seeing and increased blood pressure. He came to our physiotherapy clinic with a diagnosis of paralysis of the sixth cranial nerve for rehabilitation treatment. In the strabismus test we found endotropia in the primary gaze position and in the forced ductility test only response to ductile movements and version with an absence of abduction movements corresponding to the paralysed muscle. Three cycles of rehabilitation treatment with magnetotherapy and HIVAMAT and eye muscle exercises were indicated, resulting in total regression of the ocular paralysis after 21 days of rehabilitation treatment.
Conclusions:
After having analysed the case and its rapid evolution after rehabilitation treatment, we can conclude that physiotherapy constitutes a less invasive, effective and more accessible therapeutic alternative for the treatment of sixth cranial nerve palsy
Keywords: Paralysis, sixth nerve palsy, HIVAMAT, magnetic field therapy
INTRODUCTION
Oculomotor paresis and paralysis involve all those processes likely to produce a partial or total deficit of eyeball movements. The lesion may be in any part of the oculomotor system including the cerebral cortex, brain stem, nerves, neuromuscular plate and the muscle itself. Paresis and/or paralysis of the external rectus muscle or cranial nerve VI is one of the most common in medical practice. Although there are many causes such as cerebral aneurysms, cerebrovascular accidents, traumatisms, tumours, among others, the cause is often unknown and can return within a period of three months.1 It is usually the result of small vessel disease, particularly in diabetics, as part of a disorder called multiple mono-neuropathy, but can also be the result of ischaemia or hypertension. 2,3 In many patients, cranial nerve palsies resolve once the underlying disorder is treated. Idiopathic and ischaemic palsy can usually return within 2 months. Treatment is primarily medical with: Steroids: With the aim of deflating the nerve.
1. Prisms. This consists of compensating for distance deviation by means of prisms, which are placed in a spectacle in order to eliminate diplopia. The prisms correct the deviation, and therefore allow binocular vision to be stimulated. It is useful in cases of small deviation (10-12 dioptres), when there is minimal torticollis, in cases of surgical undercorrection and in situations in which, for various reasons, the patient is unwilling or unable to undergo surgery.
2. Mechanical exercises. In isolation they do not solve a complete traumatic paralysis, but like any rehabilitation exercise they improve muscle spasms, reversible contractures, as well as bruising in the own muscle. These exercises may also be necessary in the immediate postoperative period.
3. Sectors. This consists of placing a localised, partial occlusion in an area of the visual field to eliminate or reduce diplopia in that particular field. They can be used on an ad hoc basis.
4. Occlusion. This may be the complement in desperate cases, prior to surgery or when, despite several procedures, diplopia is disabling. It should be performed alternatively to avoid muscle contracture. Occlusion of the healthy eye is not easily tolerated by the patient, since it is the paretic eye that induces past-pointing and therefore its suppression produces greater comfort.
5. Botulinum toxin. This is the treatment of choice in the acute phase of paralysis. The main objective is the disappearance of diplopia, torticollis and the correction of partial or total limitation of movement. It also prevents the appearance of secondary contracture. The action of the toxin has been studied in numerous publications and it is now known that there are motor, sensory and proprioceptive changes, as well as changes in the central nervous system. These changes produce an ocular alignment, in some cases permanent, related to several factors acting at the same time. Thus the improvement in muscle contracture, structural modifications in the injected muscle, the change in sensory homeostasis and an action at the central level, alone or together, can produce a permanent orthoposition.
Surgery: In the case of acquired paralysis, surgery should be considered only after spontaneous improvement has completely stopped. This is usually not earlier than six months to one year from the date of onset. 3,4,5
The Hivamat 200, which stands for histologyc variability manual technics, causes an intermittent electrostatic field with deep oscillations acting on the connective tissue by means of electrostatic fields that produce an intense resonant vibration in the tissues involved. The mechanism is provided by a semiconductor plate and a small electrostatic field established between the hands of the physiotherapist and the patient's tissue. The repetition of this phenomenon in rapid succession generates rhythmic deformations of the tissue, which is pumped through the complete oscillation. This action allows the tissues to gain motility and flexibility and to regenerate thanks to the increased production of ATP. It acts primarily on the intercellular circulation of the interstitial connective tissue. This treatment results in the normalisation of the fluidity of circulation in the treated area. This intensified massage system that is used successfully in various areas of Physical Medicine Therapeutics uses deep mechanical oscillations to create low frequency gentle electrostatic impulses that 'knead' the skin tissue by attracting and releasing it between 5-250 times per second. This therapy has a clinically significant influence on inflammation, pain and muscle contracture as well as an antifibrosis, haematoma resorption and wound healing effect. Based on antiinflammatory, oedematous and antioxidant phenomena, including lymph oedema, reinforcing the flow of nutrients; detoxification by treating cellulite and stimulating collagen production and cell regeneration, it lifts and tones muscles and improves skin elasticity. It has been scientifically researched that the frequencies can penetrate the surface tissue by 8 -12 cm. The gentle mode of action is the reason why it contrasts with other electrical and mechanical therapies and there is no contraindication to immediate therapy. 6,7,8,
The pulsed electromagnetic field (PEMF) is an effective therapy that creates microcurrents in the body's tissues. These microcurrents produce specific biological responses that depend on the parameters of the magnetic field such as amplitude, frequency, and waveform. The body contains multiple electromagnetic fields of its own with a unique shape in each tissue and organ. Computed tomography and magnetic resonance imaging take advantage of this phenomenon to create a map of the body's tissues. While diagnostics benefits from PEMFs and is accepted and widely used, practitioners are still realising the therapeutic benefits of PEMFs. In 1954, Japanese scientists first reported on the piezoelectric properties of bone. In 1995, scientists at the University of Kentucky found that every type of soft tissue responds favourably to electromagnetic fields.
Since then clinical research has documented the biological and therapeutic effects of electromagnetic fields. For example, it has been shown that the magnetic field is capable of lowering glycaemia levels, cholesterol, triglycerides and blood viscosity. While it raises high-density lipoproteins. The electromagnetic field has also been shown to help heal damaged nerve tissue after an acute stroke. Benefits have also been reported in the treatment of multiple sclerosis and diabetic neuropathy due to its tissue regenerating effect and those described above on metabolism. 9, 10 Since in our environment the conventional treatment of cranial nerve palsy with prisms is limited to specialised centres and is more difficult to access for the population, the administration of botulinum toxin and surgery are invasive methods that are also applied in specialised centres. The administration of botulinum toxin and surgery are invasive methods that are also applied in specialised centres. Therefore, we consider that magnetic field and deep oscillation therapy could replace conservative medical treatment of this condition due to their anti-inflammatory, muscle relaxant and regenerative effects, constituting therapeutic tools that are more widely available to the population in primary health care areas.
Objective: The aim of this case study is to illustrate the usefulness of physiotherapy in the treatment of sixth cranial nerve palsy
PRESENTATION OF THE CASE
A 49-year-old male patient with a history of arterial hypertension who on 27 February 2019 began to have difficulty in for vision and increased blood pressure, came to our physiotherapy practice for treatment.
Rehabilitator with diagnosis of sixth cranial nerve palsy.
Physical examination:
Strabismus test: Primary gaze position in endotropia.
Forced ductility test: Response to ductility and version movements. Fundus: No oedema in the papilla, normal vascular pattern.
Complementary examinations:
MRI: Cerebral and cortical atrophy, preferably frontal.
Right maxillary and ethmoidal sinusopathy.
Intrasellar aragnoidocele
Mild bilateral hippocampal atrophy. Affecting the external rectus muscle ID: Paralysis of the sixth cranial nerve or abducens nerve.
Objectives of Rehabilitation Treatment:
Relaxation of unaffected musculature
Reduction of inflammation of the affected nerve tissue
Re-education of the weakened eye muscles
Rehabilitative Treatment:
Magnetic field 50 Hz 50% in left eye. Exercises of the extrinsic musculature of the eye.
Second cycle: 3/4/2019 - HIVAMAT in the region of the external orbicularis orbicularis region 100Hz 5 min 50 Hz 5min
Magnetic field 20 Hz 50 % solenoid in head region T = 15 min. Extrinsic eye muscle exercises.
23/4/2019
HIVAMAT in the region of the external orbicular arch 50Hz 5 min 25 Hz 5min Magnetic field 20 Hz 50 % solenoid in the head region T = 15 min Exercises of the extrinsic musculature of the eye.
In the study of ocular motility, a diagnosis of atypical acquired paresis of the left external rectus muscle of unspecified aetiology was made (Fig. 1).
Fig 2: Physiotherapy protocol with magnetotherapy, Hivamat (Deep Oscillation) and eye muscle exercises
The evolution was favourable, with disappearance of diplopia, endotropia in the primary gaze position and response to abduction and eversion movements of the eye in the forced ductility test within twenty days after the start of rehabilitation treatment. (Fig. 2)
Case discussion
In terms of treatment, many methods have been described to solve this problem.
Disease. From occlusion of the healthy eye to surgery. But with regard to treatment with physiotherapy, there are very few publications reported in the literature. We only found one study carried out in our country where a magnetic field with electro acupuncture was applied to patients suffering from neurogenic ophthalmoplegia whose main cause was a lesion of the third cranial nerve in comparison with other patients who received medical treatment. This study demonstrated the efficacy of rehabilitative treatment compared to medical treatment, with three out of four patients recovering in the rehabilitative treatment group. In the medical treatment group, only one out of four patients recovered.(11)
The magnetic field is widely used in different diseases as a therapeutic option as it is attributed with biochemical changes in the organism, among which the induced movement of ionised substances in solution stands out, which makes it possible to mobilise and provoke changes in depth wherever the ions are located in our body, in the bloodstream, in the plasma or in the different tissues of the body. In addition, it facilitates the trophic effect, that is, by improving the blood flow in the treated area, it improves the absorption of nutrients and favours recovery. Therefore, the tissues will eliminate toxic substances faster and will be nourished and oxygenated in a more effective way. more effective. Magnetic fields also normalise the sodium-potassium pump due to their effect on metabolism. (12)
As far as deep oscillation therapy is concerned. As the bibliography states, it is a fairly new physical agent with a significant anti-inflammatory influence, stimulating the healing of tissues, the reabsorption of oedema and haematomas as well as a muscle relaxant. Although there are many studies where its effectiveness has been proven in the field of orthopaedics, sports medicine, oncology in the case of patients with lymphoedema and neuro-rehabilitation for the recovery of paretic areas even in children with infantile cerebral palsy. In the field of ophthalmology we did not find any study where this tool is used.(13,14,15,16,17)
Conclusions
After having analysed the case and its rapid evolution after rehabilitation treatment, we can conclude that the electromagnetic field and deep oscillation therapy may constitute a less invasive, effective and more accessible therapeutic alternative for the treatment of cranial palsy of the sixth cranial nerve.
Bibliographical references.
1. J W Chan and J Albretson. Causes of isolated recurrent ipsilateral sixth nerve palsies in older adults: a case series and review of the literature. Clin Ophthalmol. 2015; 9: 373-377. http://creativecommons.org/licenses/by-nc/3.0/
2.- David M Katz. Isolated sixth nerve palsy. Eye (lond). 2016 (lond)http://ww.nebi.nlm.gov/m/pubmed
3.- P Urban. Idiopathic cranial nerve failure. Nervenarzt. 2017. http://www.nebi.nlm.gov/m/pubmed
4.- Choi KD, et al. Acquired Ocular Motor Nerve Palsy in Neurology Clinics: A Prospective Multicenter Study. J Clin Neurol. 2019. http://ww.nebi.nlm.gov/m/pubmed
5.-Park KA, et al. Acquired onset of third, fourth, and sixth cranial nerve palsies in children and adolescents.Eye (Lond). 2019. http://ww.nebi.nlm.gov/m/pubmed
6.- Y Ch Gao, Ch Ch Peng, R Y. Peng. A long term chronic fibrotic adhesion of elbow muscles alleviated by applying hivamat 200 deep oscillation Therapy. International Journal of Multidisciplinary Research and Development 2015; 2(1): 286-289. www.allsubjectjournal.com
7. Y Coronados Valladares, C J Alba Gelabert, E L García, V M Viltres Martínez, Y G Bacallao. Deep oscillation therapy as a complement to kinesiotherapy in the treatment of gonarthrosis. Revista Cubana de Medicina Física y Rehabilitación 2017;9 (2) www. Revrehabilitaciòn.sld.cu
8. Paige H. De Leon. Honors thesis. A systematic review of deep tissue oscillation and a study proposal of its effects on geriatric bedridden patients with lower extremity lymphedema. San Marcos, Texas May 2016. www. https//digital.library txtdtate.edu
9.-Biological Effects of Pulsed Electromagnetic Field (PEMF) Therapy Keith R. Holden, 2014 http://www.ondamed.net/us/biological-effects-of-pulsedelectromagnetic-field-pemf-therapy
10.- Kubat N, Moffett J, Fray L. Effect of pulsed electromagnetic field treatment on programmed resolution on inflammation payhway markers in human cells in culture. Journal of inflammation research. Vol 8. 2014 pàg 59- 69.https//doi.org/10.2147/JIR.S78631
11.- B Martìn Piñero, V Cisneros Perdomo, A Torres Arafet, E Castillo Bueno, N Zamora Guevara, P L Pazo Molineda. Proposal of a rehabilitative treatment in neurogenic ophthalmoplegia. Revista Cubana de medicina Fìsica y rehabilitaciòn.2015; 7(1):14-24 https//www.revrehabilitaciòn.sld.cu accessed 20 March 2020.
12.- Magnetotherapy in physiotherapy. [Internet]. 14/06/16. [cited 2020 Jun 24]. https://www.efisioterapia.net
13.- S Hernàndez Tàpanes, A Suàrez, T Bravo Acosta, R Wilson Rojas, B Fernández Prieto, M Cabrera Morales. Value of the therapy with deep oscillations in the healing of AB burns. Revista cubana de medicina fìsica y rehabilitaciòn vol 2 n 1.Jan-Jun 2010 www. Revrehabilitaciòn.sld.cu [cited 2020 Jun 24].
14.- S Jahr, B Schoope and A Reisshauer. Effect of treatment with low intensity and extremely electrostatic fields(deep oscillation)on Breast tissue and pain in patients with secondary Breast lymphoedema.journal of Rehabilitation Medicine 2008; 40: 645-650 https://WWW. Medicaljournals.se html. [cited 2020 Jun 24].
15.- LR. Brilla. Deep Oscillation Therapy in Sport Injuries.joyrnal of sport medicine and doping Stud 2016;6,4 https://WWW.hilarispublisher.com [cited 2020 Jun 24].
16.- V Locheva, I Todorov, L Panayotova- Ocharova. Deep oscillation therapy: principle, biological effects, review. Varna Medical Forum, vol 8, 2019, issue 2MU-VAR https://WWWphysiomed.de/en/application. [cited 6 June 2021]
17.- E Christian, C koenig, K Winkelmann, E Games. The Effects of Deep Oscillation Therapy for individuals with lower-leg Pain.Journal os sports Medicine and AlliedHealth Sciences.VOL 4; 2019, issue3. https://WWWscholarworks.bgsu.edu/jsmahs/vol4/iss/3/3[cited 6 June 2021]
