This 16 year old patient has, for a year and a half, presented a dystonia of the
right thumb. This dystonia appeared in the first instance, after having played a
prolonged session of badminton. It was a flexing dystonia that prevented her
from writing. Three months before her consultation, while opening a pot of
yogurt, the flexing dystonia turned into an extended dystonia, which was the
case for the first phalanx of the thumb.
Clinical Description
During this consultation, she therefore presented a very particular dystonia of
the thumb (see video 1). There is no pain, but there is an important
hypoesthesia of the first two fingers of both hands and of the dorsal space
between the first two metacarpal bones.
Video 1
Magnetic Stimulation and Evolution
The first stimulation session will include a classic wide field central
transcranial magnetic stimulation and a further very high intensity stimulation
(in power mode) and at a higher frequency (8 Hz) at the anesthetised area of the
hand on the right side. There would be no immediate improvement. At the end of
the third day, the dystonia of the right thumb disappeared (see video 2). The
anesthesia persisted. I see the patient every three months in order to try and
bring back sensitivity on the anesthetised areas of both hands, but for the
moment without any success.
Video 2
Comments
This patient presents two types of symptoms, firstly an anesthesia of the first
two fingers of the hands and of the first Intermetacarpal space in a bilateral
way and secondly a dystonia of the right thumb which occurred after a relatively
small triggering factor. Once again we see the fragility of these connectivity
disorders at the origin of functional neurological symptoms. It is likely that
anesthesia was pre-dystonia. This type of anesthesia can be the base for
neurological functional disorders of the type pain, dystonia or other. Even if
the dystonia has disappeared, it is necessary to try to remove the anesthesia to
avoid relapse by stimulating these regions at high intensity and frequency.
Neither the onset date nor the triggering factor of this anesthesia are known.
It should be noted that it is always necessary to seek out this type of
anesthesia or hypoesthesia in neurological functional disorders because they can
be ignored by the patient and may require specific treatment by stimulation.
Dystonia - Patient 2
Dominique Parain MD PhD
History
This 45 year old patient has, since 10 years ago, a very severe sprain of the
left ankle resulting in a severe algodystrophy that has gradually provoked
significant bone destruction of the joint, a total anesthesia of the left leg
with dystonia of the knee and hip, justifying the installation of orthotics to
help her with walking. Subsequently, a few years later, a hypoesthesia of the
left hemi-thorax and left arm appeared with a dystonia of the left hand
predominantly on the last 3 fingers (see video 1).
Clinical Description
The patient thus presents an important hypoesthesia of the left hemibody,
predominantly on the leg where it is total but respecting the face. The leg is
very stiff with a very altered motor drive. She is most often in a wheelchair.
There is also a hypoesthesia of the left arm with dystonia very difficult to
reduce manually and predominantly on the last three fingers, significantly
disturbing the use of this hand.
Video 1
Magnetic Stimulation and Evolution
The stimulation attempts at very high intensity and frequency resulted in no
improvement to the left leg. However, it is possible, through the use of
peripheral stimulation at the level of the left hand, to reduce the dystonia, by
stimulating equally very strongly, with the two capacitors, at a frequency of 3
Hz (see video 2).
Video 2
Comments
The clinical history of this patient perfectly demonstrates the evolutionary
nature of functional neurological disorders according to a classic 'here'
pattern. When the disease begins at the foot level, it will very often be
associated with hypoesthesia which will diffuse upwards and can associate with
motor problems at arm and hand level, or even pain. The disorder usually
respects the face. Due to the significant delay between the onset of the
disturbances and the first stimulation session, the oldest affected part of the
body did not react to the simulation. In addition, at the level of the leg, she
presents a total anesthesia and I did not manage to trigger a sensation even
with a high intensity and frequency of stimulation. If I fail to trigger sensations,
with an onset of pain, there can be no recovery, even partial. However, at the
level of the upper left limb, where the troubles were less
important and occurred later on, I was able to obtain a certain efficiency,
especially at the level the dystonia of the left hand. I have to renew this
stimulation every month and a half because the effect is transient and the
dystonia reappears after this time.