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Treatment of cervical dystonia in .NET Creator barcode code 128 in .NET Treatment of cervical dystonia




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5 Treatment of cervical dystonia generate, create code 128a none in .net projects ISO Specification Reiner Benecke, Karen Frei and Cynthia L. Comella Introduction Cervical dystonia (CD), origi .net vs 2010 Code 128 Code Set C nally known as spas modic torticollis and first described by Foltz in 1959, is a neurological syndrome characterized by abnormal head and neck posture due to tonic involuntary contractions in a set of cervical muscles (Foltz et al., 1959).

Myoclonic or tremulous move ments are often superimposed in CD, producing a tremor like appearance especially early in the disease state. The terms CD and spasmodic torti collis are not interchangeable: CD is the preferred term when referring to idiopathic focal dystonia of the neck. Spasmodic torticollis is now considered to be one of four types of CD.

Cervical dystonia is classified into four types based on the principal direction of head posture: torticollis (abnormal rotation of the head to the right or to the left in the transverse plane); laterocollis (the head tilts toward the right or left shoulder); anterocollis (the head pulls forward with neck flexion); and retrocollis (the head pulls back with the neck hyperextended). Cervical dystonia is slightly more common in females, with a male to female ratio of 1:1.2 (Kessler et al.

, 1999). Onset is usually insidious, although in some patients the onset has been reported as sudden. Cervical dystonia may develop in patients of all age groups, but the peak age of onset is 41 years (Kessler et al.

, 1999). Idiopathic CD usually. progresses in severity over t he first five years until it reaches a plateau, during which time the CD remains fairly constant and becomes a lifelong condition. Although remission can occur, it is rare and the dystonia usually returns after a period of time. The cervical component may also exist as part of a more extensive form of dystonia, in which the dystonia can spread to involve adjacent structures such as the face or the arm(s).

When dystonia involves several contiguous body parts, it is considered segmental dystonia. When it involves several parts of the body that are not contiguous, such as the neck and foot, it is called multifocal, and when involving the majority of the body, it is referred to as generalized dystonia. Characteristic traits of CD include transient relief from symptoms with a sensory trick or geste antagoniste.

A common form of a sensory trick in CD is placing the hand lightly on the cheek. This allows the head to return to a more normal posture. Resting the head against the headrest while driving or against a pillow while watching TV are examples of sensory tricks.

Patients may obtain temporary relief from symptoms of CD in the morning hours following sleep; this is referred to as the honey moon effect (Truong et al., 1991). Stress can exacerbate symptoms of CD.

Neck pain is common in CD and has been reported in 70 80% of affected patients (Van Zandijcke, 1995). Cervical dystonia is often a major source of disability. The pain appears.

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5. Treatment of cervical dystonia to diffuse throughout the nec .net vs 2010 Code 128 Code Set C k and shoulders with some radiation toward the side to which the head is twisted. Pain does not appear to be correlated with the degree of severity of CD, and is thought to involve central mechanisms in addition to pain arising from muscle spasms (Kutvonen et al.

, 1997). Degenerative disc disease seems to be accelerated in CD, which can aggravate the pain associated with this disorder. Depression, anxiety, and social phobia are also common associated conditions.

There are no diagnostic tests for CD. However, multichannel electromyography (EMG) may help to elicit the involved muscle patterns producing the particular posture. Electromyographic evidence of prolonged bursts of electrical activity that correl ate with the involved musculature is helpful in diagnosing CD.

Testing agonist/antagonist pairs of muscles allows the comparison of overall activity, which can also assist in distinguishing the most active muscles involved in producing the CD posture. Conventional brain magnetic resonance imaging (MRI) is usually normal; cervical MRI may show cervical muscle hypertrophy and cervical disc disease this can be helpful but is not diagnostic. Most often, the cause of CD is unknown.

In the first part of the last century, CD was thought to be of psychogenic origin, although today an organic basis for the syndrome is well accepted. There are cases of hereditable forms of CD, such as DYT7, but the majority of hereditable dystonia types are variable in presentation and may include different forms of dystonia, such as blepharospasm, limb dystonia, and CD. Hereditable forms of dystonia generally have autosomal dominant transmission and incomplete penetrance.

With the incomplete penetrance of these disorders, not all family members with the gene mutation will have dysto nia. Moreover, affected family members may pre sent with different signs/symptoms in different body regions not all affected family members will have CD. Cervical dystonia is often a component of various secondary dystonias that manifest in a number of neurodegenerative diseases.

Secondary causes of CD include neuroleptic medication exposure or trauma. A form of CD known as post. traumatic CD may occur follow ing a relatively mild trauma. This form usually begins within days of an incident, lacks the sensory trick response and tends to be more resistant to treatment with botulinum toxin (BoNT) (Truong et al., 1991; Frei et al.

, 2004). The role of trauma, however, remains controversial. The clinical spectrum of abnormal head and neck posture is extremely variable.

The reason for this is the wide variety of the dystonic muscle patterns within the 54 muscles affecting action on head and neck posture. Furthermore, muscles can be involved on one side or on both sides. Dystonic muscles can show a dominant tonic activity, myo clonic or tremulous activity often in complex mixtures.

The extent of secondary changes in the muscles and connective and bony tissues may pre sent differently from patient to patient and in their contribution to abnormal postures. Intramuscular injections of BoNT are considered the first line of treatment in CD. Both botulinum toxin serotype A (BoNT A) (old and new Botox , Dysport , Xeomin ) and serotype B (BoNT B) (NeuroBloc /Myobloc ) have been used.

Medica tions such as the anticholinergic trihexyphenidyl (Artane ) and benztropine (Cogentin ) have some beneficial effects and can be used in more severe cases alongside BoNT injections. Other medications that have mild or limited usefulness include benzo diazepines, such as diazepam (Valium ) or loraze pam (Ativan ), and tricyclic antidepressants, such as amitriptyline (Elavil ) and nortriptyline (Pamelor ). Surgical treatment with selective peripheral denervation has been reported in open studies to be helpful in some severe cases that do not respond to either oral medications or chemodenervation.

Surgical myectomy has also been used; however, the dystonia tends to involve other muscles or con tinues to involve remnants of the resected muscles, thus producing less favorable results. Deep brain stimulation, with electrodes placed in the globus pallidus interna, has been successfully used for treatment of generalized dystonia. Although there have been less consistent results in treating CD with this method, improvements may be possible.

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