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Neurology symposium articles

Diagnosis and management of complex regional pain syndrome

22 Sep 2017Registered users

Complex regional pain syndrome (CRPS) is a chronic debilitating painful condition comprising unremitting pain, sensory, sudomotor, vasomotor and motor abnormalities in the affected extremity. It has a peak incidence in the 55-75 age group and there is an association with asthma and migraine. CRPS is three times more common in women than men. CRPS should be suspected in any patient presenting with persistent pain in an extremity beyond the expected period of tissue healing following an acute injury, sprain, fracture or surgical procedure. Severe pain in a glove or stocking distribution is the predominant symptom in > 90% of cases.

Identifying neurological causes of daytime sleepiness

22 Sep 2017Registered users

The prevalence of sleep complaints in adults in a primary care setting is > 10%. The most frequently seen condition by far is that of primary insomnia, which affects 10% of adults on a chronic basis. In contrast to primary insomnia, in which most patients report tiredness and fatigue during the day but are unable to sleep during the day either, the second most frequent sleep disorder encountered, obstructive sleep apnoea, is typified by excessive daytime sleepiness. Patients with primary insomnia or fatigue syndromes typically will score low on the Epworth Sleepiness Scale (ESS < 3) whereas those with organic sleep pathologies or sleep restriction will score higher. A score > 10 is seen as 'pathological', with a mean ESS in the population of 5-6. 

Diagnosis and management of motor neurone disease

23 Sep 2016Registered users

Motor neurone disease is a rapidly progressive and fatal neurodegenerative condition which causes progressive weakness, with normal sensation. Key clinical presentations include bulbar (slurred or difficult speech, problems swallowing, tongue fasciculation), limb (typically in one limb with weakness and muscle wasting), respiratory (breathlessness, chest muscle fasciculation) and cognitive features (behavioural change, emotional lability, features of frontotemporal dementia).

Tailor treatment to the patient with neuropathic pain

23 Sep 2016Registered users

Neuropathic pain is defined as pain that is caused by a lesion or disease of the somatosensory nervous system and is estimated to affect 6-8% of the general population. A low threshold of suspicion in conditions associated with neuropathic pain can aid diagnosis. Typical neuropathic descriptors include burning, shooting, electric shock pain with numbness, pins and needles or itching.

Early accurate diagnosis crucial in multiple sclerosis

24 Sep 2015Registered users

In around 85% of cases, multiple sclerosis (MS) starts with an acute neurological episode, a clinically isolated syndrome, which is considered to be the first clinical episode of relapsing-remitting MS. It is characterised by the presence of acute relapses, after which there is normally good functional recovery. Investigations need to rule out conditions that can mimic an inflammatory-demyelinating disease of the CNS and determine the presence of dissemination in space and dissemination in time of the inflammatory-demyelinating disease. There is no confirmatory test for MS and it remains essentially a clinical diagnosis.

Seizure classification key to epilepsy management

24 Sep 2015Registered users

The diagnosis of epilepsy is often incorrect, potentially in up to 20% of cases, so should be revisited if seizures are not responding to treatment. SIGN recommends that the diagnosis of epilepsy should be made by an epilepsy specialist, ideally in the setting of a dedicated first seizure or epilepsy clinic. Diagnosis relies primarily on the history. Distinguishing between a genetic generalised epilepsy and a focal epilepsy is vital as this influences investigation, treatment and prognosis.

Improving outcomes for chronic pain in primary care

23 Sep 2014Registered users

Although the patient’s goal is often complete pain relief, this is rarely a realistic outcome, so the role of the physician in managing chronic pain involves optimising pain relief as far as possible. A thorough biopsychosocial assessment is essential so that an individualised multidisciplinary approach to management can be developed. The aims of assessment of chronic pain are to rule out any underlying serious pathology, identify the pain mechanism and identify and evaluate risk factors that contribute to chronicity.

Migraine is underdiagnosed and undertreated

23 Sep 2014Paid-up subscribers

Migraine is a common neurovascular disorder characterised by attacks of head pain that are typically unilateral and often described as severe and throbbing in association with nausea and sensitivity to sensory input, i.e. light, sound and head movement. NICE guidelines recommend adopting the stepped-down approach to management. They suggest a combination of a triptan, NSAID or paracetamol, and an anti-emetic taken as early as possible during the headache. [With external links to the evidence base]

Community stroke rehabilitation helps patients return to work

23 Sep 2013Paid-up subscribers

A quarter of stroke survivors are under the age of 65 meaning that many are in work and/or have responsibility for caring for children or elderly parents. With a comprehensive rehabilitation team, patients with more complex or severe disability can be rehabilitated in the community providing that the home environment can be suitably adapted. The core components of a community-based programme can be broadly defined as improving emotional wellbeing, communication, cognitive function and physical independence and supporting return to work.

Managing patients with cluster headache in primary care

23 Sep 2013Paid-up subscribers

Cluster headache is a strictly unilateral headache that occurs in association with cranial autonomic features. The diagnosis is purely clinical and it is therefore crucial to take a good history looking for its distinctive features. Specialist advice should be sought at first presentation for confirmation of diagnosis, development of a plan for managing current and future cluster bouts and where first-line treatments fail.

 

Symposium articles

Early diagnosis beneficial in Alzheimer’s disease

24 Jan 2013Paid-up subscribers

A diagnosis of Alzheimer’s disease requires clinical and pathological evidence. In clinical practice, GPs should consider a diagnosis of dementia when a patient presents with functional impairment (e.g. needing a greater level of help with activities of daily living, struggling to manage own finances and bills) in addition to at least two changes in cognitive function e.g. short-term memory, language, reasoning, spatial orientation, or personality change. The patient, friends, family or professional carers should have noticed these changes for at least six months. Early diagnosis enables early, planned intervention, reduces crisis situations, delays planned admission to care homes (and helps prevent unplanned admissions).

Diagnosing and managing vascular dementia

24 Jan 2012Paid-up subscribers

Vascular dementia (VaD) is common. Pure vascular disease may account for 5–20% of all cases of dementia, while mixed dementia, Alzheimer's disease (AD) with VaD, occurs at least as frequently. It is unusually heterogeneous and frequently overlapping and comorbid with other conditions such as stroke, other cardiovascular and cerebrovascular diseases and their risk factors, as well as AD. There is no specific treatment or cure for VaD, but its proximity to other conditions may make it amenable to interventions at various stages of the disease.

Tackling dementia in patients with Parkinson’s disease

24 Jan 2011Registered users

Cognitive symptoms in patients with Parkinson's disease are associated with more rapid deterioration and eventually, a two-fold increase in mortality. Patients with cognitive impairment place a greater burden on their care givers and many such patients are admitted to nursing homes. Primary care plays a significant role in the recognition of DLB and PDD. Early recognition and referral to a specialist memory clinic can help to educate the patient about their often worrying symptoms and initiate the relevant treatment. Through the involvement of the multidisciplinary team, appropriate care networks can be set up to provide support and education for both patients and carers.

Diagnosing joint pain in older people

20 Jan 2010Paid-up subscribers

 Musculoskeletal disease is the most common cause of chronic pain and disability in older people. The prevalence in those over 75 is 83% in the UK. Older adults with arthritis have been reported to make significantly greater use of medical services compared with those without.Joint pathology may lead to reduced mobility, increased risk of falls, low energy, dependency and depression. Chronic pain itself is strongly associated with psychological distress and fatigue. Overall, arthritis places an enormous burden on the individual and on society. Therefore, the importance of correctly diagnosing and managing joint pain in the elderly is paramount and the GP is central to this process. [With external links to the evidence base]

 

Special reports

Rapid diagnosis vital in thunderclap headache

25 Apr 2016Registered users

Thunderclap headache is a severe and acute headache that reaches maximum intensity in under one minute and lasts for more than five minutes. Thunderclap headaches may be associated with symptoms such as photophobia, nausea, vomiting, neck pain, focal neurological symptoms or loss of consciousness. Subarachnoid haemorrhage (SAH) accounts for 10-25% of all thunderclap headaches and, despite advances in medical technology, has a 90-day mortality of 30%. Up to a quarter of cases of SAH are misdiagnosed, often through failure to follow guidance.

 

Diagnosing non-parkinson’s movement disorders

24 Feb 2012Paid-up subscribers

Movement disorders are a common cause of neurological disability in older people. Idiopathic Parkinson’s disease (IPD), caused by degradation of dopaminergic neurones in the nigrostriatal pathways of the brain leading to a triad of tremor, rigidity and bradykinesia, is probably the most well known. This article focuses on the most common non-parkinson’s movement disorders seen in older people.

Early aggressive treatment improves prognosis in complex regional pain syndrome

23 Jan 2011Paid-up subscribers

The condition now named complex regional pain syndrome (CRPS) has been recognised for many years, and known by many terms, although the adoption of the current taxonomy is recent. The condition typically starts with an injury to an extremity, which is often seemingly trivial, followed by immobilisation, such as an ankle sprain or Colles' fracture. However, instead of the expected resolution of symptoms, persistent pain and dysfunction develop. recent attention to its key features by international authorities should allow the diagnosis to be made with greater confidence by non-specialists. Management should be based upon general principles of neuropathic pain treatment, combined with aggressive physical rehabilitation. Many cases will resolve spontaneously, or with simple measures. For severe or resistant cases, early specialist intervention is indicated.

Improving the management of neuropathic pain

21 Jul 2010Paid-up subscribers

Neuropathic pain is relatively common. One large European study found a prevalence of 6%. The diagnosis and treatment of long-term pain has received considerable attention recently. Long-term pain is pervasive and costly. There is an interrelationship with psychosocial problems and there are often difficulties in clarifying the diagnosis. Most treatment for long-term pain, including neuropathic pain, should be provided at the primary care level, with support as necessary from specialist services.

GPs have pivotal role in care of stroke patients

15 Feb 2010Paid-up subscribers

GPs play a key role in early recognition of stroke symptoms, thus ensuring that patients receive appropriate acute treatment, early initiation of secondary prevention, lifestyle advice and referral to exercise schemes. It is becoming increasingly recognised that stroke is a chronic disease. So GPs will also be central to managing ongoing risk of recurrent stroke and identifying and managing long-term post-stroke problems.

Diagnosing joint pain in older people

20 Jan 2010Paid-up subscribers

 Musculoskeletal disease is the most common cause of chronic pain and disability in older people. The prevalence in those over 75 is 83% in the UK. Older adults with arthritis have been reported to make significantly greater use of medical services compared with those without.Joint pathology may lead to reduced mobility, increased risk of falls, low energy, dependency and depression. Chronic pain itself is strongly associated with psychological distress and fatigue. Overall, arthritis places an enormous burden on the individual and on society. Therefore, the importance of correctly diagnosing and managing joint pain in the elderly is paramount and the GP is central to this process. [With external links to the evidence base]

Diagnosing shoulder pain

01 Jan 2009Paid-up subscribers

The prevalence of shoulder disorders has been reported to range from 7 to 36% of the population accounting for 1.2% of all GP consultations. Shoulder pain has been said to be the second most common musculoskeletal complaint presenting in primary care. On average GPs are consulted approximately seven times each week for a complaint relating to the neck or upper extremity; three of these consultations will be for new complaints or new episodes. [With external links to the evidence base]

Rapid assessment vital in stroke and TIA

19 Nov 2008Paid-up subscribers

In the 1990s, patients in the UK had a greater risk of stroke-related mortality and disability than elsewhere in Europe. Overall standards have risen.In July 2008 NICE published guidelines for the management of acute stroke and TIA. At the same time, the Intercollegiate Stroke Working Party at the RCP produced guidance covering the rest of the stroke pathway, including secondary prevention, rehabilitation and the management of long-term stroke-related disability.