Qiang Gao, Yonghong Yang, Chengqi He, Shaxin Liu

Department of Rehabilitation Medicine, Key Laboratory of Rehabilitation Medicine of Sichuan Province, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China

Rehabilitation of shoulder paresis caused by herpes zoster according to the International Classification of Functioning, Disability and HealthA case report☆

Qiang Gao, Yonghong Yang, Chengqi He, Shaxin Liu

Department of Rehabilitation Medicine, Key Laboratory of Rehabilitation Medicine of Sichuan Province, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China

We describe the case of a 73-year-old man with left shoulder paresis caused by a herpes zoster infection of the left C5dermatomes. The patient had been affected by pain for 10 days, a skin rash on his left shoulder and back for 5 days, and weakness of his left shoulder for 2 days before admission. Electromyography revealed denervation discharges from the left supraspinatus, infraspinatus and deltoid muscles, which was compatible with radiculopathy showing after zoster infection. The patient was examined in accordance with the International Classification of Functioning, Disability and Health, and treated with range-of-movement and strengthening exercises as well as activities of daily living and social participation. At 14 months after the onset of the condition, muscle strength had returned to normal. Electromyography revealed that motor unit action potentials were largely normal. These results indicate that the rehabilitation of paresis caused by herpes zoster can obtain positive results with suitable movement training.

herpes zoster; motor paralysis; rehabilitation; International Classification of Functioning, Disability and Health

INTRODUCTION

The varicella-zoster virus is responsible for chickenpox, during primary infection, and shingles during reactivation episodes later in life. Following primary infection, the virus remains latent in the dorsal root ganglia of the nervous system. Its reactivation gives rise to shingles (herpes zoster), which is usually characterized by unilateral neuralgia followed by a vesiculobullous eruption in a dermatomal distribution. Herpetic paresis, a rare complication of herpes zoster, is characterized by focal, asymmetric motor weakness in the myotome that corresponds to the dermatome of the rash[1]. Emphasis on the rehabilitation of post-herpetic paresis is lacking in the literature, but physiotherapy and occupational therapy are expected to play an important role in the motor recovery of patients suffering from segmental zoster paresis[1]. We reported a patient with shoulder weakness secondary to herpetic myotomal paresis, and described the rehabilitation management we employed.

CASE REPORT

A 73-year-old man was admitted to hospital with a 10-day history of pain, 5 days of skin rash on the left shoulder and back, and 2 days of weakness of the left shoulder. There was no history of trauma to his left shoulder, head, or neck region. He had never smoked or drunk alcohol in his life, and had no history of cardiovascular disease. The patient was diagnosed with herpes zoster with left neuralgia followed by a vesiculobullous eruption in the C5dermatomal distribution.

Neurological examination on the first day of admission revealed left shoulder weakness in abduction (2/5), flexion (2/5) and external rotation (2/5). No muscular atrophy or fasciculation were observed. The power of the rest of the patient’s left upper limb was normal. The biceps, triceps, and brachioradialis reflexes were preserved. The sensation in the patient’s left shoulder and the left side of his back was decreased. The rest of the neurological examination revealed no notable findings.

The patient’s pain was rated at an intensity of 8 on a visual analog scale, from 0 (no pain) to 10 (worst pain imaginable), and was characterized by a burning sensation. The patient cried when his skin was examined. Laboratory examination and chest radiographs were normal.Electromyography (Keypoint 4 Electromyograph, Dantec, Denmark) revealed denervation discharge from the left supraspinatus, infraspinatus and deltoid muscles, indicating radiculopathy, in accord with the myotomes affected by the zoster infection with incomplete denervation. In the department of dermatology, interferon (Hua Li Da Biotech, Tianjin, China) and dexamethasone (Tian Yao Pharmaceutical Industry, Hubei, China) were both administered. After 4 weeks of drug treatment, the patient reported feeling better. The skin lesion had healed, and the pain was clearly relieved, rated at 2/10 (Visual Analog Scale). However, the patient felt paroxysmal numbness on his left shoulder and the left side of his back. The patient attended the rehabilitation department for further therapy because of the remaining weakness of his left shoulder muscle strength. When the patient was admitted to the rehabilitation department for the first time, physiotherapists and occupational therapists assessed him in terms of body functions, activities, and participation according to the definitions of the International Classification of Functioning, Disability and Health (ICF)[2]. Environmental and personal factors were also taken into account[3]. First, examination at the level of structure and function revealed the following findings: (1) the range of movement (ROM) was limited: the passive ROM of the left shoulder was 150° on flexion, 150° on abduction (while the ROM of the other shoulder and other joints was normal); (2) muscle strength was weak and there was mild atrophy on the weak muscles: the left shoulder exhibited weakness in abductors (2/5), flexors (2/5) and external rotators (2/5).

Second, at the level of activities, the patient could not take care of himself independently, and needed help dressing, so he scored 95 on the modified Barthel Index. Third, at the level of participation, the patient enjoyed fishing very much before the onset of this disease, but could no longer go fishing by himself as a result of his condition. Based on the patient’s symptoms, he was given the following exercise protocols: (1) Neuromuscular electrical stimulation to prevent atrophy and activate the muscles; (2) ROM exercises for the left shoulder; (3) muscle strengthening exercises for the flexors, abductors and external rotators of the left shoulder; (4) teaching the patient to dress with his right hand; (5) training with mimetic fishing actions such as throwing and reeling; and (6) aerobic exercises to maintain cardiovascular fitness and psychological health.

The patient was discharged from hospital after 8 weeks of therapy in the rehabilitation department. Upon discharge, the patient had regained full ROM in his left shoulder, and shoulder girdle strength showed an obvious improvement: abduction (4/5), flexion (4/5) and external rotation (4/5). The patient could take care of himself independently, and exhibited a score of 100 on the modified Barthel Index. He was able to go fishing by himself, reporting that he had become a normal man and lived a normal life again.

A physical examination at 1 year after discharge revealed that the patient’s left shoulder paresis had almost completely resolved. He also reported almost complete resolution of postherpetic neuralgia. A follow-up electromyogram at 14 months after the initial study revealed that motor unit action potentials were essentially normal in terms of overall number, amplitude, duration, and firing pattern.

DISCUSSION

Herpes zoster, or shingles, is a common vesicular eruption due to the reactivation of latent varicella zoster virus in the dorsal sensory ganglia. Herpes zoster affects 10-20% of all people[4]. This reactivation is thought to migrate in a retrograde manner along the sensory nerve to cutaneous tissue[5]. Although no age group is spared from this condition, it is more common among the elderly with a peak incidence between the ages of 50 and 70 years[6]. Several precipitating factors for herpes zoster have been proposed, including localized trauma, underlying malignant disease and diabetes mellitus[7-8]. Cigarette smoking is also thought to be a risk factor for herpes zoster reactivation[9], as is epidural steroid injection[10]. Immunocompromised individuals are also at an increased risk of reactivation, and infection is usually more severe and extensive[11-12].

Postherpetic neuralgia is the most common complication of herpes zoster. Although some studies have indicated new options for treating patients with postherpetic neuralgia, up to half of all patients do not obtain satisfactory pain relief[13], and the main type of treatment for postherpetic neuralgia is drug therapy[13-14]. Shakiret al[15]reported a case whose pain failed to improve with oral narcotics, divalproex, gabapentin, pregabalin, and topical 2% lidocaine cream. The pain was finally resolved with a cervical transforaminal epidural steroid injection. However, in this case, postherpetic neuralgia was not very severe and did not affect the patient’s sleep or other activities, so this course of action was not considered in the rehabilitation program. Herpes zoster is complicated by motor involvement in 0.5% to 5% of cases[16]. Mondelliet al[17], in an electroneuromyography study, reported segmental paresis in 19% of 158 cases of herpes zoster. The sites of involvement, in descending order of frequency, are the thorax, neck, face, cervical, and lumbosacral area[18], and the lumbosacral dermatome may cause the voiding dysfunction[19]. Eyigoret al[20]reported a severe case of a 54-year-old man infected with varicella zoster virus suffering from monoparesis, hyperalgesia, allodynia, edema, and both color and skin-temperature changes in his left arm after a skin eruption. These symptoms were similar to those of brachial plexopathy. Segmental zoster paresis is rare and affects the upper limbs more often than the lower limbs.

The long-term prognosis for herpes zoster paresis is good[21]. Complete or near-complete recovery of muscular function occurs in approximately two thirds of patients. The time of recovery varies but is usually between 1 and 2 years[22]. In many cases, the loss of motor function goes unrecognized because the extent of impairment is mild. However, in severe cases, motor weakness may lead to clinical problems[23]. The main goals of treatment for segmental paresis include pain relief, prevention of muscle atrophy and contractures, and strengthening of weak muscles. Complete functional recovery was reported in 80% of cases after 12 months[24].

Treatment options for segmental paresis include analgesia for post-herpetic neuralgia, protection of the weakened muscles, maintenance of ROM exercises, and a program of strengthening exercises. Neuromuscular electrical stimulation can be used to prevent muscular atrophy, and concomitantly with exercises to enhance the strength of force production[25]. In this case, therapists described and managed the patient’s condition from the perspective of the ICF. The ICF systematically describes the consequences of disease on function and health. This classification covers almost all aspects of health, which are systematically grouped in domains related to“body functions and body structures” (body functions and structures domain), “performance of tasks” (activities domain), “involvement in life situations” (participation domain) as well as “factors with an impact on all domains of functioning” (environmental factors)[2]. With approximately 1 500 categories in its original form, the ICF is relatively impractical and lacks feasibility.

Therefore, many researchers have suggested defining short lists, referred to as “core sets”[26-27]. Overall, the ICF is seen as a promising tool for the future development of rehabilitation services and research[3]. In the currently reported case, the therapists described the problems of the patient using the concepts of ICF, but did not rigidly adhere to ICF coding and items. This approach is thus flexible and practical. Nevertheless, there are advantages in using an international classification of variables for exercise therapy, and an ICF core set for neuromuscular diseases could improve the comparability of results between studies[28].

Author contributions: Chengqi He participated in the study design. Qiang Gao participated in the study design and drafted the manuscript. Yonghong Yang provided the data of the study and revised the manuscript. Shaxin Liu carried out the treatment plan and followed up the case.

Conflicts of interest: None declared.

[1] Yoleri O, Olmez N, Oztura I, et al. Segmental zoster paresis of the upper extremity: a case report. Arch Phys Med Rehabil. 2005;86(7): 1492-1494.

[2] World Health Organization. International classification of functioning, disability and health (ICF). Geneva: WHO. 2001.

[3] Tora HD. International classification of function, disability and health: an introduction and discussion of its potential impact on rehabilitation services and research. J Rehabil Med. 2002;34(5): 201-204.

[4] Head H, Campbell AW, Kennedy PG. The pathology of Herpes Zoster and its bearing on sensory localisation. Rev Med Virol. 1997; 7(3):131-143.

[5] Merchut MP, Gruener G. Segmental zoster paresis of limbs. Electromyogr Clin Neurophysiol. 1996;36(6):369-375.

[6] Rosenfeld T, Price MA. Paralysis in herpes zoster. Aust NZ J Med. 1985;15(6):712-716.

[7] Thomas JE, Howard FM Jr. Segmental zoster paresis--a disease profile. Neurology. 1972;22(5):459-466.

[8] Chang CM, Woo E, Yu YL, et al. Herpes zoster and its neurological complications. Postgrad Med J. 1987;63(736):85-89.

[9] Guidetti D, Gabbi E, Motti L, et al. Neurological complications of herpes zoster. Ital J Neurol Sci. 1990;11(6):559-565.

[10] Schuchmann JA, McAllister RK, Armstrong CS, et al. Zoster sine herpete with thoracic motor paralysis temporally associated with thoracic epidural steroid injection. Am J Phys Med Rehabil. 2008; 87(10):853-858.

[11] Mazur MH, Dolin R. Herpes zoster at the NIH: a 20 year experience. Am J Med. 1978;65(5):738-744.

[12] Schimpff S, Serpick A, Stoler B. Varicella-Zoster infection in patients with cancer. Ann Intern Med. 1972;76(2):241-254.

[13] Robert HD. Post-herpetic Neuralgia. Herpes. 2006;13 Supplement 1:21A-27.

[14] Argoff CE, Katz N, Backonja M. Treatment of postherpetic neuralgia: a review of therapeutic options. J Pain Symptom Manage. 2004; 28(4):396-411.

[15] Shakir A, Kimbrough DA, Mehta B. Postherpetic neuralgia involving the right C5 dermatome treated with a cervical transforaminal epidural steroid injection: a case report. Arch Phys Med Rehabil. 2007;88(2):255-258.

[16] Gupta SK, Helal BH, Keily P. The prognosis in zoster paralysis. J Bone Joint Surg Br. 1969;51(4):593-603.

[17] Mondelli M, Romano C, Rossi S, et al. Herpes zoster of the head and limbs: electroneuromyographic and clinical findings in 158 consecutive cases. Arch Phys Med Rehabil. 2002;83(9):1215-1221.

[18] Gottschau P, Trojaborg W. Abdominal muscle paralysis associated with herpes zoster. Acta Neurol Scand. 1991;84(4):344-347.

[19] Chen PH, Hsueh HF, Hong CZ. Herpes zoster-associated voiding dysfunction: a retrospective study and literature review. Arch Phys Med Rehabil. 2002;83(11):1624-1628.

[20] Eyigor S, Durmaz B, Karapolat H. Monoparesis with complex regional pain syndrome-like symptoms due to brachial plexopathy caused by the varicella zoster virus: a case report. Arch Phys Med Rehabil. 2006;87(12):1653-1655.

[21] Brown GR. Herpes zoster: correlation of age, sex, distribution, neuralgia, and associated disorder. South Med J. 1976;69(5): 576-578.

[22] Rice JP. Segmental motor paralysis in herpes zoster. Clin Exp Neurol. 1984;20:129-140.

[23] Baek JO, Kim M, Roh JY, et al. A case of unilateral motor paralysis of the shoulder caused by herpes zoster. Ann Dermatol. 2007;19(2): 91-95.

[24] Cruz-Velarde JA, Mu?oz-Blanco JL, Traba A, et al. Segmental motor paralysis caused by the varicella zoster virus. Clinical study and functional prognosis. Rev Neurol. 2001;32(1):15-18.

[25] Reinold MM, Macrina LC, Wilk KE, et al. The effect of neuromuscular electrical stimulation of the infraspinatus on shoulder external rotation force production after rotator cuff repair surgery. Am J Sports Med. 2008;36(12):2317-2321.

[26] Starrost K, Geyh S, Trautwein A, et al. Interrater reliability of the extended ICF core set for stroke applied by physical therapists. Phys Ther. 2008;88(7):841-851.

[27] Paul B, Leitner C, Vacariu G, et al. Low-back pain assessment based on the Brief ICF Core Sets: diagnostic relevance of motor performance and psychological tests. Am J Phys Med Rehabil. 2008;87(6):452-460.

[28] Cup EH, Pieterse AJ, Ten Broek-Pastoor JM, et al. Exercise therapy and other types of physical therapy for patients with neuromuscular diseases: a systematic review. Arch Phys Med Rehabil. 2007;88(11): 1452-1464.

Cite this article as:Neural Regen Res. 2011;6(26):2050-2052.

Qiang Gao☆, M.D., P.T., Department of Rehabilitation Medicine, Key Laboratory of Rehabilitation Medicine of Sichuan Province, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China

Chengqi He, M.D., Professor, Department of Rehabilitation Medicine, Key Laboratory of Rehabilitation Medicine of Sichuan Province, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China hechqi@yahoo.com.cn

2011-02-23

2011-05-04 (N20101222001/WLM)

Gao Q, Yang YH, He CQ, Liu SX. Rehabilitation of shoulder paresis caused by herpes zoster according to the International Classification of Functioning, Disability and Health: a case report. Neural Regen Res. 2011;6(26):2050-2052.

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10.3969/j.issn.1673-5374. 2011.26.010

(Edited by Liu SW, Zhou MW/Qiu Y/Song LP)