Trigeminal neuralgia: A case study

Introduction

Trigeminal neuralgia (TN) is a unilateral facial pain disorder that involves dysfunction of the 5th cranial nerve (CN V). It is typically caused by a compression of the nerve by a blood vessel which overtime causes degeneration of the protective myelin sheath. It may arise as a complication of multiple sclerosis, a tumor in the area, or arteriovenous malformation. It can also be brought on by physical damage to the nerve from factors like stroke, oral surgery or other facial trauma. The trigeminal nerve exits the brainstem from the pons and branches out into 3 sections that supply the upper, middle and lower portions of the face. The upper most branch, the ophthalmic nerve, supplies sensation to the scalp and forehead. The middle branch, or maxillary nerve, supplies sensation to the nose, lips and cheeks. Finally the lowest branch, the mandibular nerve, supplies sensation to the bottom lip, teeth and gums. The main symptom that people seek medical attention for is the severe attacks of pain in one side of the face over the sensory distribution of the nerve, depending on which branches are affected. The maxillary and mandibular branches are most commonly affected, with the ophthalmic nerve only being affected in 5% of cases. The attacks of pain are usually triggered by touch, cold temperatures, and sound.

This case study describes a 35 year old woman named Mrs. R who presented with an insidious onset of left sided facial pain that was impacting her activities of daily living and her occupation. The case of Mrs. R’s trigeminal neuralgia was especially unique because she presented with pain in all three branches of the trigeminal nerve, over the entire left side of her face, making her symptoms more severe than what is typical. The case was perplexing due to her young age, complex symptoms, and absence of any notable etiologies. Mrs. R’s case was even more intricate due the nature of her occupation as a news reporter. Her job requires her to be in cold weather conditions and demands a lot of speaking, both of which have been known to trigger the painful attacks that are characteristic of trigeminal neuralgia.

The purpose of this case study is to display how a multidisciplinary team can positively impact the presentation of symptoms of trigeminal neuralgia. The case study will describe interventions from the interdisciplinary team of healthcare professionals, with a focus on the importance of physiotherapy assessment and treatment of these patients. Most of the literature on the role of physiotherapy on TN patients describes the use of electrical physical agents and modalities to alleviate some of these patients’ pain. These modalities proved to be beneficial for Mrs. R, but this case study will also describe the use of other PT interventions that markedly helped Mrs. R with her symptoms. This in turn improved her work performance, reduced her feelings of hopelessness and anxiety, and increased her quality of life. The hope is that this case study can function as a guide for physiotherapists with TN patients that would like to explore alternate techniques that physiotherapists can apply to help these patients. The case study will offer suggestions for PT treatment techniques that encourage patients to take an active role in their recovery, ultimately getting them to a place where they are able to independently use self-management techniques to help themselves in the long term.