Top

Published in:

Open Access 08-08-2023 | Original Article

Effects of intensive rehabilitation on functioning in patients with mild and moderate Charcot–Marie-Tooth disease: a real-practice retrospective study

Authors: Francesco Ferraro, Dario Calafiore, Claudio Curci, Francesco Fortunato, Irene Carantini, Filippo Genovese, Giuseppe Lucchini, Andrea Merlo, Antonio Ammendolia, Alessandro de Sire

Published in: Neurological Sciences | Issue 1/2024

Abstract

Charcot–Marie-Tooth (CMT) disease is one of the most common inherited neuropathies and can lead to progressive muscular weakness, pes cavus, loss of deep tendon reflexes, distal sensory loss, and gait impairment. There are still no effective drugs or surgical therapies for CMT, and supportive treatment is limited to rehabilitative therapy and surgical treatment of skeletal deformities. Many rehabilitative therapeutic approaches have been proposed, but timing and cadence of rehabilitative intervention are not clearly defined, and long-term follow-up is lacking in literature. The aim of this real-practice retrospective study was to assess the effectiveness of an intensive neurorehabilitation protocol on muscle strength and functioning in CMT patients. We analyzed data of patients with diagnosis of mild to moderate CMT. The rehabilitation program lasted 2–4 h a day, 5 days a week, for 3 weeks and consisted of manual treatments, strengthening exercises, stretching, core stability, balance and resistance training, aerobic exercises, and tailored self-care training. Data were collected at baseline (T₀), after treatment (T₁), and at the 12-month mark (T₂) in terms of the following outcome measures: muscle strength, pain, fatigue, cramps, balance, walking speed, and ability. We included 37 CMT patients with a median age of 50.72 ± 13.31 years, with different forms: demyelinating (n = 28), axonal (n = 8), and mixed (n = 1). After intensive rehabilitation treatment, all outcomes significantly improved. This improvement was lost at the 1-year mark. Taken together, these findings suggest that an intensive rehabilitation program improves short-term symptoms and functional outcomes in a cohort of inpatients affected by mild to moderate CMT.

Morena J, Gupta A, Hoyle JC (2019) Charcot-Marie-Tooth: from molecules to therapy. Int J Mol Sci 20(14):3419. https://doi.org/10.3390/ijms20143419CrossRefPubMedPubMedCentral

Rudnik-Schöneborn S, Tölle D, Senderek J, Eggermann K, Elbracht M, Kornak U, von der Hagen M, Kirschner J, Leube B, Müller-Felber W, Schara U, von Au K, Wieczorek D, Bußmann C, Zerres K (2016) Diagnostic algorithms in Charcot-Marie-Tooth neuropathies: experiences from a German genetic laboratory on the basis of 1206 index patients. Clin Genet 89(1):34–43. https://doi.org/10.1111/cge.12594CrossRefPubMed

Pareyson D, Saveri P, Pisciotta C (2017) New developments in Charcot-Marie-Tooth neuropathy and related diseases. Curr Opin Neurol 30(5):471–480. https://doi.org/10.1097/WCO.0000000000000474CrossRefPubMed

Barreto LCM, Oliveira FS, Nunes PS, de França Costa IM, Garcez CA, Goes GM, Neves EL, de Souza Siqueira Quintans J, de Souza Araújo AA (2016) Epidemiologic study of Charcot-Marie-Tooth disease: a systematic review. Neuroepidemiology 46(3):157–165. https://doi.org/10.1159/000443706CrossRefPubMed

El-Bazzal L, Ghata A, Estève C, Gadacha J, Quintana P, Castro C, Roeckel-Trévisiol N, Lembo F, Lenfant N, Mégarbané A, Borg JP, Lévy N, Bartoli M, Poitelon Y, Roubertoux PL, Delague V, Bernard-Marissal N (2022) Imbalance of NRG1-ERBB2/3 signalling underlies altered myelination in Charcot-Marie-Tooth disease 4H. Brain 31:awac402. https://doi.org/10.1093/brain/awac402CrossRef

Pipis M, Rossor AM, Laura M, Reilly MM (2019) Next-generation sequencing in Charcot-Marie-Tooth disease: opportunities and challenges. Nat Rev Neurol 15(11):644–656. https://doi.org/10.1038/s41582-019-0254-5CrossRefPubMed

Pareyson D, Marchesi C (2009) Diagnosis, natural history, and management of Charcot-Marie-Tooth disease. Lancet Neurol 8(7):654–667. https://doi.org/10.1016/S1474-4422(09)70110-3CrossRefPubMed

Fridman V, Bundy B, Reilly MM, Pareyson D, Bacon C, Burns J, Day J, Feely S, Finkel RS, Grider T, Kirk CA, Herrmann DN, Laurá M, Li J, Lloyd T, Sumner CJ, Muntoni F, Piscosquito G, Ramchandren S et al (2015) Inherited Neuropathies Consortium. CMT subtypes and disease burden in patients enrolled in the Inherited Neuropathies Consortium natural history study: a cross-sectional analysis. J Neurol Neurosurg Psychiatry 86(8):873–878. https://doi.org/10.1136/jnnp-2014-308826CrossRefPubMed

Wojciechowski E, Sman A, Cornett K, Raymond J, Refshauge K, Menezes MP, Burns J (2017) FAST Study Group. Gait patterns of children and adolescents with Charcot-Marie-Tooth disease. Gait Posture 56:89–94. https://doi.org/10.1016/j.gaitpost.2017.05.005CrossRefPubMed

10.

Õunpuu S, Pierz K, Garibay E, Acsadi G, Wren TAL (2022) Stance and swing phase ankle phenotypes in youth with Charcot-Marie-Tooth type 1: an evaluation using comprehensive gait analysis techniques. Gait Posture 21(98):216–225. https://doi.org/10.1016/j.gaitpost.2022.09.077CrossRef

11.

Tazir M, Hamadouche T, Nouioua S, Mathis S, Vallat JM (2014) Hereditary motor and sensory neuropathies or Charcot-Marie-Tooth diseases: an update. J Neurol Sci 347(1–2):14–22. https://doi.org/10.1016/j.jns.2014.10.013CrossRefPubMed

12.

Spiesshoefer J, Henke C, Kabitz HJ, Akova-Oeztuerk E, Draeger B, Herkenrath S, Randerath W, Young P, Brix T, Boentert M (2019) Phrenic nerve involvement and respiratory muscle weakness in patients with Charcot-Marie-Tooth disease 1A. J Peripher Nerv Syst 24(3):283–293. https://doi.org/10.1111/jns.12341CrossRefPubMed

13.

Pazzaglia C, Padua L, Stancanelli C, Fusco A, Loreti C, Castelli L, Imbimbo I, Giovannini S, Coraci D, Vita GL, Vita G (2022) Role of sport activity on quality of life in Charcot-Marie-Tooth 1A patients. J. Clin. Med 11:7032. https://doi.org/10.3390/jcm11237032CrossRefPubMedPubMedCentral

14.

Azevedo H, Pupe C, Pereira R, Nascimento OJM (2018) Pain in Charcot-Marie-Tooth disease: an update. Arq Neuropsiquiatr 76(4):273–276. https://doi.org/10.1590/0004-282x20180021CrossRefPubMed

15.

Menotti F, Felici F, Damiani A, Mangiola F, Vannicelli R, Macaluso A (2011) Charcot-Marie-Tooth 1A patients with low level of impairment have a higher energy cost of walking than healthy individuals. Neuromuscul Disord 21(1):52–57. https://doi.org/10.1016/j.nmd.2010.09.008CrossRefPubMed

16.

Kennedy RA, Carroll K, Paterson KL, Ryan MM, Burns J, Rose K, McGinley JL (2019) Physical activity of children and adolescents with Charcot-Marie-Tooth neuropathies: a cross-sectional case-controlled study. Allen MD, editor. PLoS One 14(6):e0209628 https://doi.org/10.1371/journal.pone.0209628.

17.

Pisciotta C, Saveri P, Pareyson D (2021) Challenges in treating Charcot-Marie-Tooth disease and related neuropathies: current management and future perspectives. Brain Sci 11(11):1447. https://doi.org/10.3390/brainsci11111447CrossRefPubMedPubMedCentral

18.

Nonnekes J, Hofstad C, de Greef-Rotteveel A, van der Wielen H, van Gelder JH, Plaats C, Altmann V, Krause F, Keijsers N, Geurts A, Louwerens JWK (2021) Management of gait impairments in people with Charcot-Marie-Tooth disease: a treatment algorithm. J Rehabil Med 53(5):jrm00194. https://doi.org/10.2340/16501977-2831CrossRefPubMed

19.

McCorquodale D, Pucillo EM, Johnson NE (2016) Management of Charcot-Marie-Tooth disease: improving long-term care with a multidisciplinary approach. J Multidiscip Healthc 19(9):7–19. https://doi.org/10.2147/JMDH.S69979CrossRef

20.

Kenis-Coskun O, Matthews DJ (2016) Rehabilitation issues in Charcot-Marie-Tooth disease. J Pediatr Rehabil Med 9(1):31–34. https://doi.org/10.3233/PRM-160359CrossRefPubMed

21.

Corrado B, Ciardi G, Bargigli C (2016) Rehabilitation management of the Charcot-Marie-Tooth syndrome : a systematic review of the literature. Medicine (Baltimore) 95(17):e3278. https://doi.org/10.1097/MD.0000000000003278CrossRefPubMed

22.

Sman AD, Hackett D, Fiatarone Singh M, Fornusek C, Menezes MP, Burns J (2015) Systematic review of exercise for Charcot-Marie-Tooth disease. J Peripher Nerv Syst 20(4):347–362. https://doi.org/10.1111/jns.12116CrossRefPubMed

23.

Matjačić Z, Zupan A (2016) Effects of dynamic balance training during standing and stepping in patients with hereditary sensory motor neuropathy. Disabil Rehabil 28(23):1455–1459. https://doi.org/10.1080/09638280600646169CrossRef

24.

Pazzaglia C, Camerota F, Germanotta M, Di Sipio E, Celletti C, Padua L (2016) Efficacy of focal mechanic vibration treatment on balance in Charcot-Marie-Tooth 1A disease: a pilot study. J Neurol 263(7):1434–1441. https://doi.org/10.1007/s00415-016-8157-5CrossRefPubMed

25.

Pagliano E, Foscan M, Marchi A, Corlatti A, Aprile G, Riva D (2018) Intensive strength and balance training with the Kinect console (Xbox 360) in a patient with CMT1A. Dev Neurorehabil 21(8):542–545. https://doi.org/10.1080/17518423.2017.1354091CrossRefPubMed

26.

Mori L, Signori A, Prada V, Pareyson D, Piscosquito G, Padua L, Pazzaglia C, Fabrizi GM, Picelli A, Schenone A (2020) TreSPE study group. Treadmill training in patients affected by Charcot-Marie-Tooth neuropathy: results of a multicenter, prospective, randomized, single-blind, controlled study. Eur J Neurol 27(2):280–287. https://doi.org/10.1111/ene.14074CrossRefPubMed

27.

Knak KL, Andersen LK, Vissing J (2017) Aerobic anti-gravity exercise in patients with Charcot–Marie–Tooth disease types 1A and X: a pilot study. Brain Behav 7(12):1–5. https://doi.org/10.1002/brb3.794CrossRef

28.

Wallace A, Pietrusz A, Dewar E, Dudziec M, Jones K, Hennis P, Sterr A, Baio G, Machado PM, Laurá M, Skorupinska I, Skorupinska M, Butcher K, Trenell M, Reilly MM, Hanna MG, Ramdharry GM (2019) Community exercise is feasible for neuromuscular diseases and can improve aerobic capacity. Neurology 92(15):e1773–e1785. https://doi.org/10.1212/WNL.0000000000007265CrossRefPubMedPubMedCentral

29.

Sheikh AM, Vissing J (2019) Exercise therapy for muscle and lower motor neuron diseases. Acta Myol 38(4):215–232PubMedPubMedCentral

30.

Jones K, Hawke F, Newman J, Miller JA, Burns J, Jakovljevic DG, Gorman G, Turnbull DM, Ramdharry G (2021) Interventions for promoting physical activity in people with neuromuscular disease. Cochrane Database Syst Rev 5(5):CD013544. https://doi.org/10.1002/14651858.CD013544.pub2CrossRefPubMed

31.

Petryaeva OV, Shnayder NA, Artyukhov IP, Sapronova MR, Loginova IO (2018) The role of orthotic service in modern rehabilitation of patients with Charcot-Marie-Tooth disease. J Biosci Med 06(07):23–34. https://doi.org/10.4236/jbm.2018.67003CrossRef

32.

Zuccarino R, Anderson KM, Shy ME, Wilken JM (2021) Satisfaction with ankle foot orthoses in individuals with Charcot-Marie-Tooth disease. Muscle and Nerve 63(1):40–45. https://doi.org/10.1002/mus.27027CrossRefPubMed

33.

Djordjevic D, Fell S, Baker S (2017) Effects of self-selected exercise on strength in Charcot-Marie-Tooth disease subtypes. Can J Neurol Sci 44(5):572–576. https://doi.org/10.1017/cjn.2017.204CrossRefPubMed

34.

Burns J, Sman AD, Cornett KMD, Wojciechowski E, Walker T, Menezes MP, Mandarakas MR, Rose KJ, Bray P, Sampaio H, Farrar M, Refshauge KM, Raymond J (2017) FAST Study Group. Safety and efficacy of progressive resistance exercise for Charcot-Marie-Tooth disease in children: a randomised, double-blind, sham-controlled trial. Lancet Child Adolesc Health. 1(2):106–113. https://doi.org/10.1016/S2352-4642(17)30013-5CrossRefPubMed

35.

Reynaud V, Morel C, Givron P, Clavelou P, Cornut-Chauvinc C, Pereira B, Taithe F, Coudeyre E (2019) Walking speed is correlated with the isokinetic muscular strength of the knee in patients with Charcot-Marie-Tooth type 1A. Am J Phys Med Rehabil 98(5):422–425. https://doi.org/10.1097/PHM.0000000000001084CrossRefPubMed

36.

Ferraro F, Dusina B, Carantini I, Strambi R, Galante E, Gaiani L (2017) The efficacy of functional surgery associated with early intensive rehabilitation therapy in Charcot-Marie-Tooth type 1A disease. Eur J Phys Rehabil Med 53(5):788–793. https://doi.org/10.23736/S1973-9087.17.04448-3CrossRefPubMed

37.

Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, Initiative STROBE (2007) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370(9596):1453–1457. https://doi.org/10.1016/S0140-6736(07)61602-XCrossRef

38.

Merlo A, Rodà F, Carnevali D, Principi N, Grimoldi L, Auxilia F, Lombardi F, Maini M, Brianti R, Castaldi S (2020) Appropriateness of admission to rehabilitation: definition of a set of criteria and rules through the application of the Delphi method. Eur J Phys Rehabil Med 56(5):537–546. https://doi.org/10.23736/S1973-9087.20.06148-1CrossRefPubMed

39.

Pisciotta C, Ciafaloni E, Zuccarino R, Calabrese D, Saveri P, Fenu S, Tramacere I, Genovese F, Dilek N, Johnson NE, Heatwole C, Herrmann DN, Pareyson D (2020) ACT-CMT Study Group. Validation of the Italian version of the Charcot-Marie-Tooth Health Index. J Peripher Nerv Syst 25(3):292–296. https://doi.org/10.1111/jns.12397CrossRefPubMedPubMedCentral

40.

Eggmann S, Luder G, Verra ML, Irincheeva I, Bastiaenen CHG, Jakob SM (2020) Functional ability and quality of life in critical illness survivors with intensive care unit acquired weakness: a secondary analysis of a randomised controlled trial. PLoS One 15(3):e0229725. https://doi.org/10.1371/journal.pone.0229725CrossRefPubMedPubMedCentral

41.

Kleyweg RP, Van Der Meché FGA, Schmitz PIM (1991) Interobserver agreement in the assessment of muscle strength and functional abilities in Guillain-Barré syndrome. Muscle & Nerve 14(11):1103–1109. https://doi.org/10.1002/mus.880141111CrossRef

42.

Monti Bragadin M, Francini L, Bellone E, Grandis M, Reni L, Canneva S, Gemelli C, Ursino G, Maggi G, Mori L, Schenone A (2015) Tinetti and Berg balance scales correlate with disability in hereditary peripheral neuropathies: a preliminary study. Eur J Phys Rehabil Med 51(4):423–427PubMed

43.

Hobart JC, Riazi A, Lamping DL, Fitzpatrick R, Thompson AJ (2003) Measuring the impact of MS on walking ability: the 12-Item MS Walking Scale (MSWS-12). Neurology 60(1):31–36. https://doi.org/10.1212/wnl.60.1.31CrossRefPubMed

44.

Niu HX, Wang RH, Xu HL, Song B, Yang J, Shi CH, Li YS, Zhang BQ, Wang SP, Yong Q, Wang YY, Xu YM (2017) Nine-hole peg test and ten-meter walk test for evaluating functional loss in Chinese Charcot-Marie-Tooth disease. Chin Med J 130(15):1773–1778. https://doi.org/10.4103/0366-6999.211550CrossRefPubMedPubMedCentral

45.

Ellis Paul D (2010) The essential guide to effect sizes: statistical power, meta-analysis, and the interpretation of research results. Cambridge University Press ISBN 978-0-521-14246-5CrossRef

46.

A Power Primer Psychological Bulletin; July 1992; 112, 1; PsycARTICLES pg. 155

47.

Merkies IS, van Nes SI, Hanna K, Hughes RA, Deng C (2010) Confirming the efficacy of intravenous immunoglobulin in CIDP through minimum clinically important differences: shifting from statistical significance to clinical relevance. J Neurol Neurosurg Psychiatry 81(11):1194–1199. https://doi.org/10.1136/jnnp.2009.194324CrossRefPubMed

48.

de França Costa IMP, Nunes PS, de Aquino Neves EL, Lima Santos Barreto LC, Garcez CA, Souza CC, Pereira Oliveira PM, Sales Ferreira LA, Brandão Lima VN, de Souza Araújo AA (2018) Evaluation of muscle strength, balance and functionality of individuals with type 2 Charcot-Marie-Tooth disease. Gait Posture 62:463–467. https://doi.org/10.1016/j.gaitpost.2018.04.001CrossRefPubMed

49.

Colaianni G, Oranger A, Dicarlo M, Lovero R, Storlino G, Pignataro P, Fontana A, Di Serio F, Ingravallo A, Caputo G, Di Leo A, Barone M, Grano M (2022) Irisin serum levels and skeletal muscle assessment in a cohort of Charcot-Marie-Tooth patients. Front Endocrinol 13:886243. https://doi.org/10.3389/fendo.2022.886243CrossRef

50.

Pesce M, La Fratta I, Paolucci T, Grilli A, Patruno A, Agostini F, Bernetti A, Mangone M, Paoloni M, Invernizzi M, de Sire A (2021) From exercise to cognitive performance: role of Irisin. Appl Sci 11(15):7120. https://doi.org/10.3390/app11157120CrossRef

51.

Peterson DS, Moore A, Ofori E (2021) Performance fatigability during gait in adults with Charcot-Marie-Tooth disease. Gait Posture 85:232–237. https://doi.org/10.1016/j.gaitpost.2021.02.002CrossRefPubMed

52.

Mori L, Schenone C, Cotellessa F, Ponzano M, Aiello A, Lagostina M, Massucco S, Marinelli L, Grandis M, Trompetto C, Schenone A (2022) Quality of life and upper limb disability in Charcot-Marie-Tooth disease: a pilot study. Front Neurol 13:964254. https://doi.org/10.3389/fneur.2022.964254CrossRefPubMedPubMedCentral

53.

Maggi G, Monti Bragadin M, Padua L, Fiorina E, Bellone E, Grandis M, Reni L, Bennicelli A, Grosso M, Saporiti R, Scorsone D, Zuccarino R, Crimi E, Schenone A (2011) Outcome measures and rehabilitation treatment in patients affected by Charcot-Marie-Tooth neuropathy: a pilot study. Am J Phys Med Rehabil 90(8):628–637. https://doi.org/10.1097/PHM.0b013e31821f6e32CrossRefPubMed

54.

Estilow T, Glanzman AM, Burns J, Harrington A, Cornett K, Menezes MP, Shy R, Moroni I, Pagliano E, Pareyson D, Bhandari T, Muntoni F, Laurá M, Reilly MM, Finkel RS, Eichinger KJ, Herrmann DN, Troutman G, Bray P et al (2019) Balance impairment in pediatric Charcot-Marie-Tooth disease. Muscle Nerve 60(3):242–249. https://doi.org/10.1002/mus.26500CrossRefPubMed

55.

Ramdharry GM, Reilly-O’Donnell L, Grant R, Reilly MM (2018) Frequency and circumstances of falls for people with Charcot–Marie–Tooth disease: a cross sectional survey. Physiother Res Int 23(2):e1702. https://doi.org/10.1002/pri.1702CrossRefPubMed

56.

Tozza S, Bruzzese D, Severi D, Spina E, Iodice R, Ruggiero L, Dubbioso R, Iovino A, Aruta F, Nolano M, Santoro L, Manganelli F (2022) The impact of symptoms on daily life as perceived by patients with Charcot-Marie-Tooth type 1A disease. Neurol Sci 43(1):559–563. https://doi.org/10.1007/s10072-021-05254-7CrossRefPubMed

57.

Agostini M, Moja L, Banzi R, Pistotti V, Tonin P, Venneri A, Turolla A (2015) Telerehabilitation and recovery of motor function: a systematic review and meta-analysis. J Telemed Telecare 21(4):202–213. https://doi.org/10.1177/1357633X15572201CrossRefPubMed

58.

Prada V, Bellone E, Schenone A, Grandis M (2020) The suspected SARS-Cov-2 infection in a Charcot-Marie-Tooth patient undergoing postsurgical rehabilitation: the value of telerehabilitation for evaluation and continuing treatment. Int J Rehabil Res 43(3):285–286. https://doi.org/10.1097/MRR.0000000000000418CrossRefPubMed

59.

Andrenelli E, Negrini F, de Sire A, Arienti C, Patrini M, Negrini S, Ceravolo MG (2020) International Multiprofessional Steering Committee of Cochrane Rehabilitation REH-COVER action. Systematic rapid living review on rehabilitation needs due to COVID-19: update to May 31st, 2020. Eur J Phys Rehabil Med 56(4):508–514. https://doi.org/10.23736/S1973-9087.20.06435-7CrossRefPubMed

60.

de Sire A, Andrenelli E, Negrini F, Lazzarini SG, Patrini M, Ceravolo MG, International Multiprofessional Steering Committee of Cochrane Rehabilitation REH-COVER action (2020) Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review. Update as of August 31st, 2020. Eur J Phys Rehabil Med 56(6):839–845. https://doi.org/10.23736/S1973-9087.20.06614-9CrossRefPubMed

61.

de Sire A, Marotta N, Agostini F, Drago Ferrante V, Demeco A, Ferrillo M, Inzitari MT, Pellegrino R, Russo I, Ozyemisci Taskiran O, Bernetti A, Ammendolia AA (2022) Telerehabilitation approach to chronic facial paralysis in the COVID-19 pandemic scenario: what role for electromyography assessment? J Pers Med 12(3):497. https://doi.org/10.3390/jpm12030497CrossRefPubMedPubMedCentral

Title: Effects of intensive rehabilitation on functioning in patients with mild and moderate Charcot–Marie-Tooth disease: a real-practice retrospective study
Authors: Francesco Ferraro
Dario Calafiore
Claudio Curci
Francesco Fortunato
Irene Carantini
Filippo Genovese
Giuseppe Lucchini
Andrea Merlo
Antonio Ammendolia
Alessandro de Sire
Publication date: 08-08-2023
Publisher: Springer International Publishing
Published in: Neurological Sciences / Issue 1/2024
Print ISSN: 1590-1874
Electronic ISSN: 1590-3478
DOI: https://doi.org/10.1007/s10072-023-06998-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Effects of intensive rehabilitation on functioning in patients with mild and moderate Charcot–Marie-Tooth disease: a real-practice retrospective study

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 1/2024

Resting and re-emergent jaw tremor as the presenting symptom of Parkinson’s disease

The association between varicella zoster virus and dementia: a systematic review and meta-analysis of observational studies

New approaches to recovery after stroke

Medical versus neurosurgical treatment in ICH patients: a single center experience

When the nerve keeps firing: an institutional experience and systematic review on delayed response after microvascular decompression for trigeminal neuralgia

Back to the future: encephalitis lethargica as an autoimmune disorder?