Factors that ameliorate or aggravate spasmodic torticollis

Classification of Dystonia

Dystonia is a hyperkinetic movement disorder characterized by abnormal movement or posture caused by excessive muscle contraction. Because of its wide clinical spectrum, dystonia is often underdiagnosed or misdiagnosed. In clinical practice, dystonia could often present in association with other movement disorders. An accurate physical examination is essential to describe the correct phenomenology. To help clinicians reaching the proper diagnosis, several classifications of dystonia have been proposed. The current classification consists of axis I, clinical characteristics, and axis II, etiology. Through the application of this classification system, movement disorder specialists could attempt to correctly characterize dystonia and guide patients to the most effective treatment. The aim of this article is to describe the phenomenological spectrum of dystonia, the last approved dystonia classification, and new emerging knowledge.

Sensory tricks modulate corticocortical and corticomuscular connectivity in cervical dystonia

OBJECTIVE

To examine interactions between cortical areas and between cortical areas and muscles during sensory tricks in cervical dystonia (CD).

METHODS

Thirteen CD patients and thirteen age-matched healthy controls performed forewarned reaction time tasks, sensory tricks, and two tasks replicating aspects of the tricks (moving necks/arms). Control subjects mimicked sensory tricks. Corticocortical and corticomuscular coherence values were calculated from surface electrodes placed over motor, premotor, and sensory cortical areas and dystonic muscles.

RESULTS

During initial preparation (after the warning stimulus), the only between-task difference was found in the γ-band corticocortical coherence (higher during tricks than during voluntary neck movements). With movements (before/after the imperative stimulus), the γ-band coherence of CD patients significantly increased during tricks but decreased during voluntary movements, while opposite trends were observed in healthy subjects. Additionally, the α- and β-band coherence decreased in healthy subjects during movements. Between the two patient subgroups (typical vs. forcible tricks), only those with typical tricks showed significant decrease in corticomuscular coherence during tricks.

CONCLUSIONS

Observed changes in the corticocortical coherence suggest that sensory tricks improve cortical function, which reduces corticomuscular connectivity and the dystonia.

SIGNIFICANCE

We demonstrated that sensory tricks fundamentally affect sensorimotor integration in CD, both in movement preparation and execution.

Mood and emotional disorders associated with parkinsonism, Huntington disease, and other movement disorders

This chapter provides a review of mood, emotional disorders, and emotion processing deficits associated with diseases that cause movement disorders, including Parkinson's disease, Lewy body dementia, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, frontotemporal dementia with parkinsonism, Huntington's disease, essential tremor, dystonia, and tardive dyskinesia. For each disorder, a clinical description of the common signs and symptoms, disease progression, and epidemiology is provided. Then the mood and emotional disorders associated with each of these diseases are described and discussed in terms of clinical presentation, incidence, prevalence, and alterations in quality of life. Alterations of emotion communication, such as affective speech prosody and facial emotional expression, associated with these disorders are also discussed. In addition, if applicable, deficits in gestural and lexical/verbal emotion are reviewed. Throughout the chapter, the relationships among mood and emotional disorders, alterations of emotional experiences, social communication, and quality of life, as well as treatment, are emphasized.

It's tricky: Rating alleviating maneuvers in cervical dystonia

OBJECTIVES

To investigate hypothesized sources of error when quantifying the effect of the sensory trick in cervical dystonia (CD) with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS-2), test strategies to mitigate them, and provide guidance for future research on the sensory trick.

METHODS

Previous analyses suggested the sensory trick (or "alleviating maneuver", AM) item be removed from the TWSTRS-2 because of its poor clinimetric properties. We hypothesized three sources of clinimetric weakness for rating the AM: 1) whether patients were given sufficient time to demonstrate their AM; 2) whether patients' CD was sufficiently severe for detecting AM efficacy; and 3) whether raters were inadvertently rating the item in reverse of scale instructions. We tested these hypotheses with video recordings and TWSTRS-2 ratings by one "site rater" and a panel of five "video raters" for each of 185 Dystonia Coalition patients with isolated CD.

RESULTS

Of 185 patients, 23 (12%) were not permitted sufficient testing time to exhibit an AM, 23 (12%) had baseline CD too mild to allow confident rating of AM effect, and 1 site- and 1 video-rater each rated the AM item with a reverse scoring convention. When these confounds were eliminated in step-wise fashion, the item's clinimetric properties improved.

CONCLUSIONS

The AM's efficacy can contribute to measuring CD motor severity by addressing identified sources of error during its assessment and rating. Given the AM's sensitive diagnostic and potential pathophysiologic significance, we also provide guidance on modifications to how AMs can be assessed in future CD research.

The effects of a relaxation program featuring aquatic therapy and autogenic training among people with cervical dystonia (a pilot study)

Classic physical interventions for cervical dystonia (CD) have focused on treating motor components or, on motor components and relaxation programs. However, no CD treatment study has focused on a relaxation program alone. We developed a pilot study to assess whether a therapy completely based on a relaxation program could improve the physical and mental symptomatologies of patients with CD. Fifteen persons were included in the experimental group, which received individual sessions of aquatic (Watsu) therapy (WT) and autogenic training (AT). In addition, 12 persons were included in passive control group. We administered different questionnaires related to quality of life (SF-36), pain (Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) and Visual Analog Scale (VAS)) and mood (Beck Depression Inventory (BDI-II) and State-Trait Anxiety Inventory (STAI)). A significant interaction was observed between treatment and time with regard to the SF-36, VAS, and TWSTRS within the experimental group (p < 0.01). The BDI-II showed depression decrease as a simple effect (p < 0.05), and the STAI did not change. No effects were found with regard to the control group. In this exploratory study, we found that a therapy based on whole body relaxation improved the symptoms of patients with CD. This knowledge enables a disease-management strategy that uses a holistic perspective and moves beyond the dystonic focus.

[The efficacy of botulinotherapy in the correction of the pain syndrome and quality of life of patients with cervical dystonia]

AIM

To evaluate the severity of pain, emotional status and humoral serotonin in patients with cervical dystonia (CD) before and after the botulinotherapy.

MATERIAL AND METHODS

A simple, open, comparative study of clinical characteristics of hyperkinesis, pain and emotional status, quality of life and contents of serum and blood platelet serotonin in 48 patients (32 women and 16 men) with CD, in age from 37 to 53 years, before and one month after the botulinotherapy with disport in dose of 500--1000 U was carried out. A control group included 15 healthy people.

RESULTS

All patients (100%) complained of involuntary movements and pain in the neck. The overall score on a scale of dystonic movements in the group of patients was 16,7±7,7 points, on TWSTRS - 46,48±6,2 points, on the Visual Analogue Scale, the average level of pain was 6,4±1,08 points. The degree of depression according to the Hamilton scale was significantly higher (p<0.05) compared to the control group. The level of trait and state anxiety measured with the Spielberger-Khanin scale was significantly higher (p<0.005) in patients with CD than in the controls. The correlation analysis revealed a direct dependence of the intensity of pain subscale TWSTRS with the degree of anxiety on the Hamilton scale and the amount of final points of dystonic movements. The level of serotonin in the serum was significantly lower in patients compared to the controls. After botulinotherapy, pain scores, anxiety and depression have significantly decreased and the level of blood platelet serotonin has increased.

CONCLUSION

Botulinotherapy with dysport in CD patients reduces the degree of pain, depression, improves quality of life and stimulates the serotoninergic system.

Treatment satisfaction with botulinum toxin: a comparison between blepharospasm and cervical dystonia

BACKGROUND

Differential effects of botulinum toxin (BoNT) treatment in cervical dystonia (CD) and blepharospasm (BSP) treatment satisfaction and emotional responses to a life with a disabling condition were investigated. Special interest was drawn to the course within a BoNT treatment cycle and the effects of subjective well-being vs perceived intensity of motor symptoms and quality of life.

METHODS

A questionnaire was distributed among 372 CD patients and 125 BSP patients, recruited from 13 BoNT centers throughout Germany. Items were related to dystonic symptoms, BoNT treatment responses and treatment satisfaction, quality of life, working situation, and emotional reactions to a life with dystonia.

RESULTS

CD patients and BSP patients were widely satisfied with BoNT treatment, but treatment satisfaction worsened significantly within the treatment cycle. Especially CD patients reported that both the dystonic symptoms and the effects of BoNT treatment were influenced by emotional factors. Despite good overall treatment effects, patients from both groups perceived marked persistence of motor symptoms, restrictions of everyday life functions, and reduced quality of life. Functional amelioration of motor symptoms and emotional well-being were only moderately correlated. About 22% of patients from both groups reported mental disorders or emotional disturbances prior to the onset of dystonia.

CONCLUSION

As numerous psychological factors determine perceived outcome, BoNT treatment should be further improved by patient's education strategies enhancing behavioral self-control. From the patient's perspective, individual intervals, which may avoid exacerbation between injection points, should be considered. Moreover, patients at risk, with reduced adherence and poor BoNT outcome, should be identified and addressed within psychoeducation.

The clinical phenomenology and associations of trick maneuvers in cervical dystonia

Sensory trick is an unusual clinical feature in cervical dystonia that attenuates disease symptoms by slight touch to a specific area of the face or head. Using a semi-quantitative questionnaire-based study of 197 patients with idiopathic cervical dystonia, we sought to determine probable pathophysiologic correlates, with the wider aim of examining its eventual clinical significance. The typical sensory trick, i.e., light touch, not necessitating the use of force leading to simple overpowering of dystonic activity, was present in 83 (42.1 %) patients. The vast majority of the patients required a specific sequence of sensorimotor inputs, including touch sensation on the face or different areas of the head, and also sensory and motor input of the hand itself. Deviations often led to a significant decrease in effectiveness and lack of expected benefit. Moreover, patients able to perform the maneuver reported compellingly higher subjective effect of botulinum toxin treatment (median 7 vs. 5 on a scale of 0-10; p < 0.0001) and lower depression score (median 10 vs. 14 on the Montgomery Åsberg Depression Rating scale; p < 0.001). Overall, the results point to marked disruption of sensorimotor networks in cervical dystonia. The mechanism of the sensory trick action may be associated with balancing the abnormal activation patterns by specific sensorimotor inputs. Its presence may be considered a positive predictive factor for responsiveness to botulinum toxin treatment.

Exploring factors related to physical activity in cervical dystonia

Background

People with disabilities have reported worse health status than people without disabilities and receiving fewer preventive health services such as counseling around exercise habits. This is noteworthy considering the negative consequences associated with physical inactivity. No research has been conducted on physical activity in cervical dystonia (CD), despite its possible major impact on self-perceived health and disability. Considering the favorable consequences associated with physical activity it is important to know how to promote physical activity behavior in CD. Knowledge of variables important for such behavior in CD is therefore crucial. The aim of this study was to explore factors related to physical activity in individuals with cervical dystonia.

Methods

Subjects included in this cross-sectional study were individuals diagnosed with CD and enrolled at neurology clinics (n = 369). Data was collected using one surface mailed self-reported questionnaire. Physical activity was the primary outcome variable, measured with the Physical Activity Disability Survey. Secondary outcome variables were: impact of dystonia measured with the Cervical Dystonia Impact Scale; fatigue measured with the Fatigue Severity Scale; confidence when carrying out physical activity measured with the Exercise Self-Efficacy Scale; confidence in performing daily activities without falling measured with the Falls Efficacy Scale; enjoyment of activity measured with Enjoyment of Physical Activity Scale, and social influences on physical activity measured with Social Influences on Physical Activity in addition to demographic characteristics such as age, education level and employment status.

Results

The questionnaire was completed by 173 individuals (47 % response rate). The multivariate association between related variables and physical activity showed that employment, self-efficacy for physical activity, education level and consequences for daily activities explained 51 % of the variance in physical activity (Adj R 0.51, F (5, 162) = 35.611, p = 0.000). Employment and self-efficacy for physical activity contributed most strongly to the association with physical activity.

Conclusions

Considering the favorable consequences associated with physical activity it could be important to support the individuals with CD to remain in work and self-efficacy to physical activity as employment and self-efficacy had significant influence on physical activity level. Future research is needed to evaluate causal effects of physical activity on consequences related to CD .

Early Illustrations of Geste Antagoniste in Cervical and Generalized Dystonia

Background

Geste antagoniste, or sensory trick, is a voluntary maneuver that temporarily reduces the severity of dystonic postures or movements. We present a historical review of early reports and illustrations of geste antagoniste.

Results

In 1894, Brissaud described this phenomenon in Paris in patients with torticollis. He noted that a violent muscular contraction could be reversed by a minor voluntary action. He considered the improvement obtained by what he called “simple mannerisms, childish behaviour or fake pathological movements” was proof of the psychogenic origin of what he named mental torticollis. This concept was supported by photographical illustrations of the patients. The term geste antagoniste was used by Brissaud’s pupils, Meige and Feindel, in their 1902 monograph on movement disorders. Other reports and illustrations of this sign were published in Europe between 1894 and 1906. Although not mentioned explicitly, geste antagoniste was also illustrated in a case report of generalized dystonia in Oppenheim’s 1911 seminal description of dystonia musculorum deformans in Berlin.

Discussion

Brissaud-Meige’s misinterpretation of the geste antagoniste unfortunately anchored the psychogenic origin of dystonia for decades. In New York, Herz brought dystonia back into the realm of organic neurology in 1944. Thereafter, it was given prominence by other authors, notably Fahn and Marsden in the 1970–1980s. Nowadays, neurologists routinely investigate for geste antagoniste when a dystonic syndrome is suspected, because it provides a further argument in favor of dystonia. The term alleviating maneuver was proposed in 2014 to replace sensory trick or geste antagoniste. This major sign is now part of the motor phenomenology of the 2013 Movement Disorder Society’s classification of dystonia.

Tricks in dystonia: ordering the complexity

Sensory tricks are various manoeuvres that can ameliorate dystonia. Common characteristics are well known, but their variety is wide, sensory stimulation is not necessarily the critical feature, and their physiology is unknown. To enumerate the various forms of sensory tricks and describe their nature, research findings and theories that may elucidate their neurophysiologic mechanism, we reviewed the literature pertaining to sensory tricks, including variants like motor tricks, imaginary tricks, forcible tricks and reverse sensory tricks. On the basis of this information, we propose a new classification of sensory tricks to include its variants. We highlight neurophysiologic evidence suggesting that sensory tricks work by decreasing abnormal facilitation. We tie this with established dystonia pathogenesis and postulate that sensory tricks decrease abnormally increased facilitation to inhibition ratios in the dystonic brain. It appears worthwhile for patients to search for possible sensory tricks.

Alleviating manoeuvres (sensory tricks) in cervical dystonia

BACKGROUND

There is limited information on the phenomenology, clinical characteristics and pathophysiology of alleviating manoeuvres (AM), also called 'sensory tricks' in cervical dystonia (CD).

METHODS

Individual data, collected from 10 sites participating in the Dystonia Coalition (http://clinicaltrials.gov/show/NCT01373424), included description of localisation and phenomenology of AM collected by systematic review of standardised video examinations. Analyses correlated demographic, neurologic, and psychiatric features of CD patients with or without effective AM.

RESULTS

Of 154 people studied, 138 (89.6%) used AM, of which 60 (43.4%) reported partial improvement, 55 (39.8%) marked improvement, and 4 (0.03%) no effect on dystonic posture. Light touch, usually to the lower face or neck, was used by >90%. The presence or location of AM did not correlate with the severity of the dystonia.

CONCLUSIONS

In this large and comprehensive study of CD, we found no clinical predictors of effective AM. Further studies of sensorimotor integration in dystonia are needed to better understand the pathophysiology of AM.

Psychiatric comorbidities in dystonia: emerging concepts

Psychiatric disorders are highly prevalent in patients with dystonia and have a profound effect on quality of life. Patients with dystonia frequently meet criteria for anxiety disorders, especially social phobia, and major depressive disorder. Deficits in emotional processing have also been demonstrated in some dystonia populations. Onset of psychiatric disturbances in patients with dystonia often precedes onset of motor symptoms, suggesting that the pathophysiology of dystonia itself contributes to the genesis of psychiatric disturbances. This article examines the hypothesis that mood and anxiety disorders are intrinsic to the neurobiology of dystonia, citing the available literature, which is derived mostly from research on focal isolated dystonias. Limitations of studies are identified, and the role of emotional reactivity, especially in the context of pain secondary to dystonia, is recognized. Available evidence underscores the need to develop dystonia assessment tools that incorporate psychiatric measures. Such tools would allow for a better understanding of the full spectrum of dystonia presentations and facilitate research on the treatment of dystonia as well as the treatment of psychiatric illnesses in the context of dystonia. This article, solicited for a special Movement Disorders issue on novel research findings and emerging concepts in dystonia, addresses the following issues: (1) To what extent are psychiatric disturbances related to the pathophysiology of dystonia? (2) What is the impact of psychiatric disturbances on outcome measures of current assessment tools for dystonia? (3) How do psychiatric comorbidities influence the treatment of dystonia? Answers to these questions will lead to an increased appreciation of psychiatric disorders in dystonia, a better understanding of brain physiology, more nuanced research questions pertaining to this population, better clinical scales that can be used to further patient management and research, and improved patient outcomes. © 2013 Movement Disorder Society.

Positional torticollis while lying on side

BACKGROUND

Spasmodic torticollis refers to involuntary dystonic movements of the head that may be associated with certain body and neck positions. The pathophysiology of dystonia is not fully known.

CASE REPORT

We report a case of torticollis that was unusual in the sense that it occurred only when the patient was lying on one side.

DISCUSSION

The cause of the cervical dystonia in this patient was unclear and the positional nature of the movements was unusual.

Active exercise for individuals with cervical dystonia: a pilot randomized controlled trial

Objective:

To investigate the feasibility and effectiveness of an active exercise program for cervical dystonia.

Design:

Pilot randomized controlled, single-blind trial of a 12-week intervention followed by a four-week follow-up period.

Setting:

Supervised physiotherapy and outcome measurement sessions were conducted in a hospital outpatient physiotherapy setting. Participants also performed exercises at home.

Subjects:

Twenty participants with idiopathic cervical dystonia were randomized into an experimental ( n = 9) or control ( n = 11) group. Two participants from the experimental group and one from the control group dropped out.

Interventions:

The experimental group undertook a semi-supervised active exercise program aimed at correcting the dystonic head position, plus relaxation. The control group performed relaxation only.

Main outcome measures:

Feasibility of the intervention was assessed by recording adherence, muscle soreness, and adverse events. The primary outcome measure was blinded analysis of the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) score.

Results:

The active exercise program was feasible and safe, with participants in the experimental group completing 84% of prescribed training sessions in the 12-week intervention period. There were no adverse events in either group, while mild muscle soreness was reported by 66% of the experimental group. There was no significant difference between groups at post-test or follow-up. The difference between groups of −1.9 (95% confidence interval (CI) –9.0–5.2) on the TWSTRS demonstrates a trend towards greater improvement for the experimental group.

Conclusion:

Active exercise for people with cervical dystonia is feasible and can be completed with good adherence and no adverse effects.

Milestones in tremor research

Tremor is one of the most frequent movement disorders and covers a wide spectrum of entities summarized in the 1998 consensus statement of the Movement Disorder Society. Essential tremor and Parkinson tremor are most common and are also the most thoroughly studied. Major progress has occurred in the clinical semiology, neuroimaging, epidemiology, and pathophysiology of tremors. Pathology and genetic research are rapidly growing fields of study. Recently described tremor entities include orthostatic tremor, dystonic tremor, cortical tremor, and thalamic tremor. Treatment research methodology has improved substantially, but few double-blind controlled trials have been published. Deep brain stimulation is the most effective treatment for most tremors but is reserved for advanced cases.

The phenomenology of the geste antagoniste in primary blepharospasm and cervical dystonia

The geste antagoniste (GA), a relatively common feature of adult-onset primary dystonia, has been systematically evaluated only in cervical dystonia, but it is still unclear whether its frequency and phenomenology differ among the various forms of focal dystonia. We analysed the frequency, phenomenology, effectiveness, and relationship of the GA with demographic/clinical features of dystonia in a representative clinical series of patients with the two most common forms of adult-onset primary dystonia, blepharospasm (BSP) and cervical dystonia (CD). Clinical data were gathered using a standardized questionnaire, which showed substantial test-retest reliability (kappa = 0.79, P < 0.00001). The frequency of GA was similar among patients with BSP (42/59, 71.2%) and patients with CD (27/32, 84.4%), and in both groups GA showed similar effectiveness in reducing dystonia. The repertoire of GA was heterogenous in both BSP and CD patients, in whom seven BSP-related and five CD-related types of GA were recorded, and a "forcible" type of GA was present in 69% of BSP patients and in 48.1% of CD patients. In our whole patient population, age at dystonia onset was significantly lower among patients reporting a GA compared to those without GA (P = 0.01). GA features shared by BSP and CD predominate over differences, suggesting common mechanisms underlying this phenomenon in the two forms of primary adult-onset dystonia.

Oromandibular dystonia and hormonal factors: twelve years follow-up of a case report

Oromandibular dystonia (OMD) is a focal neurological movement disorder characterized by involuntary sustained and often painful muscle contraction, usually producing repetitive movements or abnormal positions of the mouth, jaw and/or tongue. We report on a 30-year-old woman affected with OMD with a 12-year follow-up. Focal dystonia involved an involuntary activity of the lateral pterygoid muscles causing forceful jaw displacement in the maximal protrusive position. These episodes initially occurred during jaw function and increased up to an open-lock with bilateral pre-auricular pain. Dystonic spasms were absent during sleep and were reduced temporarily by sensory tricks. Treatment with botulinum toxin type A (BTX) was performed during three different sessions over a 1-year period. Electromyographic-guided BTX injections into the lateral pterygoid muscles were given with cannula electrodes. Botox reduced the involuntary activity of the muscles. Recurrence and exacerbation of dystonic symptoms occurred during the two pregnancies and completely disappeared immediately after both deliveries with prolonged symptom-free periods. During the last 8 years, the patient had a slight relapse of symptoms during flu attacks, periods of stress and during menses. The temporal pattern of these symptoms indicates a possible relationship between OMD and hormonal factors.

Cervical dystonia

Cervical dystonia is a common disorder with significant associated morbidity. Although limited benefit can be derived from oral pharmacologic agents, the advent of botulinum neurotoxin (BoNT) injection has provided a valuable tool in the treatment of this disorder. In order to provide effective treatment, the physician must have an intimate knowledge of the anatomy and function of the neck musculature. Novel BoNT formulations, even of the same serotype, are not equivalent and thus require careful dose titration. Formulation improvements may result in reduced immunoresistance. In patients labeled as treatment resistant to BoNT, careful electromyographic reassessment of select muscles for injection will frequently result in improved clinical benefit.

Impact of dystonia on quality of life and health in a Swedish population

OBJECTIVES

Dystonia is often disabling and disfiguring. The aim of the study was to identify factors influencing the impact of dystonia on self-reported quality of life and health.

MATERIAL AND METHODS

Members of the Swedish Dystonia Patient Association participated in a survey covering demographic variables, satisfaction with treatment, physiotherapy and physical activity. Quality of life and health were assessed by the Craniocervical Dystonia Questionnaire and the Cervical Dystonia Impact Profile, respectively. Of 378 questionnaires, 76% were analysed. Multiple linear regression analyses were performed to evaluate associations of the above variables with quality of life and health.

RESULTS

Level of physical activity and satisfaction with treatment showed the highest association with quality of life and health. No significant relationship was found between form of dystonia and quality of life.

CONCLUSIONS

The study indicates a need for health care professionals to encourage physical activity and to question dystonia patients about satisfaction with treatment. Further investigations with prospective controlled trials are necessary to evaluate the value of physiotherapy and physical activity in patients with dystonia.

Cervical dystonia: clinical and therapeutic features in 85 patients

We studied patients with cervical dystonia (CD) to determine clinical features and response to botulinum toxin A (BoNT/A). Patients were submitted to clinical, laboratory and neuroimaging evaluation. BoNT/A was injected locally in 81 patients using electromyographic guidance. Four patients who had had previous treatment were considered to be in remission. The average ages at onset of focal dystonia and segmental dystonia were greater than for generalized dystonia (p<0.0003). The severity of the abnormal head-neck movements were more severe among the patients with generalized dystonia (p<0.001). Pain in the cervical area was noted in 59 patients. It was not possible to determine the etiology of the disease in 62.3% of patients. Tardive dystonia was the most common secondary etiology. A major improvement in the motor symptoms of CD and pain was observed in patients following treatment with BoNT/A. The tardive dystonia subgroup did not respond to the treatment. Dysphagia was observed in 2.35% of the patients.

Cervical dystonia: disease profile and clinical management

Cervical dystonia, the most common focal dystonia, frequently results in cervical pain and disability as well as impairments affecting postural control. The predominant treatment for cervical dystonia is provided by physicians, and treatment can vary from pharmacological to surgical. Little literature examining more conservative approaches, such as physical therapy, exists. This article reviews the etiology and pathophysiology of the disease as well as medical and physical therapist management for people with cervical dystonia.

The management of cervical dystonia

Cervical dystonia (CD), also known as 'spasmodic torticollis', is the most common form of adult-onset focal dystonia. It is a chronic disorder for which there is no curative treatment. Proposed interventions only have a symptomatic effect that is directed at controlling the intensity of the dystonic contractions and their associated symptoms. Both serotypes of botulinum toxin (BtA and BtB) have shown efficacy for the treatment of CD, and they constitute the first-line therapy for CD. BtB constitutes the best medical treatment for secondary failures to BtA. The efficacy of all other proposed medications, including anticholinergics, should be considered unknown due to the lack of good-quality trials. This lack of evidence applies also to all physical rehabilitation treatments. Although the authors have concluded that all surgical procedures for CD should still be considered investigational, the best data supporting benefit of surgery comes from case series of selective peripheral denervation and pallidal deep brain stimulation.

My battle with spasmodic torticollis: a healing experience

The life-transforming experience of overcoming spasmodic torticollis compelled the author to write the following personal account. The author, who triumphed over this debilitating disease, is now an advocate of holistic nursing practices that motivate patients through a genuine concern for patient well-being, community, and humanity. The author describes her personal experience of grief and the grieving process; the healing effects of crying; and her selection of the complementary and alternative therapies of prayer, music, and massage that became instrumental in finding a pathway to recovery. The story has appealing implications for strategies that utilize these concepts and techniques in clinical practice.

A cognitive-behavioural approach to the management of idiopathic cervical dystonia

A case is described in which a patient with idiopathic cervical dystonia is treated successfully with cognitive-behavioural therapy. It was hypothesised that although the dystonia was organic in origin, it was exacerbated and perpetuated by catastrophic thoughts and abnormal illness beliefs, and that modification of maintaining cognitive and behavioural responses would lead to improvement. Self-report outcome measures were consistent with this hypothesis and improvements were maintained at 6-month follow-up.

Disturbed egocentric space representation in cervical dystonia

In addition to visual spatial input, vestibular and proprioceptive signals are used in judging the egocentric space. We asked whether the abnormal head posture of patients with cervical dystonia (CD) is associated with distortions of their internal spatial reference frame. The perception of subjective straight-ahead (SSA) was tested under various conditions in 28 CD patients and in matched controls. They were asked to direct a laser pointer to the position that they believed to be "straight ahead" relative to their bodies' orientation (body-centered spatial perception). Body-independent visual spatial perception was assessed with different neuropsychological tests. CD patients had a greater deviation of the subjective straight ahead, indicating body-centered visual spatial perception, than controls. No effects were seen in body-independent visual spatial perception. Patients with CD are impaired in body-centered, egocentric spatial perception, but not in body-independent, allocentric spatial perception.

Segmental dystonia induced by wearing glasses with a ribbon: an unusual case of a reverse sensory geste

Craniocervical muscles are the most frequently involved in dystonia, which can be either focal of segmental. While often experiencing an increase in dystonia with voluntary motor activity, many patients report temporary relief with geste antagoniste. We describe a patient who presented a peculiar craniocervical segmental dystonia, triggered by putting on glasses with a ribbon.

Cognitive executive function in dystonia

Dystonia is a movement disorder considered to result from basal ganglia dysfunction. The aim of this study was to investigate the functional significance of frontal hyperactivity demonstrated in dystonia in imaging studies by examining executive function and working memory, in which the prefrontal cortex is known to be involved. We assessed 10 patients with idiopathic dystonia and 12 age- and IQ-matched normal controls. All subjects completed tests of first letter, category, and alternating category word fluency, the Wisconsin Card Sorting Test, the Stroop Colour Word Naming Test, the Missing Digit Test of working memory, a test of random number generation, a test requiring generation of self-ordered random number sequences, the Paced Serial Addition Test, a test of conditional associative learning, and finger tapping and peg insertion under unimanual, bimanual, and dual task conditions. The patients with dystonia did not differ significantly from controls on any measures of executive function or working memory used other than category word fluency and the extent of decline in tapping with one hand under dual task conditions when simultaneously inserting pegs with the other hand. For this small sample, the results suggest that unlike other movement disorders associated with fronto-striatal dysfunction such as Parkinson's disease or Huntington's disease, dystonia was not associated with deficits on the tests of executive function or working memory used. A more detailed investigation of cognitive function in a larger sample of patients is required.

Post-traumatic myofascial pain of the head and neck

Post-traumatic myofascial pain describes the majority of chronic head and neck pain seen in clinical practice. If conditions such as vascular headaches, neuropathic pain, degenerative cervical joint disease, and dental pain are excluded, myofascial tissues are directly or indirectly involved in all other forms of head and neck pain. The most common of these include temporomandibular disorders, neck pain such as whiplash-associated disorder, cervicogenic headaches, and tension-type headaches. The pathophysiology of these conditions is not widely understood; however, peripheral and central mechanisms appear to play a role.

Cervical dystonia pathophysiology and treatment options

Dystonia is a syndrome of sustained involuntary muscle contractions, frequently causing twisting and repetitive movements or abnormal posturing. Cervical dystonia (CD) is a form of dystonia that involves neck muscles. However, CD is not the only cause of neck rotation. Torticollis may be caused by orthopaedic, musculofibrotic, infectious and other neurological conditions that affect the anatomy of the neck, and structural causes. It is estimated that there are between 60,000 and 90,000 patients with CD in the US. The majority of the patients present with a combination of neck rotation (rotatory torticollis or rotatocollis), flexion (anterocollis), extension (retrocollis), head tilt (laterocollis) or a lateral or sagittal shift. Neck posturing may be either tonic, clonic or tremulous, and may result in permanent and fixed contractures. Sensory tricks ('geste antagonistique') often temporarily ameliorate dystonic movements and postures. Commonly used sensory tricks by patients with CD include touching the chin, back of the head or top of the head. Patients with CD are classified according to aetiology into two groups: primary CD (idiopathic--may be genetic or sporadic) or secondary CD (symptomatic). Patients with primary CD have no evidence by history, physical examination or laboratory studies (except primary dystonia gene) of any secondary cause for the dystonic symptoms. CD is a part of either generalised or focal dystonic syndrome which may have a genetic basis, with an identifiable genetic association. Secondary or symptomatic CD may be caused by central or peripheral trauma, exposure to dopamine receptor antagonists (tardive), neurodegenerative disease, and other conditions associated with abnormal functioning of the basal ganglia. In the majority of patients with CD, the aetiology is not identifiable and the disorder is often classified as primary. Unless the aetiological investigation reveals a specific therapeutic intervention, therapy for CD is symptomatic. It includes supportive therapy and counselling, physical therapy, pharmacotherapy, chemodenervation [botulinum toxin (BTX), phenol, alcohol], and central and peripheral surgical therapy. The most widely used and accepted therapy for CD is local intramuscular injections of BTX-type A. Currently, both BTX type A and type B are commercially available, and type F has undergone testing. Pharmacotherapy, including anticholinergics, dopaminergic depleting and blocking agents, and other muscle relaxants can be used alone or in combination with other therapeutic interventions. Surgery is usually reserved for patients with CD in whom other forms of treatment have failed.