Cervical Dystonia - Ideas for PTs

As a nice follow up to last month's post, we thought we'd put together a little resource for physical therapists who work with patients with dystonia.  Dystonia is a difficult diagnosis to treat and requires such a broad approach.  Traditional PT has not been shown to benefit those with dystonia.  And the more Julie and I learn, the more we realize this, so we thought it would be nice to put together some resources for physical therapists.  Today's blog includes a treatment approach and ideas for working with patients with cervical dystonia.  It was adapted from the Sensorimotor learning article (actually an article for focal hand dystonia, but with many relevant concepts) by Byl, Archer, McKenzie, 2008 and from our recent course "Sensorimotor Processing Dysfunction and Movement Dysfunction" presented by Byl, McKenzie, and Merzenich in July 2013.  I think it's a nice little jumping off point for a therapist to work with this incredibly challenging diagnosis. Please share your successes with any other treatments!

Objectives: 

·       Retrain the brain to recover effective and efficient performance by integrating the principles of neuroplasticity, healthy biomechanics, good postural alignment, minimal stress/anxiety, and positive physical and emotional feedback.

·       Get rid of the noise – quiet excessive sensory and motor firing

·       Improve accuracy of sensory discrimination

o   All sensory, including auditory and vestibular

·       Inhibit involuntary co-contractions of antagonists with the contraction of agonists

·       Improve selectivity, latency and amplitude of sensory inputs and motor outputs

o   Recruit the right neurons in movement

·       Enhance the ability to turn off muscle contractions once engaged in firing

Steps:

1)    Must have full commitment

a.     Must be willing to do repetitive, learning based training at home and at work

2)    Encourage positive thinking about recovery

3)    Intervention Options:

a.     Regular exercise, balanced diet, reduce stress

b.     Decrease muscle tension – good posture, regular massage, AROM, wear cervical collar if helpful (esp when driving), strengthen weak muscles and stabilizers

c.     Botox (has shown benefit for 17 years without problems; no longer studies completed)

d.     DBS in severe cases

e.     Retrain CNS to restore normal postural righting through improved sensory, vestibular and proprioceptive processing matched with voluntary control of head re-positioning

                                               i.     Modify sensory inputs to get better motor outputs – cervical dystonia may result from repetitive aberrant postural righting

f.       Improve sensory input and quite over-activity with TENS or inhibitory taping over the over-active muscle

g.      Yoga, tai chi, Feldenkrais to improve balance, control, postural awareness and reduce stress

4)    Plasticity principles (educate patients on these):

a.      Attend to activities to involve the cortex – must use mindfulness

b.     Have adequate but not excessive repetitions

c.      Make training intense

                                               i.     Do in the am and pm plus fitness exercises 6 hours per week.  Avoid lifting heavy weights that strain the neck, choose cardio activities like NuStep or bike.

                                              ii.     Must have neck in normal position more than abnormal position

d.     Vary training sequence

e.      Restore ability to right the head progressively against gravity – start with partial sitting, progress to full sitting, then standing.  Slow progression of difficulty

f.       Be specific

g.      Make learning fun and salient

h.     Space practice over time (8-12 weeks)

i.       Reinforce learning with feedback/accuracy

j.       Strengthen learning with interference/surprise

5)    Other Training Considerations

a.      Restore ability to come from supine to sit and sit to stand without using neck muscles

b.     Teach to breathe diaphragmatically (not from neck)

c.      Retrain ability to voluntarily turn the head in both directions, slowly and quickly in prone, supine, and sitting

d.     Restore ability to tuck chin (open OA joint) and turn head in both directions to drive

e.      Maintain neutral posture while working on a computer

f.       Help with driving by using mirrors in car or cameras to help look where they can’t

g.      If the patient is having jaw problems, may need to see dentist for mouthpiece to relax the jaw at night and begin jaw exercises with PT

h.     If affected, work on improving speech quality and have the patient listen to speech with earphones to copy the speech

Progressive Phases (adapted for cervical dystonia; will become integrated as training progresses):

1)    Phase 1:  Use imagery and mental practice to stop abnormal movements, quiet the nervous system, and restore for normal postural righting.  Use tricks and strategies to stop abnormal movements as much as possible.  Address biomechanical issues including posture, increase aerobic exercise and fitness level, eat balanced diet, drink water, decrease caffeine intake.  Person should think constantly about gravity and normal righting.

2)    Phase 2: Improve sensory input: vestibular, sensorimotor and integrative postural retraining (especially with eyes closed).

3)    Phase 3:  Practice graded movements using different body positions, error, mirror and/or biofeedback to inhibit unwanted movements.

4)    Phase 4:  Maintenance and daily practice

Treatment Strategies

·       Stop abnormal movements by quieting the nervous system

·       Quiet the nervous system by teaching the patient to move the head more slowly and smoothly

·       Quiet the nervous system by having the patient slip his/her arms inside a T-shirt and

o   Rocking in a rocking chair

o   Swinging on a swing

o   Swinging in a hammock

·       Incorporate sensory tricks to achieve normal

·       Use mirror and mental imagery to facilitate normal movements and restore normal image of self with good alignment

o   Try 2 mirrors at 90-degree angle to right the head.  Gives positive feedback and helps re-map “normal” in the brain

·       Use a laser pointer on the head.   Instruct the patient to:

o   Keep head still for 10-20 seconds

o   Turn head smoothly in both directions

o   Look up and down smoothly

o   Side bend head

o   Squat and lunge keeping head straight

o   Walk forward and backward keeping head still

o   Stand on unstable surface keeping head still

·       Improve cervical alignment

o   Stabilization exercises for home, such as thinking man’s posture and stabilize ant/post then rotation R/L

o   If appropriate instruct in McKenzie techniques to use repetitive movements to facilitate righting and decrease pain

o   Carefully assess response to manual traction – can make things worse rather than better

·       Improve posture

o   Strengthen core and lower abdominals

o   Stabilize the neck with taping or cervical collar

o   Have patient request reminders from others to stand tall and keep neck aligned

o   Strengthen neck with specific isometric exercises

·       Controlled head movements.  Ask the patient to:

o   Lie in supine then in sitting, patient points one finger out in front.  Eyes and head follow the finger in large circles

o   Hold a ball in both hands and move arms in large circles first R then L keeping eyes on the ball

o   Try in different positions: lying on back, sitting on chair, standing on stable and unstable surfaces

·       Head control and righting

o   Patient looks into mirror, PT or patient provides gentle guidance to orient head

§  Patient turns eyes slowly L and R

§  Patient turns head slowly L and R (may be helpful to have them follow their or your finger)

·       Perform activities that inhibit the dystonia.   Determine which may help:

o   Bending over with arms over head

o   Sitting and bouncing on a ball

o   Propping on side

o   Prone, head down/up gravity

o   BWSTT

o   Rolling

o   Inversion traction

o   Gently shaking the table they are on to quiet the nervous system

o   Biofeedback

o   Guided imagery

o   Follow ball with eyes

·       Improve VOR (Vestibulo-occular Reflex) and OKN (Optokinetic Nystagmus) reflex responses

o   Have patient practice reading out loud with head turning or nodding (slow and fast)

o   Ask the patient to try reading in different positions:

§  Sit and read a book

§  Lie supine under glass table with a book turned down

§  Stand or jog in place and read works on a wall

§  Sit and read out lout with the book moving back and forth/ up and down

§  Shake the bed and have the patient read

·       Feedback/Stimulation

o   Electrical stimulation + active contraction of muscles that turn and rotate neck opposite direction of the dystonia

o   “EyeToy” from Sony Kinect

o   Have patient rent a biofeedback machine to quiet over active muscles and activate underactive muscles; avoid co-contraction

·       Improve Balance

o   Persons with cervical dystonia demonstrate abnormal posturography

o   Challenge the limits of stability

o   Dynamic walking with quick starting/stopping

o   Balance on unstable surfaces

o   Walking around house and other environments with eyes closed (can be part of home program)

§  Put ankle or trunk weights on to increase unconscious proprioception

o   Standing in progressively challenging conditions with light finger touch (stable, unstable surfaces, feet together, tandem, SLS, stepping in place).  Try to take fingers off surface for short periods of time and keep balance.  (can be part of home program)

§  Eyes open

§  Reading

§  Eyes open, head turns, counting

§  Distorting glasses

§  Eyes closed

§  Eyes closed head turns

o   Sitting on theraball (can be part of home program)

§  Bounce to encourage righting of trunk and head

§  Balance on ball in good posture lifting one leg

§  Balance on ball in good posture, lift one leg, and put arms out in front or side

o   Lying on stomach over large ball (can be part of home program)

§  Balance and lift both legs

§  Balance and lift both arms

§  Balance and bring head to neutral off ball

§  Balance and lift arms, legs and head

o   Walking/jogging on BWST while participating in activities that require

§  Attention

§  Repetition

§  Progression of difficulty

§  Multi-tasking

Considerations and Summary

·       Risk Factors for dystonia

o   High achiever, perfectionist, “Type A”, compulsive personalities

o   Poor vestibular righting responses to gravity

o   History of poor posture

o   Trauma (could be physical or emotional/psychological) or MVA

·       In case series:

o   Patients responded positively to a complex re-eduational program

o   Retraining postural righting and balance was associated with improved head control

o   In severe cases that require DBS, retraining is still necessary after surgery

o   More evidence is needed – no RCTs – but difficult due to the high variability

·       Cervical dystonia is a multifactorial disorder and all risk factors need to be considered.  A team approach including a Neurologist with a specialization in Movement Disorders is ideal.

·       Patient buy-in is critical: they must be 100% committed to the program

·       Patients who receive botulinum toxin will also benefit from PT though are often not referred

·       Mindfulness training improves results

·       There is no cure but symptoms can be managed enough for a person to return to normal activities and lead an enjoyable life