1
|
Mohamed AA, Faragalla S, Khan A, Flynn G, Rainone G, Johansen PM, Lucke-Wold B. Neurosurgical and pharmacological management of dystonia. World J Psychiatry 2024; 14:624-634. [PMID: 38808085 PMCID: PMC11129150 DOI: 10.5498/wjp.v14.i5.624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 04/20/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024] Open
Abstract
Dystonia characterizes a group of neurological movement disorders characterized by abnormal muscle movements, often with repetitive or sustained contraction resulting in abnormal posturing. Different types of dystonia present based on the affected body regions and play a prominent role in determining the potential efficacy of a given intervention. For most patients afflicted with these disorders, an exact cause is rarely identified, so treatment mainly focuses on symptomatic alleviation. Pharmacological agents, such as oral anticholinergic administration and botulinum toxin injection, play a major role in the initial treatment of patients. In more severe and/or refractory cases, focal areas for neurosurgical intervention are identified and targeted to improve quality of life. Deep brain stimulation (DBS) targets these anatomical locations to minimize dystonia symptoms. Surgical ablation procedures and peripheral denervation surgeries also offer potential treatment to patients who do not respond to DBS. These management options grant providers and patients the ability to weigh the benefits and risks for each individual patient profile. This review article explores these pharmacological and neurosurgical management modalities for dystonia, providing a comprehensive assessment of each of their benefits and shortcomings.
Collapse
Affiliation(s)
- Ali Ahmed Mohamed
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Steven Faragalla
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Asad Khan
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Garrett Flynn
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Gersham Rainone
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33606, United States
| | - Phillip Mitchell Johansen
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33606, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, United States
| |
Collapse
|
2
|
Liu B, Xu J, Yang H, Yu X, Mao Z. PAllidal versus SubThalamic deep brain Stimulation for Cervical Dystonia (PASTS-CD): study protocol for a multicentre randomised controlled trial. BMJ Open 2023; 13:e073425. [PMID: 37832982 PMCID: PMC10582967 DOI: 10.1136/bmjopen-2023-073425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION Deep brain stimulation (DBS) has been validated as a safe and effective treatment for refractory cervical dystonia (CD). Globus pallidus internus (GPi) and subthalamic nucleus (STN) are the two main stimulating targets. However, there has been no prospective study to clarify which target is the better DBS candidate for CD. The objective of this trial is to compare directly the efficacy and safety of GPi-DBS and STN-DBS, thereby instructing the selection of DBS target in clinical practice. METHODS AND ANALYSIS This multicentre, prospective, randomised, controlled study plans to enrol 98 refractory CD patients. Eligible CD patients will be randomly allocated to GPi-DBS group or STN-DBS group, with the DBS electrodes implanted into the posteroventral portion of GPi or the dorsolateral portion of STN, respectively. The primary outcome will be the improvement of symptomatic severity, measured by the changes in the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) severity subscale and the Tsui scale at 3 months, 6 months and 12 months after surgery. The secondary outcomes include the improvement of the TWSTRS-disability subscale, TWSTRS-pain subscale, quality of life, mental and cognitive condition, as well as the differences in stimulation parameters and adverse effects. In addition, this study intends to identify certain predictors of DBS efficacy for CD. ETHICS AND DISSEMINATION The trial has been approved by the Medical Ethics Committee of Chinese PLA General Hospital (S2022-613-01). The results of this study will be published in international peer-reviewed journals and shared in professional medical conferences. TRIAL REGISTRATION NUMBER NCT05715138.
Collapse
Affiliation(s)
- Bin Liu
- Medical School, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Junpeng Xu
- Medical School, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Haonan Yang
- Medical School, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xinguang Yu
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhiqi Mao
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
3
|
Khanom AA, Franceschini PR, Lane S, Osman-Farah J, Macerollo A. Bilateral globus pallidus internus (GPi) deep brain stimulation for cervical dystonia: Effects on motor and non-motor symptoms within 5 years follow. J Neurol Sci 2023; 452:120752. [PMID: 37542824 DOI: 10.1016/j.jns.2023.120752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/04/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Cervical Dystonia ("CD") is a movement disorder characterised by sustained muscle contractions in the neck, causing involuntary posturing. Deep brain stimulation ("DBS") of the globus pallidal internus (GPi) is advanced treatment for pharmaco-refractory patients. As CD is a rare disease, cohort studies are often limited to patients of heterogenous disease profile, small sample size or short follow-up. This study firstly aimed to measure the efficacy of GPi-DBS on motor and non-motor symptoms of CD. A secondary aim was to evaluate if clinical factors - such as age, disease duration and baseline disease severity - influence variability of motor outcomes. METHODS 37 idiopathic CD patients were recruited from movement disorders clinics at The Walton NHS Foundation Trust, Liverpool, UK. Patients were assessed pre-operatively, and 1 year, 3 years and 5 years post-operatively with the following clinical scales: Toronto Western Spasmodic Torticollis Rating Scale ("TWSTRS"), Hospital Anxiety and Depression Scale and EuroQuol-5D. RESULTS GPI-DBS significantly improved overall TWSTRS scores by 57% from baseline to 5Y FU (p < 0.001). It also significantly improved TWSTRS severity, disability, and pain sub-scores by 72%, 59% and 46% respectively. We did not find a significant improvement in mood or quality of life scores at 5 years. Similarly, clinical factors at baseline did not correlate with variability in motor outcome. CONCLUSION We concluded that GPi-DBS is an effective treatment for motor symptoms and pain in CD. There was limited effect on mood and QoL, and no clinical predictive factors of outcome were identified.
Collapse
Affiliation(s)
- Anjum Aarifa Khanom
- University of Liverpool Medical School, Liverpool, UK; The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK
| | - Paulo Roberto Franceschini
- The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK; Functional Neurosurgery Department, Universidade de Caxias do Sul, Brazil
| | - Steven Lane
- Institute of Data Health Sciences, University of Liverpool, UK
| | - Jibril Osman-Farah
- The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK
| | - Antonella Macerollo
- The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK; Institute of Systems, Molecular and Integrative Biology, University of Liverpool, UK.
| |
Collapse
|
4
|
Opara J. Is There a Standard Rehabilitation Procedure in Cervical Dystonia? REHABILITACJA MEDYCZNA 2023. [DOI: 10.5604/01.3001.0016.3419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Introduction: Idiopathic cervical dystonia, also known as spasmodic torticollis, is the most common form of focal dystonia in adults. Cervical dystonia usually appears between the ages of 30 and 50, twice as often in women, and is characterised by uncontrollable painful contractions of the sternocleidomastoid muscle, which results in misalignment of the head and shoulder. Over time, the disease becomes very burdensome for the patient and reduces his/her independence and quality of life; falls happen.Aim: The aim of the article is to present the current state of knowledge on comprehensive rehabilitation in cervical dystonia. Data on the prevalence, symptoms, diagnosis, clinical assessment, pharmacological treatment (including the most commonly used botulinum toxin), neurosurgical treatment and comprehensive rehabilitation are presented.Methods: The applied methods was a narrative critical review of scientific reports.Results: Out of several hundred publications, works worthy of particular attention were selected. In them, are described of conducting exercises, the main goal of which is to stretch and relax the dystonic muscles while strengthening the antagonistic muscles and correcting the position of the head. The selected authors used manual therapy, exercises at the patient's home, EMG biofeedback, magnetic stimulation of the cerebellum, vibration of the neck muscles, functional electrostimulation (FES) of antagonistic muscles, mobilisation of the cervical spine, postural exercises, isometric exercises, muscle relaxation, the PNF method, relaxation training, balance exercises, coordination, corrective exercises, massage, relaxation exercises, stretching and kinesiotaping.Conclusions: The variety of disease forms (10 head positioning patterns are described) and different severity of symptoms make it impossible to draw up a scheme of rehabilitation. In each case, rehabilitation must be tailored individually, and the physiotherapist taking care of the patient should have extensive experience. Physiotherapy can alleviate the disability caused by dystonia, however, due to the many non-motor symptoms, a holistic approach to the patient should also be kept in mind.
Collapse
Affiliation(s)
- Józef Opara
- Faculty of Physiotherapy, Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| |
Collapse
|
5
|
Alkarras M, Nabeeh A, El Molla S, El Gayar A, Fayed ZY, Ghany WA, Raslan AM. Evaluation of outcome of different neurosurgical modalities in management of cervical dystonia. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022. [DOI: 10.1186/s41983-022-00493-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Abstract
Background
Cervical dystonia is the most common form of focal dystonia and is managed by multiple modalities including repeated botulinum toxin injections, in addition to medical treatment with anticholinergics, muscle relaxants, and physiotherapy. However, surgical interventions could be beneficial in otherwise refractory patients. This study aims to report our experience in the neurosurgical management of cervical dystonia and evaluate patient outcomes using reliable outcome scores for the assessment of patients with cervical dystonia and possible complications. This case series study was conducted on 19 patients with cervical dystonia of different etiologies who underwent surgical management [ten patients underwent selective peripheral denervation, five patients underwent pallidotomy, and four patients underwent bilateral globus pallidus internus (GPi) deep brain stimulation (DBS)] in the period between July 2018 and June 2021 at Ain Shams University Hospitals, Cairo, Egypt. With the assessment of surgical outcomes using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) and the Tsui scale 6 months postoperatively.
Results
Surgical management of patients with cervical dystonia of either primary or secondary etiology was associated with significant improvement in head and neck postures after 6 months without major complications associated with the different surgical procedures. The mean improvement in total TWSTRS and Tsui scores were 51.2% and 64.8%, respectively, compared with preoperative scores, while the mean improvement in the TWSTRS subscales (severity, disability, and pain) were 40.2%, 66.9%, and 58.3%, respectively.
Conclusion
Cervical dystonia patients in whom non-surgical options have failed to alleviate their symptoms can be managed surgically leading to significant improvements with minimal adverse effects. However, surgical treatment should be tailored according to several factors including but not limited to the etiology, pattern of dystonic activity, and comorbidities. Therefore, management should be tailored to achieve long-term improvement with minimal risk of complications.
Collapse
|
6
|
Zuckerman SL, Tang AR, Richard KE, Grisham CJ, Kuhn AW, Bonfield CM, Yengo-Kahn AM. The behavioral, psychological, and social impacts of team sports: a systematic review and meta-analysis. PHYSICIAN SPORTSMED 2021; 49:246-261. [PMID: 33196337 DOI: 10.1080/00913847.2020.1850152] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives: To assess the association between team sport participation and behavioral, psychological, and social health outcomes in young athletes.Methods: A systematic review and meta-analysis were undertaken to identify studies published between 01/01/1950-05/01/2020 investigating the association between team sport participation and health outcomes in young athletes (<25 years). Included studies compared team sport participants to controls or themselves, assessed health outcomes, and had a sample size >50. Prospective and retrospective studies were included; non-primary literature was excluded. Health outcomes were categorized as: 1) behavioral, 2) psychological, or 3) social. Data were extracted to form 2 × 2 tables for each study to calculate odds ratios (OR) and 95% confidence intervals (CI).Results: Of 371 queried articles, 34 studies from 10 countries across 4 continents were included, with 9 reporting homogenous outcomes for meta-analysis.Behavioral: Fifteen studies evaluated behavioral health outcomes of alcohol and/or drug use, fitness, and diet. Quantitatively, team sport participation was found to decrease rates of cigarette/tobacco use across 5 studies (OR 0.72, 95% CI 0.69-0.76) and alcohol/drug use across 7 studies (OR 0.73, 95% CI 0.69-0.77). Qualitatively, 12/15 (80%) of studies confirmed improved behavioral health outcomes with team sport participation.Psychological: Nineteen studies evaluated psychological health outcomes including anorexia, anxiety, depression, self-esteem, and suicidal ideation. Quantitatively, team sport participation was associated with decreased depression/anxiety rates across 5 studies (OR 0.59, 95%CI 0.54-0.64). Qualitatively, 14/19 (74%) of studies confirmed improved psychological health.Social: Ten studies evaluated social health outcomes including academic performance, commitment, psychosocial health, social behavior/identity, and delinquency/high-risk activity. Qualitatively, 7/10 (70%) of studies confirmed improved social health outcomes with team sport participation.Conclusion: Team sport participation was associated with decreased odds of smoking/tobacco use, alcohol/drug use, and depression/anxiety. Though few studies mentioned potential negative effects of team sport participation, the majority reported improved behavioral, psychological, and social health outcomes in youth athletes worldwide.
Collapse
Affiliation(s)
- Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan R Tang
- School of Medicine, Vanderbilt University, Nashville, TN, USA
| | | | | | - Andrew W Kuhn
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Christopher M Bonfield
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron M Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
7
|
Aljuboori Z, Ball T, Nauta H. Modified McKenzie procedure for the treatment of fixed painful torticollis. NEUROSURGICAL FOCUS: VIDEO 2020; 3:V10. [PMID: 36285258 PMCID: PMC9542593 DOI: 10.3171/2020.5.focvid205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/28/2020] [Indexed: 12/05/2022]
Abstract
Spasmodic torticollis is characterized by involuntary movements of the neck muscles. In this video, the authors present the case of a 48-year-old man with painful right-sided rotational torticollis with contributions from both the suboccipital and the left sternocleidomastoid (SCM) muscles. He underwent a suboccipital craniectomy and C1–2 laminectomy with selective denervation of bilateral suboccipital and left-sided SCM muscles (modified McKenzie procedure). At the 2-week follow-up, he showed significant improvement and was able to rotate his neck about 70° toward the midline. Surgical treatment of spasmodic torticollis focuses on interrupting the motor pathway responsible for head turning. The modified McKenzie procedure is valuable, especially when other therapies fail. The video can be found here: https://youtu.be/TK-WybKnGJM
Collapse
|
8
|
Popov VA, Tomskiy AA, Gamaleya AA, Sedov AS. [Historical view on the pathogenesis and surgical treatment of cervical dystonia]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:128-133. [PMID: 32790987 DOI: 10.17116/jnevro2020120071128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the past few decades, approaches to surgical treatment of dystonia passed through paradigmatic shift. Intradural upper cervical anterior rhizotomy was replaced by selective peripheral denervation with lesser spectrum of side-effects. Such techniques as microvascular decompression of accessory nerve or spinal cord stimulation for cervical dystonia were abandoned due to lack of proven efficacy. Introducing globus pallidus interna (GPi) DBS in 1990's to treat all types of dystonia, including cervical dystonia, was a fundamental factor. With the growing body of knowledge on the pathophysiology of dystonia, GPi DBS appears to be the most expedient, effective and safe method with limited indications to peripheral destructive procedures.
Collapse
Affiliation(s)
- V A Popov
- Burdenko Neurosurgical Institute, Moscow, Russia.,Human Cell Neurophysiology Laboritory, N.N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow, Russia
| | - A A Tomskiy
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A A Gamaleya
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A S Sedov
- Human Cell Neurophysiology Laboritory, N.N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow, Russia
| |
Collapse
|
9
|
Macerollo A, Sajin V, Bonello M, Barghava D, Alusi SH, Eldridge PR, Osman-Farah J. Deep brain stimulation in dystonia: State of art and future directions. J Neurosci Methods 2020; 340:108750. [DOI: 10.1016/j.jneumeth.2020.108750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 01/03/2023]
|
10
|
Abstract
The dystonias are a large and heterogenous group of disorders characterized by excessive muscle contractions leading to abnormal postures and/or repetitive movements. Their clinical manifestations vary widely, and there are many potential causes. Despite the heterogeneity, helpful treatments are available for the vast majority of patients. Symptom-based therapies include oral medications, botulinum toxins, and surgical interventions. For some subtypes of dystonia, specific mechanism-based treatments are available. Advances in understanding the biological basis for many types of dystonia have led to numerous recent clinical trials, so additional treatments are likely to become available in the very near future.
Collapse
|
11
|
Tsuboi T, Wong JK, Almeida L, Hess CW, Wagle Shukla A, Foote KD, Okun MS, Ramirez-Zamora A. A pooled meta-analysis of GPi and STN deep brain stimulation outcomes for cervical dystonia. J Neurol 2020; 267:1278-1290. [DOI: 10.1007/s00415-020-09703-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 12/24/2022]
|
12
|
Jeong Y, Wagner MA, Ploutz-Snyder RJ, Holden JE. Pain condition and sex differences in the descending noradrenergic system following lateral hypothalamic stimulation. IBRO Rep 2020; 8:11-17. [PMID: 31890982 PMCID: PMC6931064 DOI: 10.1016/j.ibror.2019.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/11/2019] [Indexed: 01/28/2023] Open
Abstract
LH stimulation produced pronociceptive and antinociceptive effects from alpha-adrenoceptors in naïve male and female rats. LH stimulation produced pronociceptive and antinociceptive effects from alpha-adrenoceptors in male CCI rats. LH stimulation produced alpha-adrenoceptor-mediated pronociception, but not antinociception in female CCI rats.
The lateral hypothalamus (LH) is known to modulate nociception via the descending noradrenergic system in acute nociception, but less is known about its role in neuropathic pain states. In naïve females, LH stimulation produces opposing effects of α-adrenoceptors, with α2-adrenoceptors mediating antinociception, while pronociceptive α1-adrenoceptors attenuate the effect. Whether this opposing response is seen in neuropathic conditions or in naïve males is unknown. We used a mixed factorial design to compare male and female rats with chronic constriction injury (CCI) to naïve rats, measured by Total Paw Withdrawal (TPW) responses to a thermal stimulus. Rats received one of three doses of carbachol to stimulate the LH followed by intrathecal injection of either an α1- or an α2-adrenoceptor antagonist (WB4101 or yohimbine, resp.) or saline for control. Overall, naïve rats showed a more pronounced opposing alpha-adrenergic response than CCI rats (p < 0.04). Naïve male and female rats demonstrated antinociception following α1-adrenoceptor blockade and hyperalgesia following α2-adrenoceptor blockade. Male CCI rats also showed dose dependent effects from either WB4101 or yohimbine (p < 0.05), while female CCI rats had significant antinociception from WB4101 (p < 0.05), but no effect from yohimbine. These results support the idea that peripheral nerve damage differentially alters the descending noradrenergic modulatory system in male and female rats, and notably, that female CCI rats do not show antinociception from descending noradrenergic input. These findings are suggestive that clinical therapies that recruit the descending noradrenergic system may require a different approach based on patient gender.
Collapse
Affiliation(s)
- Younhee Jeong
- College of Nursing Science, Kyung Hee University, 26 Kyunghee-daero, Dongdaemun-gu, Seoul 130-701, Republic of Korea
| | - Monica A Wagner
- The University of Pittsburgh School of Nursing, 3500 Victoria Street, Victoria Bldg, Pittsburgh, PA 15261, United States
| | - Robert J Ploutz-Snyder
- The University of Michigan School of Nursing, 400 N. Ingalls Bldg, Ann Arbor, MI 48109-5482, United States
| | - Janean E Holden
- The University of Michigan School of Nursing, 400 N. Ingalls Bldg, Ann Arbor, MI 48109-5482, United States
| |
Collapse
|
13
|
Wojtasiewicz T, Butala A, Anderson WS. Dystonia. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|