Physiotherapy in cervical dystonia: Six experimental single-case studies

Longitudinal predictors of health-related quality of life in isolated dystonia

OBJECTIVE

To determine longitudinal predictors of health-related quality of life (HR-QoL) in an international multicenter cohort of patients with isolated dystonia.

METHODS

Out of 603 dystonia patients prospectively enrolled in the Natural History Dystonia Coalition study, 155 were assessed three times within 2 years for HR-QoL, symptoms of depression, generalized anxiety disorder (GAD), and social anxiety disorder (SAD), as well as dystonia severity and dystonic tremor. In addition, the impact of botulinum neurotoxin (BoNT) injections on HR-QoL was evaluated after 1 year.

RESULTS

Depressive symptoms at baseline predicted lower HR-QoL on all subscales after 2 years (all p ≤ 0.001). Higher GAD scores at baseline predicted lower HR-QoL related to general health, pain and emotional well-being, whereas higher SAD scores predicted higher pain-related QoL after 2 years (all p ≤ 0.006). Dystonia severity at baseline predicted social functioning (p = 0.002). Neither dystonic tremor, age, or sex predicted HR-QoL at 2 years. Two latent categories were revealed across the three-time points: Category 1 with higher total HR-QoL scores (mean HR-QoL = 74.4% ± 16.1), susceptible to symptoms of depression and SAD, and Category 2 with lower total HR-QoL scores (mean HR-QoL = 45.5% ± 17.6), susceptible to symptoms of GAD. HR-QoL improved over the course of 1 year irrespective of the use of BoNT.

CONCLUSION

The longitudinal impact of psychiatric symptoms on HR-QoL emphasizes the importance of incorporating mental health treatment, in particular also the therapy of anxiety disorders, into treatment regimens for dystonia.

The effectiveness of physiotherapy for patients with isolated cervical dystonia: an updated systematic review and meta-analysis

BACKGROUND

Cervical dystonia is a movement disorder typically characterized by a patterned and twisting movement of sustained or intermittent muscle contractions. Recently, new clinical trials are emerging, highlighting the potential benefit of physiotherapy (PT) on disease outcomes. Thus, the objective of this review is to update the effectiveness of PT on cervical dystonia disease outcomes and subsequently perform a meta-analysis.

METHODS

Interventional studies published in English with adult patients with isolated cervical dystonia following a physiotherapy program were included. Relevant articles were searched in PubMed (MEDLINE), Web of Science, and Scopus. Cochrane and Joanna Briggs Institute risk of bias checklists were used for quality reporting. Meta-analysis was done using Review Manager 5.3 statistical software and a pooled mean difference for pain was presented.

RESULTS

Fourteen articles were included in the review and two articles were included in the meta-analysis. The meta-analysis revealed that PT intervention had a significant effect on pain reduction scale (-5.00, 95% CI -6.26, -3.74) when used as an additional therapy with botulinum toxin (BoNT) injection. Additionally, findings indicate a possible positive effect of PT disease severity, disability, and quality of life.

CONCLUSIONS

Physiotherapy in addition to BoNT is recommended to decrease pain. The findings suggest a reduction of disease severity, disability, and improvement in quality of life. The variety in the type and duration of PT interventions did not allow a clear recommendation of a specific type of PT.

Early Intervention Eye Movement Desensitization and Reprocessing Following Major Musculoskeletal Trauma: How Soon Is Too Soon?

Major trauma centers have increased survival following serious physical injury, resulting in increased demand for specialist multidisciplinary rehabilitation. We aimed to explore the feasibility of using early intervention eye movement desensitization and reprocessing (EMDR) therapy in an acute inpatient setting, using a non-concurrent, multiple-baseline, pre-post test case-series design. Unfortunately, no patients were recruited. This paper sets out the challenges and reflections of setting up a psychological intervention study in this setting and provides suggestions for further research.

Best Practices in the Clinical Management of Progressive Supranuclear Palsy and Corticobasal Syndrome: A Consensus Statement of the CurePSP Centers of Care

Progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS; the most common phenotype of corticobasal degeneration) are tauopathies with a relentless course, usually starting in the mid-60s and leading to death after an average of 7 years. There is as yet no specific or disease-modifying treatment. Clinical deficits in PSP are numerous, involve the entire neuraxis, and present as several discrete phenotypes. They center on rigidity, bradykinesia, postural instability, gait freezing, supranuclear ocular motor impairment, dysarthria, dysphagia, incontinence, sleep disorders, frontal cognitive dysfunction, and a variety of behavioral changes. CBS presents with prominent and usually asymmetric dystonia, apraxia, myoclonus, pyramidal signs, and cortical sensory loss. The symptoms and deficits of PSP and CBS are amenable to a variety of treatment strategies but most physicians, including many neurologists, are reluctant to care for patients with these conditions because of unfamiliarity with their multiplicity of interacting symptoms and deficits. CurePSP, the organization devoted to support, research, and education for PSP and CBS, created its CurePSP Centers of Care network in North America in 2017 to improve patient access to clinical expertise and develop collaborations. The directors of the 25 centers have created this consensus document outlining best practices in the management of PSP and CBS. They formed a writing committee for each of 12 sub-topics. A 4-member Steering Committee collated and edited the contributions. The result was returned to the entire cohort of authors for further comments, which were considered for incorporation by the Steering Committee. The authors hope that this publication will serve as a convenient guide for all clinicians caring for patients with PSP and CBS and that it will improve care for patients with these devastating but manageable disorders.

Quality of life in idiopathic dystonia: a systematic review

OBJECTIVE

Dystonia is characterised by sustained muscular contractions frequently producing repetitive, twisting and patterned movements. The primary aim of this systematic review was to establish how quality of life (QoL) is affected in idiopathic focal, multifocal and segmental dystonia. This review aimed to evaluate variations in QoL between different subtypes of dystonia, identify the determinants of QoL and assess the effects of different treatments on QoL.

METHODOLOGY

A systematic computer-based literature search was conducted using the PubMed database to search for papers on QoL in idiopathic focal, segmental, multifocal and generalized dystonia. We identified 75 studies meeting our inclusion criteria. Information was extracted regarding prevalence, demographics and response to treatment where indicated.

RESULTS

This review revealed QoL to be a significant yet often overlooked issue in idiopathic dystonia. Data consistently showed that dystonia has a negative effect on QoL in patients compared to healthy controls, when measured using disease-specific and generic QoL measures. The majority of studies (n = 25) involved patients with cervical dystonia, followed by benign-essential blepharospasm (n = 10). Along with the beneficial effect to the dystonia symptoms, treatment using Botulinum Toxin and Deep Brain Stimulation is also effective in improving overall QoL across the majority of subtypes.

CONCLUSION

The findings demonstrate that patients' QoL should routinely be assessed and monitored, as this may affect subsequent management. Further research will allow for more robust management of factors contributing to impaired QoL, aside from the physical defects found in dystonia.

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.

Pilot Study of a Device to Induce the Hanger Reflex in Patients with Cervical Dystonia

The hanger reflex (HR) is an involuntary head rotation that occurs in response to a clothes hanger encircling the head and compressing the unilateral fronto-temporal area. Here, we developed an elliptical device to induce the HR and examined its utility for the treatment of cervical dystonia (CD). The study included 19 patients with rotational-type CD. The device was applied to each subject’s head for at least 30 min/day for 3 months. Severity scores on part 1 of the Toronto Western Spasmodic Torticollis Rating Scale were evaluated at baseline and after the 3-month trial. Mean scores without and with the device were significantly different both at baseline (16.6 vs. 14.7, respectively; P < 0.05) and after the trial (14.9 vs. 13.6, respectively; P < 0.05). This preliminary trial suggests that our device can improve abnormal head rotation in patients with CD.

Systematic Review of Rehabilitation in Focal Dystonias: Classification and Recommendations

Background

Rehabilitation interventions are rarely utilized as an alternative or adjunct therapy for focal dystonias. Reasons for limited utilization are unknown, but lack of conclusive evidence of effectiveness is likely a crucial factor.

Methods and Findings

The purpose of this systematic review was to determine the level of evidence for rehabilitation interventions in focal dystonias. Rehabilitation interventions were classified based upon the underlying theoretical basis of different approaches, and the strength of evidence for each category was evaluated to identify gaps in the field. Prospective studies using rehabilitation methods in cervical, hand, and foot dystonia were reviewed. The key elements of treatments tested were identified and studies were grouped into six categories based on the theoretical basis of the intervention: (1) movement practice, (2) training with constraint, (3) sensory reorganization, (4) normalization of muscle activity with external techniques, (5) neuromodulation with training, and (6) compensatory strategies. Quality of the body of evidence ranged from very low‐to‐low according to the grades of recommendation, assessment, development, and evaluation (GRADE). Despite inconclusive evidence for these rehabilitation approaches, data suggest that intensive movement practice and neuromodulation combined with motor training should be further explored.

Conclusions

This systematic review presents a novel approach to classify studies of rehabilitation in focal dystonias based on the theoretical basis of intervention. The proposed classification system will move toward a unified theoretical understanding of rehabilitation interventions in dystonia. Moreover, it will help provide recommendations for clinical applications and future investigations.

The influence of occlusal stabilization appliances on cervical dystonia symptoms

Objectives

The aim of this study was to assess the therapeutic efficiency of the occlusal stabilization appliance (OSA) in patients with cervical dystonia (CD).

Methods

The study included 11 patients aged between 29 and 80 years, 7 women and 4 men, diagnosed with primary CD. The patients underwent an extra- and intra-oral clinical examination, followed by para-clinical examinations, necessary for the specifications of the OSA. The following data were recorded: demographic parameters, CD duration, management of the disease, dental impression, recording of the centric relationship, recording of the position of the upper jaw with the facial bow. A standardized OSA was manufactured in a private dental laboratory. Patients received instructions for wearing the OSA for 24 hours. Patients filled a questionnaire designed by us, which evaluated the effects of wearing the OSA over a 24-hours period on the symptoms of CD: muscles contraction, pain, discomfort while walking, sleep quality, tremor. The patients kept the dental appliances, and after three months they completed the questionnaire one more time.

Results

The OSA was applied on the lower arch in 3 (27.3%) patients and on the upper arch in 8 (72.7%) patients. The OSA wearing time for the first 24 h was on average 19.2±6 hours. Total relaxation of dystonic muscles was reported by 9 (81.8%) patients, while 2 (18.2%) patients related partial muscle relaxation. Seven (63.6%) patients reported a pain decrease. Increased comfort while walking was observed by 8 (72.7%) patients. Two (18.2%) patients described an increase of sleep quality. In two (18.2%) patients the tremor disappeared. All patients reported difficulties while eating and removed the OSA during meals. Patients who wore the OSA for more hours, experienced a pain decrease (p=0.08), an increase in sleep quality (p=0.1), the disappearance of the tremor (p=0.1). After three months, only seven patients continued to use the OSA. More patients described a pain decrease after three months (5 (71.4%) vs. 4 (57.1%); p=0.5), relaxation of dystonic muscles (7 (100%) vs. 6 (85.7%); p=0.3).

Conclusions

The use of OSA might be beneficial in CD patients, as it reduced the dystonic symptoms, pain severity and improved the quality of sleep.

Rate of Hanger Reflex Occurrence: Unexpected Head Rotation on Fronto-temporal Head Compression

When the head is encircled with a wire clothes hanger and the unilateral fronto-temporal region is compressed, the head rotates unexpectedly. As the mechanism is unclear, however, we have temporarily named this phenomenon as the "hanger reflex." We previously reported a case wherein this phenomenon was applied to treat cervical dystonia. Because little is known about this phenomenon, we determined how often this phenomenon is observed in healthy subjects. Study participants were 120 healthy Japanese adults (60 men and 60 women) aged 19-65 years. A wire clothes hanger was applied to each subject's head. The longer side of the hanger was attached over the volunteer's fronto-temporal regions on both sides of the head in succession (i.e., two applications per volunteer). We evaluated whether the subjects felt the sensation of head rotation by using a questionnaire. The sensation of head rotation was observed in 95.8% of subjects. There were five non-responders (4.2%). In 85.4% of the trials, head rotation was observed in the direction that coincided with the side compressed by the hanger. There were no differences in responses between genders. The incident rate of the hanger reflex was remarkably high and most likely represents a prevalent phenomenon in humans. The mechanism underlying the reflex remains unknown. Further research should be performed to elucidate the underlying causes of the hanger reflex, which represents a potential treatment for cervical dystonia.

Focal hand dystonia: individualized intervention with repeated application of repetitive transcranial magnetic stimulation

OBJECTIVES

To examine for individual factors that may predict response to inhibitory repetitive transcranial magnetic stimulation (rTMS) in focal hand dystonia (FHD); to present the method for determining optimal stimulation to increase inhibition in a given patient; and to examine individual responses to prolonged intervention.

DESIGN

Single-subject design to determine optimal parameters to increase inhibition for a given subject and to use the selected parameters once per week for 6 weeks, with 1-week follow-up, to determine response.

SETTING

Clinical research laboratory.

PARTICIPANTS

A volunteer sample of subjects with FHD (N = 2). One participant had transcranial magnetic stimulation responses indicating impaired inhibition, and the other had responses within normative limits.

INTERVENTIONS

There were 1200 pulses of 1-Hz rTMS delivered using 4 different stimulation sites/intensity combinations: primary motor cortex at 90% or 110% of resting motor threshold (RMT) and dorsal premotor cortex (PMd) at 90% or 110% of RMT. The parameters producing the greatest within-session increase in cortical silent period (CSP) duration were then used as the intervention.

MAIN OUTCOME MEASURES

Response variables included handwriting pressure and velocity, subjective symptom rating, CSP, and short latency intracortical inhibition and facilitation.

RESULTS

The individual with baseline transcranial magnetic stimulation responses indicating impaired inhibition responded favorably to the repeated intervention, with reduced handwriting force, an increase in the CSP, and subjective report of moderate symptom improvement at 1-week follow-up. The individual with normative baseline responses failed to respond to the intervention. In both subjects, 90% of RMT to the PMd produced the greatest lengthening of the CSP and was used as the intervention.

CONCLUSIONS

An individualized understanding of neurophysiological measures can be an indicator of responsiveness to inhibitory rTMS in focal dystonia, with further work needed to determine likely responders versus nonresponders.

Dystonia rating scales: critique and recommendations

Many rating scales have been applied to the evaluation of dystonia, but only few have been assessed for clinimetric properties. The Movement Disorders Society commissioned this task force to critique existing dystonia rating scales and place them in the clinical and clinimetric context. A systematic literature review was conducted to identify rating scales that have either been validated or used in dystonia. Thirty-six potential scales were identified. Eight were excluded because they did not meet review criteria, leaving 28 scales that were critiqued and rated by the task force. Seven scales were found to meet criteria to be "recommended": the Blepharospasm Disability Index is recommended for rating blepharospasm; the Cervical Dystonia Impact Scale and the Toronto Western Spasmodic Torticollis Rating Scale for rating cervical dystonia; the Craniocervical Dystonia Questionnaire for blepharospasm and cervical dystonia; the Voice Handicap Index (VHI) and the Vocal Performance Questionnaire (VPQ) for laryngeal dystonia; and the Fahn-Marsden Dystonia Rating Scale for rating generalized dystonia. Two "recommended" scales (VHI and VPQ) are generic scales validated on few patients with laryngeal dystonia, whereas the others are disease-specific scales. Twelve scales met criteria for "suggested" and 7 scales met criteria for "listed." All the scales are individually reviewed in the online information. The task force recommends 5 specific dystonia scales and suggests to further validate 2 recommended generic voice-disorder scales in dystonia. Existing scales for oromandibular, arm, and task-specific dystonia should be refined and fully assessed. Scales should be developed for body regions for which no scales are available, such as lower limbs and trunk.

The effectiveness of physiotherapy for cervical dystonia: a systematic literature review

Cervical dystonia is a form of adult-onset, focal dystonia characterized by involuntary contractions of the neck muscles, leading to a disabling, abnormal head posture. CD has a great impact on the activities of daily living (ADL) and quality of life. Currently, the most widely used and recommended first line treatment is botulinum toxin type A (BoNT/A) injections. Physiotherapy is a potentially useful adjuvant, but little is known about its effectiveness. Consequently, our objective was to investigate the effectiveness of physiotherapy alone or as an adjuvant treatment to BoNT/A injections in cervical dystonia (CD) by means of a systematic literature review. Two online databases, PubMed and Web of Science, were searched for articles describing the effectiveness of physiotherapy treatment for CD. After screening, based on predefined in- and exclusion criteria, 16 studies were retained. Their methodological quality was assessed according to Cochrane guidelines. The methodological quality of most studies was low. Examples of shortcomings are small sample sizes, lack of randomization or blinding, and diversity in therapeutic techniques and outcome measures. Only seven studies were clinical trials; the remaining were either case reports or case series. The reported physiotherapy treatments included EMG biofeedback training, muscular elongation, postural exercises and electrotherapy. Improvements in head position, pain, cervical range of motion, quality of life and ADL have been reported, which is promising. Cautious interpretation on the effectiveness of physiotherapy as an adjuvant therapy is required. Before firm conclusions can be drawn, additional high quality trials are needed.

Sustainable Reduction of Sleepiness through Salutogenic Self-Care Procedure in Lunch Breaks: A Pilot Study

The aim of the study was to elucidate the immediate, intermediate, and anticipatory sleepiness reducing effects of a salutogenic self-care procedure called progressive muscle relaxation (PMR), during lunch breaks. The second exploratory aim deals with determining the onset and long-term time course of sleepiness changes. In order to evaluate the intraday range and interday change of the proposed relaxation effects, 14 call center agents were assigned to either a daily 20-minute self-administered PMR or a small talk (ST) group during a period of seven months. Participants' levels of sleepiness were analyzed in a controlled trial using anticipatory, postlunchtime, and afternoon changes of sleepiness as indicated by continuously determined objective reaction time measures (16,464 measurements) and self-reports administered five times per day, once per month (490 measurements). Results indicate that, in comparison to ST, the PMR break (a) induces immediate, intermediate, and anticipatory reductions in sleepiness; (b) these significant effects remarkably show up after one month, and sleepiness continues to decrease for at least another five months. Although further research is required referring to the specific responsible mediating variables, our results suggest that relaxation based lunch breaks are both accepted by employees and provide a sustainable impact on sleepiness.

The role of the trigeminal sensory nuclear complex in the pathophysiology of craniocervical dystonia

Isolated focal dystonia is a neurological disorder that manifests as repetitive involuntary spasms and/or aberrant postures of the affected body part. Craniocervical dystonia involves muscles of the eye, jaw, larynx, or neck. The pathophysiology is unclear, and effective therapies are limited. One mechanism for increased muscle activity in craniocervical dystonia is loss of inhibition involving the trigeminal sensory nuclear complex (TSNC). The TSNC is tightly integrated into functionally connected regions subserving sensorimotor control of the neck and face. It mediates both excitatory and inhibitory reflexes of the jaw, face, and neck. These reflexes are often aberrant in craniocervical dystonia, leading to our hypothesis that the TSNC may play a central role in these particular focal dystonias. In this review, we present a hypothetical extended brain network model that includes the TSNC in describing the pathophysiology of craniocervical dystonia. Our model suggests the TSNC may become hyperexcitable due to loss of tonic inhibition by functionally connected motor nuclei such as the motor cortex, basal ganglia, and cerebellum. Disordered sensory input from trigeminal nerve afferents, such as aberrant feedback from dystonic muscles, may continue to potentiate brainstem circuits subserving craniocervical muscle control. We suggest that potentiation of the TSNC may also contribute to disordered sensorimotor control of face and neck muscles via ascending and cortical descending projections. Better understanding of the role of the TSNC within the extended neural network contributing to the pathophysiology of craniocervical dystonia may facilitate the development of new therapies such as noninvasive brain stimulation.

The focal dystonias: current views and challenges for future research

The most common forms of dystonia are those that develop in adults and affect a relatively isolated region of the body. Although these adult-onset focal dystonias are most prevalent, knowledge of their etiologies and pathogenesis has lagged behind some of the rarer generalized dystonias, in which the identification of genetic defects has facilitated both basic and clinical research. This summary provides a brief review of the clinical manifestations of the adult-onset focal dystonias, focusing attention on less well understood clinical manifestations that need further study. It also provides a simple conceptual model for the similarities and differences among the different adult-onset focal dystonias as a rationale for lumping them together as a class of disorders while at the same time splitting them into subtypes. The concluding section outlines some of the most important research questions for the future. Answers to these questions are critical for advancing our understanding of this group of disorders and for developing novel therapeutics.

Non-invasive cerebellar stimulation in dystonia

Primary isolated dystonia is a hyperkinetic movement disorder whereby involuntary muscle contractions cause twisted and abnormal postures. Dystonia of the cervical spine and upper limb may present as sustained muscle contractions or task-specific activity when using the hand or upper limb. There is little understanding of the pathophysiology underlying dystonia and this presents a challenge for clinicians and researchers alike. Emerging evidence that the cerebellum is involved in the pathophysiology of dystonia using network models presents the intriguing concept that the cerebellum could provide a novel target for non-invasive brain stimulation. Non-invasive stimulation to increase cerebellar excitability improved aspects of handwriting and circle drawing in a small cohort of people with focal hand and cervical dystonia. Mechanisms underlying the improvement in function are unknown, but putative pathways may involve the red nucleus and/or the cervical propriospinal system. Furthermore, recent understanding that the cerebellum has both motor and cognitive functions suggests that non-invasive cerebellar stimulation may improve both motor and non-motor aspects of dystonia. We propose a combination of motor and non-motor tasks that challenge cerebellar function may be combined with cerebellar non-invasive brain stimulation in the treatment of focal dystonia. Better understanding of how the cerebellum contributes to dystonia may be gained by using network models such as our putative circuits involving red nucleus and/or the cervical propriospinal system. Finally, novel treatment interventions encompassing both motor and non-motor functions of the cerebellum may prove effective for neurological disorders that exhibit cerebellar dysfunction.

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.

EFNS guidelines on diagnosis and treatment of primary dystonias

OBJECTIVES

to provide a revised version of earlier guidelines published in 2006.

BACKGROUND

primary dystonias are chronic and often disabling conditions with a widespread spectrum mainly in young people.

DIAGNOSIS

primary dystonias are classified as pure dystonia, dystonia plus or paroxysmal dystonia syndromes. Assessment should be performed using a validated rating scale for dystonia. Genetic testing may be performed after establishing the clinical diagnosis. DYT1 testing is recommended for patients with primary dystonia with limb onset before age 30, and in those with an affected relative with early-onset dystonia. DYT6 testing is recommended in early-onset or familial cases with cranio-cervical dystonia or after exclusion of DYT1. Individuals with early-onset myoclonus should be tested for mutations in the DYT11 gene. If direct sequencing of the DYT11 gene is negative, additional gene dosage is required to improve the proportion of mutations detected. A levodopa trial is warranted in every patient with early-onset primary dystonia without an alternative diagnosis. In patients with idiopathic dystonia, neurophysiological tests can help with describing the pathophysiological mechanisms underlying the disorder.

TREATMENT

botulinum toxin (BoNT) type A is the first-line treatment for primary cranial (excluding oromandibular) or cervical dystonia; it is also effective on writing dystonia. BoNT/B is not inferior to BoNT/A in cervical dystonia. Pallidal deep brain stimulation (DBS) is considered a good option, particularly for primary generalized or cervical dystonia, after medication or BoNT have failed. DBS is less effective in secondary dystonia. This treatment requires a specialized expertise and a multidisciplinary team.

Paramedical treatment in primary dystonia: a systematic review

Dystonia is a disabling movement disorder with a significant impact on quality of life. The current therapeutic armamentarium includes various drugs, botulinum toxin injections, and occasionally (neuro)surgery. In addition, many patients are referred for paramedical (including allied health care) interventions. An enormous variation in the paramedical treatment is provided, largely because evidence-based, accepted treatment regimes are not available. We have conducted a systematic review of studies that explored the effect of various paramedical interventions in primary dystonia. Only studies that have used clinical outcome measures were included. There were no class A1 or A2 studies and therefore, level 1 or 2 practice recommendations for a specific intervention could not be deducted. Many papers were case reports, mostly with a very limited number of patients and a clear publication bias for beneficial effects of a particular paramedical intervention. Some potentially interesting interventions come from class B studies, which include physical therapy in addition to botulinum toxin injections (BoNT-A) in cervical dystonia; sensorimotor training and transcutaneous electrical nerve stimulation (TENS) in writer's cramp; and speech therapy added to BoNT-A injections in laryngeal dystonia. Good quality clinical studies are therefore warranted, which should have the aim to be generally applicable. A design in which the paramedical intervention is added to a current gold standard, for example, BoNT-A injections in cervical dystonia, is recommended.

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.