Cervical dystonia: effectiveness of a standardized physical therapy program; study design and protocol of a single blind randomized controlled trial

Impact of Physiotherapy in the Treatment of Pain in Cervical Dystonia

Background

Cervical dystonia (CD) is the most common form of focal dystonia in adults. Studies show that physiotherapy (PT) in combination with BoNT has an effect on pain in cervical dystonia. We intended to test this hypothesis in a real-world setting to answer the question of whether pain is a good target symptom for prescribing PT. We also aimed to assess which form of PT is most appropriate for the treatment of pain.

Methods

Study design: cross-sectional survey-based study of 91 patients with a confirmed diagnosis of cervical dystonia. The survey consisted of a questionnaire on type, frequency and content of physiotherapy, an assessment of quality of life with the Craniocervical Dystonia Questionnaire 24 (CDQ 24) and subjective pain scores.

Results

53.8% of patients received physiotherapy, mostly a mixture of exercises to either correct the abnormal posture or to reduce the muscle tone. Additional therapies included stress-reducing exercises (14.3%), psychotherapy (9.9%) and EMG biofeedback (2.2%). Patients who received PT showed a non-significant tendency towards higher pain scores. The severity of dystonia-associated pain was significantly associated with the patients' quality of life (F (1,54) = 22.9, adjusted R2 = 0.286, p < 0.001).

Discussion

Pain is a frequent problem in patients with CD and severely affects quality of life. Physiotherapy could therefore be a valuable treatment option for patients with CD and pain.

Highlights

Our uncontrolled study illustrates the high frequency of physiotherapy in addition to BoNT treatment in a real-life cohort of patients with cervical dystonia. We were able to show that PT reduces patients' perceived pain in a patient reported outcome measure. This highlights the importance of PT in reducing CD-related pain, which considerably impairs quality of life.

Research progress in spasmodic torticollis rehabilitation treatment

Spasmodic torticollis (ST) is a focal dystonia that affects adults, causing limited muscle control and impacting daily activities and quality of life. The etiology and curative methods for ST remain unclear. Botulinum toxin is widely used as a first-line treatment, but long-term usage can result in reduced tolerance and adverse effects. Rehabilitation therapy, with its minimal side effects and low potential for harm, holds significant clinical value. This article explores the effectiveness of adjunctive therapies, including exercise therapy, transcranial magnetic stimulation, shockwave therapy, neuromuscular electrical stimulation, vibration therapy, electromyographic biofeedback, and acupuncture, in the treatment of ST. The aim is to provide clinicians with additional treatment options and to discuss the efficacy of rehabilitation therapy for ST.

Evaluation of outcome of different neurosurgical modalities in management of cervical dystonia

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.

Effective botulinum toxin injection guide for treatment of cervical dystonia

The aim of this study was to elucidate the distribution of the accessory nerve within the sternocleidomastoid muscle (SCM) to aid identifying the optimum sites for botulinum neurotoxin (BoNT) injections and applying chemical neurolysis. Thirty SCM specimens from 15 Korean cadavers were used in this study. Sihler's staining was applied to 10 of the SCM specimens. Transverse lines were drawn in 20 sections to divide the SCM into 10 divisions vertically, and a vertical line was drawn into the medial and lateral halves from the mastoid process to the sternoclavicular joint. The most densely innervated areas were 5/10-6/10 and 6/10-7/10 along the lateral and medial parts of the muscle, respectively. We suggest injecting BoNT in the medial region 6/10-7/10 along the SCM prior to injecting in the lateral region 5/10-6/10 along the muscle to ensure safe and effective treatment. Clin. Anat. 33:192-198, 2020. © 2019 Wiley Periodicals, Inc.

New approaches to discovering drugs that treat dystonia

Introduction: Dystonia consists of involuntary movements, abnormal posturing, and pain. In adults, dystonia presents in a particular region of the body and causes significant disability due to pain as well as impairment in activities of daily living and employment. The current gold standard treatment, botulinum toxin (BoNT), has limitations - painful, frequent injections due to 'wearing off' of treatment effect; expense; and expected side effects like swallowing difficulty and weakness. There is a clear therapeutic gap in our current treatment options for dystonia and also a clear need for an effective novel treatment. Testing any novel treatment is complicated because most adults with focal dystonia are treated with BoNT. Areas covered: This review focuses on establishing the need for novel therapeutics. It also suggests potential leads from preclinical studies; and, discusses the issue of clinical trial readiness in the dystonia field. Expert opinion: Identifying a novel therapeutic intervention for dystonia patients faces two major challenges. The first is acknowledging the therapeutic gap that currently exists. Second, shifting some of our research aims in dystonia to clinical trial readiness is imperative if we are to be ready to test novel therapeutic agents.

Long-Term Specialized Physical Therapy in Cervical Dystonia: Outcomes of a Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of a specialized physical therapy (SPT) program on disability in cervical dystonia (CD) compared to regular physical therapy (RPT).

DESIGN

A single-blinded randomized controlled trial.

SETTING

This study was performed by a physical therapist in a primary health care setting. Measurements were performed at baseline, 6 and 12 months in the botulinum toxin (BoNT) outpatient clinic of the neurology department.

PARTICIPANTS

Patients with primary CD and stable on BoNT treatment for 1 year (N=96).

MAIN OUTCOME MEASURES

The primary outcome was disability assessed with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Secondary outcomes were pain, anxiety, depression, quality of life (QOL), and health related costs over 12 months.

RESULTS

A total of 72 participants (30 men, 42 women) finished the study: 40 received SPT, 32 RPT. No significant between group differences were found after 12 months of treatment (P=.326). Over these 12 months both groups improved significantly (P<.001) on the TWSTRS disability scale compared to baseline (SPT 1.7 points, RPT 1.0 points). Short Form 36 (SF-36) General Health Perceptions (P=.046) and self-perceived improvement (P=.007) showed significantly larger improvements after 12 months in favor of SPT. Total health related costs after 12 months were $1373±556 for SPT compared to $1614±917 for RPT.

CONCLUSION

SPT revealed no significant differences compared to RPT after 12 months of treatment on the TWSTRS disability scale. Both groups showed similar improvements compared to baseline. Positive results in the SPT group were higher patient perceived effects and general health perception. Treatment costs were lower in the SPT group. With lower costs and similar effects, the SPT program seems to be the preferred program to treat CD.

The effects of a laser-guided postural reeducation program on pain, neck active range of motion, and functional improvement in a 75-year-old patient with cervical dystonia

Background and Purpose: Limited research exists regarding physical therapy management for patients with cervical dystonia (CD). The purpose of this case report is to describe the clinical management of a patient with CD using manual techniques, cervical traction, and laser-guided postural reeducation. Case Description: The patient was a 75-year-old female with CD, diagnosed 40 years prior, with a 10-year history of botulinum neurotoxin injections. She reported a 1-year history of worsening neck pain and cervical range of motion loss which was significantly affecting her ability to sleep and drive. The patient was seen for 12 visits over a 6-week period. Outcomes: Discharge scores indicated marked improvements in active range of motion, neck disability index, and the CDIP-58 questionnaire. Improvement in motor control as measured during the SenMorCor™ Laser Functional Error Assessment was demonstrated in the motions of "looking right" (53%) and up (48%). Discussion: This case report indicates that a physical therapy program consisting of a daily laser-guided home program for head postural reeducation in conjunction with classic physical therapy techniques may be an option for patients with CD; however, further research is needed prior to adoption of these techniques as standard of care for patients with CD.

Functional activity of the sensorimotor cortex and cerebellum relates to cervical dystonia symptoms

Cervical dystonia (CD) is the most common type of focal dystonia, causing abnormal movements of the neck and head. In this study, we used noninvasive imaging to investigate the motor system of patients with CD and uncover the neural correlates of dystonic symptoms. Furthermore, we examined whether a commonly prescribed anticholinergic medication in CD has an effect on the dystonia-related brain abnormalities. Participants included 16 patients with CD and 16 healthy age-matched controls. We collected functional MRI scans during a force task previously shown to extensively engage the motor system, and diffusion and T1-weighted MRI scans from which we calculated free-water and brain tissue densities. The dystonia group was also scanned ca. 2 h after a 2-mg dose of trihexyphenidyl. Severity of dystonia was assessed pre- and post-drug using the Burke-Fahn-Marsden Dystonia Rating Scale. Motor-related activity in CD was altered relative to controls in the primary somatosensory cortex, cerebellum, dorsal premotor and posterior parietal cortices, and occipital cortex. Most importantly, a regression model showed that increased severity of symptoms was associated with decreased functional activity of the somatosensory cortex and increased activity of the cerebellum. Structural imaging measures did not differ between CD and controls. The single dose of trihexyphenidyl altered the fMRI signal in the somatosensory cortex but not in the cerebellum. Symptom severity was not significantly reduced post-treatment. Findings show widespread changes in functional brain activity in CD and most importantly that dystonic symptoms relate to disrupted activity in the somatosensory cortex and cerebellum. Hum Brain Mapp 38:4563-4573, 2017. © 2017 Wiley Periodicals, Inc.

Does dystonic muscle activity affect sense of effort in cervical dystonia?

BACKGROUND

Focal dystonia has been associated with deficient processing of sense of effort cues. However, corresponding studies are lacking in cervical dystonia (CD). We hypothesized that dystonic muscle activity would perturb neck force control based on sense of effort cues.

METHODS

Neck extension force control was investigated in 18 CD patients with different clinical features (7 with and 11 without retrocollis) and in 19 control subjects. Subjects performed force-matching and force-maintaining tasks at 5% and 20% of maximum voluntary contraction (MVC). Three task conditions were tested: i) with visual force feedback, ii) without visual feedback (requiring use of sense of effort), iii) without visual feedback, but with neck extensor muscle vibration (modifying muscle afferent cues). Trapezius muscle activity was recorded using electromyography (EMG).

RESULTS

CD patients did not differ in task performance from healthy subjects when using visual feedback (ANOVA, p>0.7). In contrast, when relying on sense of effort cues (without visual feedback, 5% MVC), force control was impaired in patients without retrocollis (p = 0.006), but not in patients with retrocollis (p>0.2). Compared to controls, muscle vibration without visual feedback significantly affected performance in patients with retrocollis (p<0.001), but not in patients without retrocollis. Extensor EMG during rest, included as covariate in ANOVA, explained these group differences.

CONCLUSION

This study shows that muscle afferent feedback biases sense of effort cues when controlling neck forces in patients with CD. The bias acts on peripheral or central sense of effort cues depending on whether the task involves dystonic muscles. This may explain why patients with retrocollis more accurately matched isometric neck extension forces. This highlights the need to consider clinical features (pattern of dystonic muscles) when evaluating sensorimotor integration in CD.

Unmet Needs in the Management of Cervical Dystonia

Cervical dystonia (CD) is a movement disorder which affects daily living of many patients. In clinical practice, several unmet treatment needs remain open. This article focuses on the four main aspects of treatment. We describe existing and emerging treatment approaches for CD, including botulinum toxin injections, surgical therapy, management of non-motor symptoms, and rehabilitation strategies. The unsolved issues regarding each of these treatments are identified and discussed, and possible future approaches and research lines are proposed.

A randomized trial of specialized versus standard neck physiotherapy in cervical dystonia

BACKGROUND

Anecdotal reports suggested that a specialized physiotherapy technique developed in France (the Bleton technique) improved primary cervical dystonia. We evaluated the technique in a randomized trial.

METHODS

A parallel-group, single-blind, two-centre randomized trial compared the specialized outpatient physiotherapy programme given by trained physiotherapists up to once a week for 24 weeks with standard physiotherapy advice for neck problems. Randomization was by a central telephone service. The primary outcome was the change in the total Toronto Western Spasmodic Torticollis Rating (TWSTR) scale, measured before any botulinum injections that were due, between baseline and 24 weeks evaluated by a clinician masked to treatment. Analysis was by intention-to-treat.

RESULTS

110 patients were randomized (55 in each group) with 24 week outcomes available for 84. Most (92%) were receiving botulinum toxin injections. Physiotherapy adherence was good. There was no difference between the groups in the change in TWSTR score over 24 weeks (mean adjusted difference 1.44 [95% CI -3.63, 6.51]) or 52 weeks (mean adjusted difference 2.47 [-2.72, 7.65]) nor in any of the secondary outcome measures (Cervical Dystonia Impact Profile-58, clinician and patient-rated global impression of change, mean botulinum toxin dose). Both groups showed large sustained improvements compared to baseline in the TWSTR, most of which occurred in the first four weeks. There were no major adverse events. Subgroup analysis suggested a centre effect.

CONCLUSION

There was no statistically or clinically significant benefit from the specialized physiotherapy compared to standard neck physiotherapy advice but further trials are warranted.

Diagnosis and treatment of dystonia

The dystonias are a group of disorders characterized by excessive involuntary muscle contractions leading to abnormal postures and/or repetitive movements. A careful assessment of the clinical manifestations is helpful for identifying syndromic patterns that focus diagnostic testing on potential causes. If a cause is identified, specific etiology-based treatments may be available. In most cases, a specific cause cannot be identified, and treatments are based on symptoms. Treatment options include counseling, education, oral medications, botulinum toxin injections, and several surgical procedures. A substantial reduction in symptoms and improved quality of life is achieved in most patients by combining these options.

Normal motor adaptation in cervical dystonia: a fundamental cerebellar computation is intact

The potential role of the cerebellum in the pathophysiology of dystonia has become a focus of recent research. However, direct evidence for a cerebellar contribution in humans with dystonia is difficult to obtain. We examined motor adaptation, a test of cerebellar function, in 20 subjects with primary cervical dystonia and an equal number of aged matched controls. Adaptation to both visuomotor (distorting visual feedback by 30°) and forcefield (applying a velocity-dependent force) conditions were tested. Our hypothesis was that cerebellar abnormalities observed in dystonia research would translate into deficits of cerebellar adaptation. We also examined the relationship between adaptation and dystonic head tremor as many primary tremor models implicate the cerebellothalamocortical network which is specifically tested by this motor paradigm. Rates of adaptation (learning) in cervical dystonia were identical to healthy controls in both visuomotor and forcefield tasks. Furthermore, the ability to adapt was not clearly related to clinical features of dystonic head tremor. We have shown that a key motor control function of the cerebellum is intact in the most common form of primary dystonia. These results have important implications for current anatomical models of the pathophysiology of dystonia. It is important to attempt to progress from general statements that implicate the cerebellum to a more specific evidence-based model. The role of the cerebellum in this enigmatic disease perhaps remains to be proven.

Microvascular decompression surgery is effective for the laterocollis subtype of spasmodic torticollis: a long-term follow-up result

BACKGROUND

Spasmodic torticollis (ST) is characterized by sustained, involuntary, and painful spasms of specific muscle (s), which results into abnormal posture of the neck and head. Although various treatments for ST have been introduced, none of them shows absolute effectiveness. Earlier research from our department showed that microvascular decompression (MVD) surgery is effective in the short-term for ST patients with confirmed accessory nerve compression. However, the long-term outcome of MVD remains unknown.

METHOD

Twelve ST patients with confirmed accessory nerve compression received MVD surgery of their accessory nerves. We utilized the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) to evaluate the long-term outcome (5.4 ± 0.87 years).

RESULTS

The MVD lowered total TWSTRS scores by 42.8 % in all ST patients. This result, however, only counted for moderate relief. Interestingly, we observed that the laterocollis (LC) subtypes of ST (n = 3) obtained a higher TWSTRS score improvement (86.9 ± 6.2 %), compared to that of the non-LC (28.1 ± 12 %) (P =0.0001). Additionally, the disability (92.7 ± 2 %) subscale score in the LC subtypes had the most prominent improvement compared to the pain (88.1 ± 5.1 %) and severity (81.3 ± 10.5 %).

CONCLUSIONS

In the cases of confirmed accessory nerve compression, the MVD could be considered as a treatment alternative for ST, especially for the LC subtypes.