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Nijenhuis B, van Wensen E, Smit M, van Zutphen T, Zwerver J, Tijssen M. Treatment of task-specific dystonia in sports: A systematic review. Clin Park Relat Disord 2024; 10:100245. [PMID: 38456155 PMCID: PMC10918566 DOI: 10.1016/j.prdoa.2024.100245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 11/30/2023] [Accepted: 02/24/2024] [Indexed: 03/09/2024] Open
Abstract
Introduction Task specific dystonia is a movement disorder only affecting a highly practiced skill and is found in a broad set of expert movements including in sports. Despite affecting many sports, there is no comprehensive review of treatment options, which is in contrast to better studied forms of task specific dystonia in musicians and writers. For this reason, studies involving an intervention to treat task specific dystonia in sports were systematically reviewed, with special attention for the quality of outcome measures. Methods The PICO systematic search strategy was employed on task-specific dystonia, and all synonyms. Inclusion criteria were peer reviewed published studies pertaining to sports, studies with a measurement and/or intervention in TSD, all in English. We excluded abstracts, expert opinions, narrative review articles, unpublished studies, dissertations and studies exclusively relating to choking. We included case reports, case studies and case-control studies. Results In April 2022 Pubmed, Embase, Web of Science, and Psychinfo were searched. Of the 7000 articles identified, 31 were included that described psychological and invasive and/or pharmacological interventions. There was a lack of formal standardized outcome measures in studies resulting in low quality evidence for the effectiveness of treatment options. A descriptive synthesis showed emotional regulation was effective, but was exclusively tried in golfers. Interventions like botulinum toxin or pharmacology had a similar effectiveness compared to studies in musicians dystonia, however there was almost no formal evidence for these treatments. Conclusion The quality of studies was low with a lack of standardized outcome measures. Future studies with larger cohorts and quantitative outcome measures are needed to improve understanding of treatments for task specific dystonia in athletes.
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Affiliation(s)
- B. Nijenhuis
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Expertise Center Movement Disorders Groningen, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- University of Groningen/Faculty Campus Fryslân, Leeuwarden, The Netherlands
| | - E. van Wensen
- Department of Neurology, Gelre Ziekenhuizen Apeldoorn and Sports Dystonia Centre, Apeldoorn, The Netherlands
| | - M. Smit
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Expertise Center Movement Disorders Groningen, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - T. van Zutphen
- University of Groningen/Faculty Campus Fryslân, Leeuwarden, The Netherlands
| | - J. Zwerver
- Sports Valley, Sports Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M.A.J. Tijssen
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Expertise Center Movement Disorders Groningen, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Pedrosa M, Martins B, Araújo R. It's in the game: A review of neurological lesions associated with sports. J Neurol Sci 2023; 455:122803. [PMID: 37995461 DOI: 10.1016/j.jns.2023.122803] [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: 07/22/2023] [Revised: 10/24/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION The practice of sports may lead to neurological injuries. While relatively uncommon (overall incidence of approximately 2.5%), and mostly benign and transient, some conditions may be life-threatening and permanent. Thus, both clinical neurologists and sports physicians should be aware of their existence and relevance. We aimed to review all sports-related neurological injuries and illnesses reported in the literature. METHODS Following SANRA guidelines, we performed a narrative review and searched PubMed and Scopus databases. Relevant sports were selected based on their recognition as an Olympic sport by the International Olympic Committee. Chronic traumatic encephalopathy (CTE) and other neurodegenerative disorders were not included. RESULTS A total of 292 studies were included concerning 33 different sports. The most reported neurological injury was damage to the peripheral nervous system. Traumatic injuries have also been extensively reported, including cerebral haemorrhage and arterial dissections. Non-traumatic life-threatening events are infrequent but may also occur, e.g. posterior reversible encephalopathy syndrome, cerebral venous thrombosis, and arterial dissections. Some conditions were predominantly reported in specific sports, e.g. yips in baseball and golf, raising the possibility of a common pathophysiology. Spinal cord infarction due to fibrocartilaginous embolism was reported in several sports associated with minor trauma. CONCLUSION Sports-related neurological injuries are increasingly receiving more social and medical attention and are an important cause of morbidity and mortality. This review may serve as a guide to physicians managing these challenging situations.
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Affiliation(s)
| | - Bárbara Martins
- Neurology Department, Centro Hospitalar Universitário de São João, E.P.E., Porto, Portugal; Clinical Neuroscience and Mental Health Department, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Rui Araújo
- Neurology Department, Centro Hospitalar Universitário de São João, E.P.E., Porto, Portugal; Clinical Neuroscience and Mental Health Department, Faculty of Medicine, University of Porto, Porto, Portugal
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3
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Abstract
Background Task-specific dystonia (TSD) is a form of focal dystonia that occurs in the context of the performance of selective, highly skilled, often repetitive, motor activity. TSD may be apparent during certain tasks such as writing, playing musical instruments, or other activities requiring fine motor control, but may also occur during certain sports, and maybe detrimental to professional athletes' careers. Therefore, sports physicians and movement disorder neurologists need to be aware of the presentation and phenomenology of sports-related dystonia (SRD), the topic of this review. Methods A broad PubMed search using a wide range of keywords and combinations was done in October 2021 to identify suitable articles for this review. Results Most of the publications are on yips in golfers and on runners' dystonia. Other sports in which SRD has been reported are ice skating, tennis, table tennis, pistol shooting, petanque, baseball, and billiards. Discussion Yips, which may affect up to half of the golfers and rarely athletes in other sports (e.g., baseball, cricket, basketball, speed skating, gymnastics) seems to be a multi-factorial form of TSD that is particularly troublesome in highly skilled professional golfers. Runners' dystonia, affecting the foot, leg, and hip (in decreasing order), may evolve into more generalized and less specific dystonia. The pathophysiologic mechanisms of SRD are not well understood. Botulinum toxin has been reported to alleviate dystonia in golfers', runners', and other forms of SRD. Future studies should utilize neurophysiologic, imaging, and other techniques to elucidate mechanisms of this underrecognized group of movement disorders.
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Ogasawara I, Hattori N, Revankar GS, Konda S, Uno Y, Nakano T, Kajiyama Y, Mochizuki H, Nakata K. Symptom Locus and Symptom Origin Incongruity in Runner's Dystonia - Case Study of an Elite Female Runner. Front Hum Neurosci 2022; 15:809544. [PMID: 34975442 PMCID: PMC8716826 DOI: 10.3389/fnhum.2021.809544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/24/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Runner's dystonia is a task-specific dystonia that occurs in the lower limbs and trunk, with diverse symptomatology. We aimed to identify the origin of a dystonic movement abnormality using combined three-dimensional kinematic analysis and electromyographic (EMG) assessment during treadmill running. Participant: A 20-year-old female runner who complained of right-foot collision with the left-leg during right-leg swing-phase, which mimicked right-ankle focal dystonia. Results: Kinematic and EMG assessment of her running motion was performed, which showed a significant drop of the left pelvis during right-leg stance-phase, and a simultaneous increase of right hip adductor muscle activity. This resulted in a pronounced adduction of the entire right lower limb with respect to the pelvis segment. Trajectories of right foot were seen to encroach upon left-leg area. Discussion: These findings suggested that the symptom of this runner was most likely a form of segmental dystonia originating from an impaired control of hip and pelvis, rather than a distal focal ankle dystonia. Conclusion: We conclude that, for individualized symptom assessment, deconstructing the symptom origin from its secondary compensatory movement is crucial for characterizing dystonia. Kinematic and EMG evaluation will therefore be a prerequisite to distinguish symptom origin from secondary compensatory movement.
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Affiliation(s)
- Issei Ogasawara
- Department of Health and Sport Sciences, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Noriaki Hattori
- Department of Rehabilitation, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Gajanan S Revankar
- Department of Health and Sport Sciences, Graduate School of Medicine, Osaka University, Osaka, Japan.,Institute for Transdisciplinary Graduate Degree Programs, Osaka University, Osaka, Japan
| | - Shoji Konda
- Department of Health and Sport Sciences, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yuki Uno
- Department of Health and Sport Sciences, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tomohito Nakano
- Department of Neurology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yuta Kajiyama
- Department of Neurology, Graduate School of Medicine, Osaka University, Osaka, Japan.,Department of Neurology, Sakai City Medical Center, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Ken Nakata
- Department of Health and Sport Sciences, Graduate School of Medicine, Osaka University, Osaka, Japan
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Abstract
Noncontact sports are associated with a variety of neurologic injuries. Concussion, vascular injury (arterial dissection), and spinal cord trauma may be less common in noncontact sports, but require special attention from the sports neurologist. Complex regional pain disorders, muscle injury from repetitive use, dystonia, heat exposure, and vascular disorders (patent foramen ovale), occur with similar frequency in noncontact and contact sports. Management of athletes with these conditions requires an understanding of the neurologic consequences of these disorders, the risk of injury with return to play, and consideration for the benefits of exercise in health restoration and disease prevention.
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Affiliation(s)
- Robert J Marquardt
- Department of Neurology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Andrew Blake Buletko
- Department of Neurology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Andrew Neil Russman
- Department of Neurology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Pirio Richardson S, Altenmüller E, Alter K, Alterman RL, Chen R, Frucht S, Furuya S, Jankovic J, Jinnah HA, Kimberley TJ, Lungu C, Perlmutter JS, Prudente CN, Hallett M. Research Priorities in Limb and Task-Specific Dystonias. Front Neurol 2017; 8:170. [PMID: 28515706 PMCID: PMC5413505 DOI: 10.3389/fneur.2017.00170] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 04/11/2017] [Indexed: 11/13/2022] Open
Abstract
Dystonia, which causes intermittent or sustained abnormal postures and movements, can present in a focal or a generalized manner. In the limbs, focal dystonia can occur in either the upper or lower limbs and may be task-specific causing abnormal motor performance for only a specific task, such as in writer’s cramp, runner’s dystonia, or musician’s dystonia. Focal limb dystonia can be non-task-specific and may, in some circumstances, be associated with parkinsonian disorders. The true prevalence of focal limb dystonia is not known and is likely currently underestimated, leaving a knowledge gap and an opportunity for future research. The pathophysiology of focal limb dystonia shares some commonalities with other dystonias with a loss of inhibition in the central nervous system and a loss of the normal regulation of plasticity, called homeostatic plasticity. Functional imaging studies revealed abnormalities in several anatomical networks that involve the cortex, basal ganglia, and cerebellum. Further studies should focus on distinguishing cause from effect in both physiology and imaging studies to permit focus on most relevant biological correlates of dystonia. There is no specific therapy for the treatment of limb dystonia given the variability in presentation, but off-label botulinum toxin therapy is often applied to focal limb and task-specific dystonia. Various rehabilitation techniques have been applied and rehabilitation interventions may improve outcomes, but small sample size and lack of direct comparisons between methods to evaluate comparative efficacy limit conclusions. Finally, non-invasive and invasive therapeutic modalities have been explored in small studies with design limitations that do not yet clearly provide direction for larger clinical trials that could support new clinical therapies. Given these gaps in our clinical, pathophysiologic, and therapeutic knowledge, we have identified priorities for future research including: the development of diagnostic criteria for limb dystonia, more precise phenotypic characterization and innovative clinical trial design that considers clinical heterogeneity, and limited available number of participants.
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Affiliation(s)
- Sarah Pirio Richardson
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Eckart Altenmüller
- Institute for Music Physiology and Musicians' Medicine (IMMM), Hannover University of Music, Drama and Media, Hannover, Germany
| | - Katharine Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD, USA
| | - Ron L Alterman
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert Chen
- Division of Neurology, Department of Medicine (Neurology), Krembil Research Institute, University of Toronto, Toronto, ON, Canada
| | - Steven Frucht
- Robert and John M. Bendheim Parkinson and Movement Disorders Center, Mount Sinai Hospital, New York, NY, USA
| | - Shinichi Furuya
- Musical Skill and Injury Center (MuSIC), Sophia University, Tokyo, Japan
| | - Joseph Jankovic
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - H A Jinnah
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.,Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA.,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Teresa J Kimberley
- Department of Rehabilitation Medicine, Division of Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis, MN, USA
| | - Codrin Lungu
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Joel S Perlmutter
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Neurosciences, Washington University School of Medicine, St. Louis, MO, USA.,Department of Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA.,Department of Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Cecília N Prudente
- Department of Rehabilitation Medicine, Division of Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis, MN, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
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7
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Cutsforth-Gregory JK, Ahlskog JE, McKeon A, Burnett MS, Matsumoto JY, Hassan A, Bower JH. Repetitive exercise dystonia: A difficult to treat hazard of runner and non-runner athletes. Parkinsonism Relat Disord 2016; 27:74-80. [PMID: 27017145 DOI: 10.1016/j.parkreldis.2016.03.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/29/2016] [Accepted: 03/17/2016] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Runner's dystonia has previously been described in small series or case reports as a lower limb, task-specific dystonia. We have occasionally encountered this disorder and recognized the same phenomenon in non-runners regularly engaging in lower limb exercise. We wished to characterize the syndrome further, including outcomes, treatment, and the diagnostic usefulness of electrophysiology. METHODS We conducted a retrospective review and follow-up survey of adults seen at Mayo Clinic (1996-2015) with task-specific dystonia arising after prolonged repetitive lower limb exercise. The findings were compared to all 21 previously reported cases of runner's dystonia. RESULTS We identified 20 patients with this condition, 13 runners and seven non-runner athletes. Median age at dystonia onset was in mid-adulthood. Correct diagnosis was delayed by a median of 3.5 years in runners and 1.6 years in non-runners, by which time more than one-third of patients had undergone unsuccessful invasive procedures. Most patients had dystonia onset in the distal lower limb. Dystonia was task-specific with exercise at onset but progressed to affect walking in most. Sensory tricks were reported in some. Surface EMG was consistent with task-specific dystonia in nine patients. Botulinum toxin, levodopa, clonazepam, trihexyphenidyl, and physical therapy provided modest benefit to some, but all patients remained substantially symptomatic at last follow up. CONCLUSIONS Repetitive exercise dystonia is task-specific, confined to the lower limb and occasionally trunk musculature. It tends to be treatment-refractory and limits ability to exercise. Diagnosis is typically delayed, and unnecessary surgical procedures are common. Surface EMG may aid the diagnosis.
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Affiliation(s)
| | - J Eric Ahlskog
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
| | | | | | - Anhar Hassan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
| | - James H Bower
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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8
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Bloem BR, Voermans NC, Aerts MB, Bhatia KP, van Engelen BGM, van de Warrenburg BP. The wrong end of the telescope: neuromuscular mimics of movement disorders (and vice versa). Pract Neurol 2016; 16:264-9. [PMID: 26965497 DOI: 10.1136/practneurol-2015-001311] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2016] [Indexed: 11/04/2022]
Abstract
The rapid advances in modern neurology have led to increased specialisation in clinical practice. Being an expert in a neurology subspecialty offers advantages for diagnosing and managing specific disorders. However, specialisation also risks tunnel vision: interpreting symptoms and signs within one's own framework of reference, while ignoring differential diagnostic options from other subspecialties. This is particularly relevant when the patient's presentation potentially belongs to different neurological subspecialties. We illustrate this challenge by highlighting a series of clinical features that partially overlap between two common subspecialties: movement disorders and neuromuscular disorders. An overlap in clinical presentation is not rare, and includes, for example, involuntary eyelid closure (which could be active eye closure due to blepharospasm, or ptosis due to weakness). Other overlapping features include abnormal postures, involuntary movements and gait changes. We describe two of these overlapping features in more detail and emphasise the possible consequences of 'looking through the wrong end of the telescope' in such patients, as this may lead to a wrong differential diagnosis, unnecessary investigations and a delayed treatment start.
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Affiliation(s)
- B R Bloem
- Department of Neurology, Donders Institute of Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - N C Voermans
- Department of Neurology, Donders Institute of Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M B Aerts
- Department of Neurology, Donders Institute of Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - K P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, UK
| | - B G M van Engelen
- Department of Neurology, Donders Institute of Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - B P van de Warrenburg
- Department of Neurology, Donders Institute of Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
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9
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Abstract
Sensory tricks are various manoeuvres that can ameliorate dystonia. Common characteristics are well known, but their variety is wide, sensory stimulation is not necessarily the critical feature, and their physiology is unknown. To enumerate the various forms of sensory tricks and describe their nature, research findings and theories that may elucidate their neurophysiologic mechanism, we reviewed the literature pertaining to sensory tricks, including variants like motor tricks, imaginary tricks, forcible tricks and reverse sensory tricks. On the basis of this information, we propose a new classification of sensory tricks to include its variants. We highlight neurophysiologic evidence suggesting that sensory tricks work by decreasing abnormal facilitation. We tie this with established dystonia pathogenesis and postulate that sensory tricks decrease abnormally increased facilitation to inhibition ratios in the dystonic brain. It appears worthwhile for patients to search for possible sensory tricks.
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Affiliation(s)
| | | | - Mark Hallett
- Human Motor Control, National Institutes of Health, Bethesda, Maryland, USA
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10
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Focal task-specific lower extremity dystonia associated with intense repetitive exercise: a case series. Parkinsonism Relat Disord 2013; 19:1033-8. [PMID: 23932354 DOI: 10.1016/j.parkreldis.2013.07.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 06/28/2013] [Accepted: 07/15/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Focal task-specific dystonia of the lower extremity associated with intense repetitive exercise has recently been recognized. The clinical course, treatment response and prognosis remain poorly understood. METHODS Individuals with lower extremity task-specific dystonia evaluated at UCSF's Movement Disorders Center (2004-2012) were eligible for this descriptive case study series if he/she had a history of strenuous and prolonged exercise involving the lower extremity and had no abnormal neurological or medical conditions to explain the involuntary movements. Data was gathered from the medical history and a self-report questionnaire. The findings were compared to 14 cases previously reported in the literature. RESULTS Seven cases (4M/3F) were identified with a diverse set of exercise triggers (cycling, hiking, long-distance running, drumming). The mean age of symptom onset was 53.7 ± 6.1 years. The median symptom duration prior to diagnosis was 4 (9.5) years. Several patients underwent unnecessary procedures prior to being appropriately diagnosed. Over a median of 2 (3.5) years, signs and symptoms progressed to impair walking. Seven patients had improvement in gait with treatment (e.g. botulinum toxin injections, benzodiazepines, physical therapy, bracing, body weight supported gait training and/or functional electrical stimulation of the peroneal nerve) and six returned to a reduced intensity exercise routine. CONCLUSIONS Isolated lower extremity dystonia associated with strenuous, repetitive exercise is relatively uncommon, but disabling and challenging to treat. The pathophysiology may be similar to task-specific focal dystonias of the upper limb. Prompt recognition of leg dystonia associated with extreme exercise could minimize unnecessary testing and procedures, and facilitate earlier treatment.
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