Physical Therapy for Cervical Dystonia

Spasmodic Torticollis (also know as Cervical Dystonia) is a rare (0.37% incidence in the US as of a 2007 study) painful chronic neurological movement disorder causing the neck to involuntarily turn to the left, right, upwards, and/or downwards. The most common treatment for this disorder is the use of Botulinum Toxin Type A.  

Although directed at the symptoms of this disorder rather than the cause, physical therapy for ST is considered very effective at improving comfort, movement and posture and can be extremely helpful at improving the symptoms of the disorder in addition to other treatments.

Physical therapy treatment of ST is an advanced practice and is not taught routinely at any great depth in PT educational programs. Burke Selbst, PT has worked closely with several members of the local ST community for the past several years and has developed a number of strategies and exercises using a combination of hands-on manual therapy and a movement and posturally based approach. Burke was invited to attend and present at the Oregon Dystonia Medical Research Foundation’s Springfield Meeting in May 2014. Below is a brief outline of the presentation.

Background:

Physical Therapy helps treat the symptoms of dystonia that affect movement, posture, balance, stamina and performing everyday tasks like driving, walking, carrying and working.Working with a therapist to help restore lost joint and muscle mobility, learn movements or exercises to train weakened or compensated muscles and maintain balance and stamina are all important parts of a therapy program. Two very important foundational goals with therapy are to improve body posture awareness and control. Changes with therapy are likely to be slow, and clients are advised to approach treatment and exercise with patience. One benefit of therapy is a reduction in muscle and joint pain from extreme postures and stresses by increasing supportive strength and blood flow.

General Recommendations

• Use tools to provide feedback on body position and posture including mirrors, feedback from others (spouses for example), foam rollers and body awareness exercises .
• Practice good posture more easily by sitting on firm chairs and making sure you are in good posture when watching TV, on the computer, driving, sleeping and at work.
  • The posture log: Keep a log of anywhere you spend more than 20 minutes at a time, or that you repeat a shorter session more than 2 or 3 times over the course of a typical day.
  • Set a goal to maintain good posture 80% of the time.
• Consider using aids or modifications for repeated activities to help you maintain optimal alignment. Examples include ergonomic keyboard trays, mirrors for blind spots etc.
• Stay active or develop a regular exercise program – symmetrical movements such as swimming, cycling, walking/jogging are all excellent – a strong body fights stress more effectively.
• Come up with a stress reduction plan and practice stress reduction techniques – This can include stress reduction/relaxation techniques such as breathing exercises, visualization and progressive muscle relaxation to stress reducing activities including Tai Chi, Feldenkrais and Yoga. Make meditation a part of these activities and practice them daily.
• Weight training and specific rehab exercises targeting weak muscle groups and patterns should be incorporated into a daily routine.

How to build the perfect general exercise program

• Exercise your heart and lungs
  • 10k steps/day
  • Frequent posture changes and checks
  • Challenge your system gradually and consistently
• Large and small muscle groups
  • 3 times weekly for large groups of powerful muscles in the hips, legs, back, shoulders.
  • 3 times weekly for the smaller groups, core, neck, arm specifics
• Find the best time of day for you to exercise – morning is commonly better for many people.
• Avoid fast ballistic movements which tend to increase unwanted postural tension.
• Use body positions which encourage your body to use your weaker muscles and limit your stronger muscles – examples include strengthening your back and shoulders while laying on your front or face down over a ball.
• Stretching Guidelines
  • Use a separate workout for your flexibility/movement so you can concentrate on slow, relaxed and easy flexibility and reducing your muscle tone.
  • Find time to work on lengthening your specific spastic muscles up to three times daily if possible.
  • Think “Length” rather than “Stretch” to stay relaxed.
  • Hold stretches up to 60 seconds and also incorporate slow easy movement in the lengthened position to retrain your postural control.
• Exercises Movements and Pathways in addition to muscles – If performed slowly with body awareness and without strain, you can use movements and exercises to retrain your nervous system to control movement more symmetrically and with less force. Ideally this should be practiced often, and done before more vigorous activities are performed.

Cervical Dystonia Exercises: Focus PT Program

Guidelines:

Develop familiarity with the movements and exercises, and spend a little time in the am and pm performing a variety of the movements. It is not necessary to do them all, and they should be comfortable although a stretch may be felt. Movements should be done slowly, in a relaxed way and with easy breathing. There are MANY more movement patterns you can learn if you find these helpful.

Free Your Pelvis

1. Cat and Cow: 3 Planes of Movement Sequence
2. On your back: Lean your knees side to side
3. On your back: hold your (lifted) knees with your hands and roll side to side smoothly
4. On your back and then on your side: Make single leg hip circles in both directions.

Free Your Shoulders and Ribs

1. On your back: Arm reach towards the ceiling with a slight body lift/roll
2. On your back: Fingers interlaced behind your head – roll your head side to side with your hands, then add a body roll similar to #s 2 and 3 above.
3. In ¼ Prone (lay face down but rolled slightly off one side of your body towards your side): “Baby Alligator” – prop yourself with one hand, rotate your hips, loop under the gap of your propped hand and round your spine.
4. On your back on a foam roller: Perform the ‘Elongation Wave’ – alternately bridging your neck (with hand support) and your pelvis.

Free Your Neck

1. On your side: roll your body forward and backward with a firm head support that allows you to over-roll your neck in both directions
2. On your back: head turned slightly in weak/tight direction – one hand behind your head (kept rotated) and another hand to one of your knees (you can do either knee) – slowly fold your body (almost but not quite a situp) to lengthen your tight extensor muscles
3. On your back: Perform the ‘Fencer’ movement with your arms outstretched to either side and your knees bent. Rotate and reach alternately from each shoulder while you glide your neck side to side.

Use a Roller or Soft Ball

Spend some time with a firm foam roller or a soft ball to do self massage throughout your spine, shoulders and hips.