A Neurological Physical Therapist’s Guide to the Cervical Dystonia Assessment
Do you remember having your first introduction to cervical dystonia and saying “Cervical what?”
[Disclaimer--people with Cervical dystonia--this blog post is tailored to physical therapist assessment--but loads of good info for you, too! And educate your therapist--bring them this blog post!]
Cervical dystonia (CD) is often a topic that isn’t even mentioned as part of physical therapy education. So, when you started to see patients, you likely searched the literature and didn’t find a whole lot*.
*(But thank you Beth Crowner for a nice summary article from PTJ in 2007 (Crowner 2007)—without your article I would have been really lost!)
We have been lucky to learn by fire by seeing quite a few clients with dystonia here at re+active PT & wellness and now collaborating on research with UCLA looking very closely at the assessment and treatment of dystonia. It has become our passion to explore and understand cervical dystonia assessment and treatment, and since we know that high-quality information on cervical dystonia can be hard to come by, we we wanted to create a go-to guide for you on the most up-to-date and effective assessment and treatment methods for CD.
PLEASE NOTE: This information is only a small segment of our Dystonia Mini Course
We’ve written an entire course on the dystonia assessment, but for the purpose of this post today we’ll cover the basics so you have some great tools to start your CD assessment.
We’ve also gathered all the basics of the assessment and treatment of Cervical Dystonia into two helpful 1-page PDF Cheat Sheets that you can download for free. When you get your cheat sheets, you’ll also get 3 videos of treatment techniques we use on a regular basis at re+active!
Okay, let’s get to it!
Today we’re going to cover:
Brief introduction to the pathophysiology of CD
Sensory testing in CD
Checking muscle activity
Looking at potential predisposing factors
Trying out some tricks for immediate response
Questionnaires and assessment tools that are helpful
You can always check out Part 2 of this series that expands on the assessment and outlines some of the most effective treatment techniques for CD.
Why Pathophysiology of Cervical Dystonia Matters (Don’t Skip this Part!)
Thanks to my teaching at USC, I am a neuropathology and neurophysiology nerd, and I can’t dive into any discussion of assessment with talking a little bit about the proposed pathophysiology of cervical dystonia. I say “proposed” because there is still a lot to learn and discover in this field (don’t you just love neuro for that!) .
Now I’ll keep this simple here—we have a whole section on this in our Dystonia Mini Course. I love sensation and classifying disorders according to their presenting symptoms.
However, for our purposes today, I’ll keep it brief.
Research has demonstrated that the pathology is not simple (no surprise there!) but essentially cervical dystonia is both a sensory disorder and an integration disorder.
What exactly is a sensory and integration disorder? It means that the sensory input can be impaired (Tinazzi et al 2009 Obermann et al 2010, Hallet 2011), the integration of the sensory input with motor output can be impaired and the mismatch of inputs can lead to involuntary muscle contractions and impaired postural righting responses (Byl 2013). In the following figure, from a theoretical model of focal dystonia called SMILE (Sensory-Motor Integrative Loop for Enacting), we see this idea in focal hand dystonia.
The SMILE model for dystonia: According to a first hypothetical disorganization, FHD could be the consequence of altered calibration (CALIB) due to abnormal signal sent from S1 and M1, resulting in an aberrant motor command. (B) A second hypothesis concerns the possibility that the sensory information is distorted already in the low-level nodes, resulting in an altered signal transmitted from the sensory processing nodes to S1 and the movement preparation nodes (PM-SMA). The dashed lines represent qualitative anomalies in signal processing. The size of the arrows represents the quantitative features of the signal.
Essentially, the authors propose that FHD could be the consequence of altered calibration due to abnormal signal sent from the sensory and motor cortex, resulting in an aberrant motor command. Therefore, as PTs, we would like to distinguish the sensory problem that someone with dystonia might have in order to re calibrate the system. (This article is available open text online--yay! )
Cervical Dystonia Assessment Part 1: Sensory Testing
With the sensory system being such a big part of the pathology,it is important to do sensory testing as part of a thorough assessment.
So—this is where we will start!
**Full Disclosure: This is not actually where I start my eval, but reviewing it first is important because it is often overlooked.
There is evidence that there are impairments in many sensory areas:
vestibular, (Rosengren and Colebatch 2010)
proprioception, (Michels et al 2013)
sensory perception, and (Anastasopoulos et al 1997)
sensory organization (Perruchoud et al 2014)
This is why we recommend including the following tests in your assessment of CD:
Vestibular testing: alignment, EOM, VOR, HIT, DVA
Joint position Error (JPE)
Subjective Visual Vertical (SVV)
Sensory perception: laterality—(Love the Recognise app!) http://www.noigroup.com/en/Product/BTRAPP
Sensory organization/ balance/ Postural righting responses: orient head to vertical on flat, angled or unstable surfaces
Cervical Dystonia Assessment Part 2: Movement Analysis
Movement analysis is the heart of most physical therapy evaluations and CD is no different. This is where I usually start my evaluation.
In CD the movement analysis involved describing the position of the neck, shoulders, trunk and pelvis at rest and in movement (following the patient’s cues to where they see it the most and where they see it the least).
The added bonus part of movement analysis in CD is the manipulation of the environment, posture, positioning and speed in order to determine the effect of change in sensory input to the CD.
You will learn SOOOO much from this part of the evaluation!
This is literally where you might have your client hanging upside down (and realizing they don’t have dystonia in this position!)
One of my favorite examples of this is when I had a patient with CD who had much worsened tilt and rotation when walking. When we introduced a slight knee bend to her walking (improving her loading response and forward progression), her CD disappeared.
There are a million ways to manipulate the environment, posture, position, etc., so have fun with your problem solving here!
Cervical Dystonia Assessment Part 3: Muscle Activity
Often during the movement analysis, I will use surface EMG to look at the muscle activity in all of these different crazy positions.
But your hands are also powerful tools to palpate muscle activity in the neck and shoulder to hypothesize underlying causes (and potential treatment targets if you are collaborating with a neurologist for injections).
I remember having to study up on all of my neck muscle anatomy and function to feel confident in my skills for this part. I love this figure from the Toronto Western Spasmodic Torticollis Rating Scale assessment form that outlines some of the key injection targets—this is where I started my neck review.
Common injection sites for cervical dystonia.
Cervical Dystonia Assessment Part 4: Predisposing Factors
Muscle imbalances become quite apparent when looking at muscle activity and you often reach a chicken or egg dilemma—did the muscle imbalance contribute to the development of dystonia, or is a result?
We usually cannot tell the difference, but regardless--we need to address it.. Other potential predisposing factors to investigate include:
Flexibility: muscle and joint--especially cervical, thoracic and lumbar spine and hip
Biomechanics and alignment: look at alignment of pelvis, trunk and head in sitting, supine and standing.
Neural tension: check all upper limb tension patterns
Breathing pattern: check for diaphragmatic vs. upper chest breath and level of neck muscle activity during breathing.
Personal factors: recognizing if the person has a tendency to be a high achiever and/or perfectionist in their daily life. (Ioannou et al 2014, Kuyper et al 2011)
From a treatment standpoint, exploring and addressing these potential predisposing factors can give you a big bang for your buck.
Cervical Dystonia Assessment Part 5: Evaluate Immediate Response
In my evaluations, I am a firm believer in spending about half of the time in treatment, so I find it very helpful to evaluate for activities that provide an immediate improvement in my patient. The ideas below are especially helpful if the person is most limited by a sensory or sensory integration abnormality.
A common sensory trick for CD is the hand over the head.
Sensory tricks (the arm over the head is a common one)
TENS or vibration on overactive muscles
Kinesiotaping for inhibition of overactive muscles (very helpful for an overactive upper trapezius) (add picture)
Change in posture (hang upside down!)
Weighted vest/ weight (http://www.motiontherapeutics.com my personal favorite)
Finally, I wanted to provide you with some really great tools and questionnaires that we have found highly valuable in CD. We are currently working with UCLA to help validate the PSFS in the population (because it is our favorite tool to use), so stay tuned and we will share those results once we have them. I have included some key references to the scales as well.
Patient Specific Functional Scale (PSFS) http://www.jospt.org/doi/abs/10.2519/jospt.1922.214.171.1241?code=jospt-site
Cervical Dystonia Impact Profile (CDIP) https://www.ncbi.nlm.nih.gov/pubmed/15534247
Hospital Anxiety and Depression Scale http://www.sciencedirect.com/science/article/pii/S002239990100296
Patient Global Impression of Change (PGIC) https://s3.amazonaws.com/chirocode-data-files/deskbook/Patient+Global+Imp+of+Change.pdf
Clinician Global Impression of Change (CGIC) http://www.sciencedirect.com/science/article/pii/S0022510X14007953
Toronto-Western Specific Torticolis Scale (TWSTRS) - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3575559/
Unified Dystonia Rating Score- http://www.movementdisorders.org/MDS-Files1/PDFs/Rating-Scales/dystonia.pdf
Whew - We made it through the CD assessment! At re+active, we literally stumbled through the dystonia evaluation for several months before starting to put it together in a more systematic way. Now, with our whole clinic doing this evaluation, we have been able to get to the underlying problems more quickly and see results.
We have boiled down this approach into an easy to use Cervical Dystonia Evaluation cheat sheet. Simply fill out your information and we will also include a treatment cheat sheet and three great treatment videos that you can use in the clinic with your patients immediately!
Remember, this information is only a small segment of our Dystonia Mini Course
Cheers to your #iloveneuro spirit,
Dr. Julie Hershberg, PT, DPT, NCS
Anastasopoulos, D., Bhatia, K., Bronstein, A. M., Marsden, D., & Gresty, A. (1997). Perception of Spatial Orientation in Spasmodic Torticollis tolerance to tilt, 12(4), 561–569.
Bove, M., Brichetto, G., Abbruzzese, G., Marchese, R., & Schieppati, M. (2004). Neck proprioception and spatial orientation in cervical dystonia. Brain, 127(12), 2764–2778. http://doi.org/10.1093/brain/awh291
Byl N. (2013) Cervical Torticollis: Analysis of Etiology and Intervention. CPTA Dystonia Course, UCSF, San Francisco, CA.
Crowner, B. E. (2007). Cervical dystonia: disease profile and clinical management. Physical Therapy, 87(11), 1511–1526.
Elwischger, K., Kranz, G., Sycha, T., Rommer, P., Muller, C., Auff, E., & Wiest, G. (2013). Effects of botulinum toxin treatment on subjective visual vertical perception in cervical dystonia. Journal of the Neurological Sciences; J Neurol Sci, 333, e104. http://doi.org/10.1016/j.jns.2013.07.630
Fiorio, M., Tinazzi, M., Ionta, S., Fiaschi, A., Moretto, G., Edwards, M. J. Aglioti, S. M. (2007). Mental rotation of body parts and non-corporeal objects in patients with idiopathic cervical dystonia. Neuropsychologia, 45(10), 2346–2354.http://doi.org/10.1016/j.neuropsychologia.2007.02.005
Hallett, M. (2011). Neurophysiology of dystonia: The role of inhibition. Neurobiology of Disease, 42(2), 177–184.
Ioannou, C. I., & Altenmüller, E. (2014). Psychological characteristics in musician’ s dystonia : A new diagnostic classification, (61), 80–88.
Kuyper, D. J., Parra, V., Aerts, S., Okun, M. S., & Kluger, B. M. (2011). The Non-Motor Manifestations of Dystonia: A Systematic Review. Mov Disord., 26(7), 1206–1217.
Leplow, B., & Stubinger, C. (1994). Videuospatial Functions in Patients with Spasmodic Torticollis, 78(1), 1363–1375.
Michiels, S., De Hertogh, W., Truijen, S., November, D., Wuyts, F., & Van de Heyning, P. (2013). The assessment of cervical sensory motor control: A systematic review focusing on measuring methods and their clinimetric characteristics. Gait and Posture. http://doi.org/10.1016/j.gaitpost.2012.10.007
Obermann, M., Vollrath, C., De Greiff, A., Gizewski, E. R., Diener, H. C., Hallett, M., & Maschke, M. (2010). Sensory disinhibition on passive movement in cervical dystonia. Movement Disorders, 25(15), 2627–2633
Perruchoud, D., Murray, M. M., Lefebvre, J., & Ionta, S. (2014). Focal dystonia and the Sensory-Motor Integrative Loop for Enacting (SMILE). Frontiers in Human Neuroscience, 8(June), 458. http://doi.org/10.3389/fnhum.2014.00458
Rosengren, S. M., & Colebatch, J. G. (2010). Vestibular evoked myogenic potentials are intact in cervical dystonia. Movement Disorders : Official Journal of the Movement Disorder Society, 25(16), 2845–53.http://doi.org/10.1002/mds.23422
Tinazzi, M., Fiorio, M., Fiaschi, A., Rothwell, J. C., & Bhatia, K. P. (2009). Sensory functions in dystonia: Insights from behavioral studies. Movement Disorders, 24(10), 1427–1436. http://doi.org/10.1002/mds.22490
Zwergal, A., Rettinger, N., Frenzel, C., Dieterich, M., Brandt, T., & Strupp, M. (2009). A bucket of static vestibular function. Neurology, 72(19), 1689–1692. http://doi.org/10.1212/WNL.0b013e3181a55ecf