Cervical Dystonia or Spasmodic Torticollis is a condition characterized by abnormal spasm of the neck and shoulder muscles. This disease affects one’s ability to control their own muscles. Physical Therapy can be beneficial for people diagnosed with Cervical Dystonia. The treatment plan is highly individualized and may consist of many facets from relaxation techniques, yoga, stretching, nutrition support, meditation, dry needling and movement therapy.
The goals of physical therapy are to restore normal movement patterns, ones that have been lost. When pain occurs in the body, it shuts down the deep stabilizing muscles and our “global” muscles take over, which causes more pain, muscle tightness, postural changes, and weakness. So, it is important to stretch the shortened, tight muscles, but to also strengthen the weakened muscles in order to optimize function.
In addition to treating the painful, shortened, tight muscles in your neck, it is important to address the issues below the neck in your foundation or what is referred to as your “core”. I have found that most patients with Cervical Dystonia also have weakness in their core muscles. You are connected from head to toe by your joints and your connective tissue (muscles, fascia, tendons, ligaments). Your connective tissue is what holds you together. Chances are you have “weak links” or weaknesses in your shoulder blade and postural muscles, your trunk muscles (abdominals and low back) and your pelvic muscles (gluteals or the buttock muscles and the adductors in your inner thighs). Your trunk and pelvis are your foundation. If you are weak in your foundation, it can affect you all the way up to your neck, making it very challenging to hold your head up and to maintain good posture.
It is important to work with a physical therapist or movement specialist who understands your condition or that is willing to learn about your condition so that you do not over do it causing more pain and discomfort exacerbating your symptoms. Patients with Cervical Dystonia will benefit from individualized, supervised physical therapy care that is comprehensive focusing on the whole body to restore movement patterns, postural control and the ability to control your own muscles. The purpose of this article is to summarize the current treatment options that are available in the management of Cervical Dystonia.
Neuroplastic Movement Therapy
Specific exercises utilizing movements and mental imaginery that may induce neuroplastic change essentially rewiring the brain allowing gradual motor control recovery. Some patients use music, dance or other forms of stimulating techniques to ‘relax’ the brain into a state of pleasurable re-learning and neuroplasticity. Some individuals see immediate improvements while others may take weeks, even months before some or all movement is corrected. Each patient and situation will be different and the therapies used will be unique to the patient’s own condition, preference and lifestyle.
Dr. Joaquin Farias “considers dystonia to be a temporary lack or loss of accuracy and precision in brain activity and that movement therapy aims to retune the brain and restore proper function of cognitive processes, perception and motor functions”. The goal of movement therapy is not to create any new motor skills, but to recall the skills developed in the past, helping the brain remember how to move again. To learn more check out http://www.fariastechnique.com.
Self-stretching should be performed on the neck and cervical muscles and should also include the low back, hips, thighs, lower legs, and feet. Your connective tissue travels from head to toe, so by stretching the entire body, you can decrease tension in the neck. Almost always, the side to which your head turns is the “short side” (your muscles are more contracted on that side which pulls the head over and usually pulls that shoulder up.) You are actually short all the down on that side, so stretching your neck all the way down the back and into the hips can be effective daily stretches. To learn more you can visit https://stclinic.com/
There are many manual therapy techniques including Osteopathic Muscle Energy, Connective Tissue Mobilization, Myofascial Release, and Joint Mobilization, which aim to restore alignment and mobility in your joints, muscles, and fascia. These are all gentle techniques that are performed by physical therapists and utilized in the treatment of Cervical Dystonia.
Muscle tightness is a common cause of severe neck pain with Cervical Dystonia. The muscles in your neck and upper back are constantly in motion often from tremors, so those muscles develop “knots”, which are taut, rope-like bands located within contractured muscles fibers that cause pain. These “knots” are referred to as “myofascial triggerpoints”. Myofascial Triggerpoints decrease normal blood flow to the muscles, cause a build-up of acid, increase local inflammation, and decrease normal muscle activation.
Dry Needling is an innovative technique that is used to deactivate and release painful myofascial triggerpoints, ultimately “resetting” the system to restore normal mobility and function to the muscle. Dry Needling is very different than acupuncture. A thin filament needle is inserted into the skin and muscle directly at a myofascial triggerpoint, which elicits a local involuntary muscle contraction that decreases pain, allows the muscle to relax, and resets the muscle to its normal strength and function. The microtrauma from the needle also stimulates a healing response and increases blood flow into the painful tissue. It is called Dry Needling because it does not involve injecting a “wet” substance like saline, Botox, or cortisone. Dry needling may be highly effective in alleviating severe pain associated with Cervical Dystonia.
Redcord Suspension Training
Neuromuscular activation exercises are often used in physical therapy to re-educate and strengthen the affected neck and upper back muscles that are weakened with Cervical Dystonia. The Neurac Method is a form of neuromuscular activation that utilizes the Redcord Suspension Workstation for examination and treatment of neuromuscular weak links, asymmetries, and pain. Redcord is unique because you exercise while suspended in ropes and bungee cords, which helps your muscles activate and allows you to exercise pain-free while your body is supported. The bungee cords and ropes support your body weight making it easy to exercise, which can be challenging with Cervical Dystonia as exercise often hurt. In response to pain, our “local” muscles shut down and our larger “global” muscles take over and compensate, eventually becoming stressed, strained and painful, which is characteristic of Cervical Dystonia. The Neurac Method and Redcord aim to decrease pain and reactivate your weakened muscles. The Redcord Suspension System can also be used for general body strengthening while supported in the slings and bungees making it easy for anyone with Cervical Dystonia to exercise pain free. Even if your physical therapist does not have Redcord, they can still provide you with a host of other neuromuscular activation exercises.
Functional Electrical Stimulation (FES) for 30 minutes where electrodes are placed on the non-dystonic antagonist muscles in the neck and shoulders has been found to be effective in conjunction with cervical stretching and manual therapy. Heat packs and warm baths can be helpful in managing pain. Epsom salts contain magnesium sulphate, which is a central nervous system inhibitor, so add some epsom salts and essential oils into a warm bath to aid in muscle relaxation at night before bedtime.
Traditional Chinese Medicine
Acupuncture restores the body’s flow of energy, referred to as Qi, through various “meridians” allowing the body to heal itself. Cupping utilizes glass cups to create a vacuum to increase warmth and circulation to an injured region of the body releasing toxins from the muscles and soft tissues.
Massage Therapy is a manual technique that is highly effective in the treatment of the short, tight muscles around the neck and upper back. In addition, Massage Therapists can focus on the entire body as well as the neck to help alleviate pain. Since the body is a series of myofascial connective chains, you can affect the neck by working all the muscles within the same chain.
There are many types of yoga to practice. Restorative, Gentle, Therapeutic and Yin Yoga are often the most beneficial to patients with Cervical Dystonia. Yin Yoga is a more passive and quiet yoga (more yin-like) that targets our deeper connective tissues (ligaments, joints, fascia, bones) and strengthen the heart and mind. Anusara yoga is a type of Hatha yoga, which focuses on universal principles of alignment. Pranakriya yoga, which focuses on creating a state of deep introspection through the practice of breathwork and asanas (postures). Yoga and other forms of movement like dance makes you have to focus and plan ahead, which increases the pre-frontal brain activity thereby decreasing the tremors and abnormal tone.
Relaxation and Meditation
Meditation and breathing techniques aid in sympathetic nervous system relaxation. Often meditation and breathing are often performed in yoga practice, but they can also be performed in the comfort and safety of your own home.
As physical therapists, it is our job to understand all the aspects of injury and illness management. Nutrition and clean, healthy eating must be considered in the management of various health conditions and diseases. Taking a closer look at your nutrition may be beneficial for people living with Cervical Dystonia. Current research suggests that certain foods and food groups are inflammatory, toxic, and detrimental to the neuromusculoskeletal system. For optimal health and wellness, many registered dietitians and functional medicine physicians recommend limiting and/or avoiding sugar and sugar substitutes, alcohol, caffeine, grains, junk food, preservatives as these items may be inflammatory. To obtain more specific information about nutrition and its impact on your system, consult with a Registered Dietitian or a Functional Medicine Physician.
There is no proven universal program thus far that acts as a guideline for conservative treatment of Cervical Dystonia. In fact, treatments vary widely, with studies incorporating EMG biofeedback, neuroplastic movement therapy, vibratory therapy, flexibility techniques, postural reeducation, massage therapy, core stability training, manual therapy techniques, functional electrical stimulation, and vestibular stimulation. Studies received varying success, with the highest amount of success seen in programs utilizing physical therapy techniques and movement therapy as an adjunct to Botox injections.
Healthcare practitioners with knowledge of your condition can assist you in managing your Cervical Dystonia. There is value in building a strong team of experts around you. Some patients are not fully aware of the current physical therapy treatment options available or that there are other disciplines like Massage Therapy, Acupuncture, and Yoga that can work in concert with Physical Therapy to help achieve success. While some patients may enter remission, some may require lifelong care to manage the symptoms of Cervical Dystonia. Contact us to book an appointment so we assist you in your journey.
Dr. Melissa Baudo Marchetti is a Board Certified Sports Clinical Specialist at One on One Physical Therapy, a multidisciplinary private practice in Atlanta. For nearly five years she was a full-time sports physiotherapist for the WTA Tour and is a tennis medicine and sports medicine expert. She teaches a Sports Physical Therapy course and assists in teaching orthopedics within the Division of Physical Therapy at Emory University. Learn more by visiting www.onetherapy.com or email Dr. Baudo Marchetti at Melissa@onetherapy.com.