Treatment of spasmodic torticollis by a psycho-motor retraining: A method developed 100 years ago by Henry Meige

I was invited last week to lecture at the University of Liege ( Belgium ) about the understanding of dystonia by Henry Meige, a French neurologist . I went back to his original publications and found that he advocated in 1907 a psycho-motor retraining (“discipline psycho-motrice”) for the treatment of spasmodic torticollis…

The Magic Mirror, Magritte, 1929

 

Treatment of spasmodic torticollis by a psycho-motor retraining:  A method developed 100 years ago by Henry Meige

I was invited last week by Professor Gustave Moonen to lecture at the University of Liege (Belgium) about the understanding of dystonia by Henry Meige, a French neurologist.

I went back to his original publications and found that he advocated in 1907 a psycho-motor retraining (“discipline psycho-motrice”) for the treatment of spasmodic torticollis. It was at the time when there was no routine use of anticholinergics and Botox injection for cervical dystonia was not even a blip on the horizon. I could not resist to give you the translation of this therapeutic approach that I found quite inspiring…

1-The patient becomes actor of his treatment: “I don’t say the patient is cured, but the patient has cured himself”. This treatment is based on regular immobilizations and movements in front of a mirror; the patient has to be supported by his family and his doctor, as these daily exercises require a lot of effort and determination from the patient. “The goal of the treatment is to correct the abnormal postures, the put at rest the hyperactive muscles and to learn the control of the motor acts.”

2-The patient needs to have a regular life, going to bed at regular times. The patient is told that the course of the disease will be capricious, that he will have to perseverate and that the exercises will be eventually beneficial.

3-The patient had to exercise in front of a mirror 3 times a day; the patient is sitting, back non supported and hands flat on a table. The mirror is divided by 1 vertical line going through the middle of the face and 2 horizontal lines, through the alignment of the eyes and through the base of the neck above the shoulders, in order for the patient to be aware of the movement of his head. The patient is asked to focus on the point of crossing of the first 2 lines.

 

4-Two types of exercises:

 1-Immobilization: for 5 seconds 10 times with 15 seconds rest in between each immobilizations, increasing of 5 seconds every day the immobilization time.

2- Movement: slow and smooth movement, without saccade of the head in rotation, lateral flexion, flexion forward and extension; also movements of the shoulders, arms and trunk and exercises of relaxation of the muscles.

Then also in front of the mirror, exercises of writing, reading, breathing and speaking and daily tasks exercises.

5- Cervical dystonia has a good prognosis:

 Henry Meige was convinced that over the years the cervical dystonia always settle down, with the dystonic spasms becoming less severe and less frequent, until they disappear; the patient is left with only neck stiffness. He did not give any figure of proportion of patients who improved, but they were patients followed for more than 5 years.

6-Since the 80’s, physiotherapy for cervical dystonia has been developed by Jean-Pierre Bleton in France, but still remains a French specialty despite individual effort to develop it abroad.

Botox injections had become the first line treatment for cervical dystonia,, leaving the patient in the passive expectation of his injections every 3 months.

The mirror is still a very important tool in the therapeutic approach of neck dystonia as the patient is very inaccurate when assessing the position of his head, thinking that his head is straight when in reality the head posture has a 20 degrees tilt or rotation.

May be it’s the time for patients with cervical dystonia to become actor of their treatment and to look for a therapeutic strategy including Botox injections and “psycho-motor retraining “  without forgetting the role of the mirror, like Magritte, a Belgium painter…

Meige H : Les peripeties d’ un torticolis mental. Histoire clinique et therapeutique.. Nouvelle iconographie de la Salpetriere. 1907, 6:461-480

 

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Don’t push your dystonia!

 Push up and Press up have became part of the life of young adults…

Dr MH Marion explains why weight lifting is not advisable in cervical dystonia patients…

 

Don’t push your dystonia!

 

1-Push up and Press up have became part of the life of young adults. Going to the gym is a healthy and an advisable way of keeping fit in a urban society, which expect us to be sitting all day long in front of a computer and to be in full shape for climbing mountains.

However, it’s more recent that weight lifting to reinforce selectively muscle strength and to modify body shape is part of the routine of ordinary people, who are neither athletes, nor body builders.  Weight lifting can quickly be part of the life style, with addictive personal challenges to lift heavier and heavier weights.

2-Cervical dystonia is a neurological condition, affecting young adults, resulting in an unbalanced activity of the neck muscles. Some muscles are hyperactive, and inhibit their counterpart on the other sides (reciprocal inhibition); for instance a patient with an involuntary rotation of the head to the right (right spasmodic torticollis) will have a large , hyperactive left Sterno-Cleido Mastoid muscle and a thin right Sterno-Cleido-Mastoid muscle. For a better understanding, read the blog “What makes my head turn?”.

The treatment of cervical dystonia is based on Botulinum injections, which correct this disequilibrium by relaxing the hyperactive muscles and on physiotherapy by reinforcing the inhibited muscles.

3- Is weight lifting contra-productive in patients with cervical dystonia?

I had the opportunity to treat few patients with cervical dystonia who were adept of weight lifting practice. These patients require larger doses of Botulinum toxin, even if the small number of cases doesn’t allow any scientific conclusion. This could explain by the fact that the exercised muscles became larger and stronger.

But the question is which exercises have an impact on the neck muscles and are some exercise worst than others, by targeting neck muscles involved in the dystonia?

I had the opportunity to discuss resistance training exercises with a specialized exercise instructor , Mr Rajah James who gave me a reference book “ Strength training anatomy” from Frederic Delavier. Every resistance training exercise is analysed in terms of functional anatomy with detailed illustrations of which muscles are targeted for each exercise. It’s an amazing book full of details and drawing, that I will strongly advise to anybody interested in exercising against resistance.

4-. Exercises to avoid at any cost:

The neck muscles are involved in the erect posture of the neck, in another words keeping the neck straight; any weight lifting will tense the neck muscles to stabilize the neck during the effort.

More specifically, shoulders muscles such as Trapezius and Levator scapulae elevate the shoulder but also are involved in the rotation, lateral flexion and extension of the neck.

Lateral Arm Raises and Shoulder Shrugs (Machine and Dumbbells shrugs), have to be avoided at any cost; they both reinforce the Trapezius in his upper and anterior part and in addition the shrugs reinforce the Levator Scapulae.

Back Press, Front Press, and Dumbbell Press are reinforcing the Trapezius muscles in its upper part.

 Therefore I advise strongly against any weight lifting exercise in case of cervical dystonia;it can worsen the dystonia by reinforcing the dystonic muscles and increase the muscle unbalamnce and also it can partially compromise the effect of the Botox injections.

5- Physiotherapy for cervical dystonia

The retraining of the cervical muscles, which are becoming less active because of the dystonia, and the stretching of the overactive muscles are a very important part of the treatment. Jean-Pierre Bleton in Paris has written extensively about his original approach of physiotherapy with dystonic patients.

Frederic Delavier: Strength Training Anatomy

http://ebooksfreedownload.org/2011/04/strength-training-

Jean Pierre Bleton : Role of the physiotherapist in the treatment of dystonia

http://books.google.co.uk/books?id=haKD-PjEJ3MC&pg=PA223&lpg=PA223&dq=jean+pierre+bleton&source=bl&ots=yHGkDzRaN3&sig=VhFnlNAlPGqNlnuo7ieIMKR8yjY&hl=en&sa=X&ei=X9FXT42IDsSg8QOc2Mj-Dg&sqi=2&ved=0CFoQ6AEwBg#v=onepage&q=jean%20pierre%20bleton&f=false anatomy.htm

 

The Bali’s dancers head posture in patients with neck dystonia.

Sometimes the analysis of the posture of a patient with cervical dystonia can be tricky; For instance the horizontal translation of the head is a movement that the dancers from Bali can do side to side so graciously. For us European it’s far from natural to dissociate the movement of the head from the neck in a side to side shift. Dystonic patients sometimes have their head shift to one side ….

The Bali’s dancers head posture in patients with neck dystonia.

The horizontal shift of the head.

Sometimes the analysis of the posture of a patient with cervical dystonia can be tricky; For instance the horizontal translation of the head is a movement that the dancers from Bali can do side to side so graciously. For us European it’s far from natural to dissociate the movement of the head from the neck in a side to side shift. Dystonic patients sometimes have their head shift to one side without a lateral tilt and complained of limitation of their active head and neck movements in daily life. How to analyse this dystonic posture is very important when treating the patient with Botulinum toxin injections.

Professor Reichel from Germany kindly sent me 2 weeks ago the latest English version of his book: Therapy guide spasticity-dystonia, which is a very comprehensive and practical guide of the use of Botuinum toxin in these spasticity and dystonia and reflects his vast clinical experience in these fields.

He illustrates in details the horizontal shift of the head with the underlying principle that the role of the muscles in head and neck posture depends of their insertion either on the cervical spine ( Levator scapulae, Scalenius) or on the head itself , mastoid, linae nuchae ( Sterno-cleido-mastoid, Trapezius, Splenius capitis).

The horizontal shift of the head to the right for instance will occur if at the same time the head is tilt to the left and the neck to the right. Prof Reichel uses the terminology of left laterocaput and right laterocollis.

The right levator scapulae and the right scalenius are responsible of the right laterocollis and the left Sterno-cleido-mastoid muscle, the left cervical portion of the Trapezius, and the left Splenius are responsible of the left laterocaput.

 

It seems complicated to follow but it’s quite obvious when examining the dystonic patient with the Bali’s dancer head posture.

But is this posture a primary dystonic posture or the results of an adaptation of the patient ‘s neck posture with a left laterocaput in order to keep the eye line straight when looking in front? There is a reflex loop between eye movement and neck muscles (the cervico-ocular reflex- COR), which with other reflexes prevents visual slip during head and body motion. But this reflex had been found weak or absent in cervical dystonia.

There is still a lot of unexplained observation in dystonia. Fortunately it does not stop neurologists to treat their patients with cervical dystonia with Botulinum toxin injections, based on a careful analysis of the posture.

Dr Marie-Helene Marion

Therapy Guide Spasticity: Dystonia (Uni-Med Science) G. Reichel

http://www.amazon.co.uk/Therapy-Guide-Spasticity-Dystonia-Uni-Med/dp/389599779X

Cervico-ocular function in patients with spasmodic torticollis

R Stel, M Gresty,T Metcalfe, AM Bronstein.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1014296/pdf/jnnpsyc00499-0049.pdf

 

What makes my head turn?

What makes my head turn? Find out with Dr Marion, neurologist which muscles of the neck are responsible of turning the head on one side in neck dystonia

What makes my head turn?

The neck muscles involved in the involuntary posture in cervical dystonia need to be identified for Botulinum toxin injections and physiotherapy. Here are some hints.

See the sketche below.

The head is placed on the top of the cervical spine and can pivot about 90 degrees on both sides. The pivot of the head is possible if one neck muscle is pulling forward and if another one on the other side is pulling backward.

The Sterno-Cleido-Mastoid (SCM) muscle

is the muscle pulling forward and rotating the head to the opposite side (right SCM turns the head to the left).

The Splenius Capitis

is the muscle pulling the head backward and rotating the head to the same side (left Splenius turns the head to the left).

The SCM muscle is a long superficial muscle easy to palpate on the front of the neck, and the Splenius is a deep muscle, difficult to palpate, behind the ear.

The shoulder muscles

In addition, there are 2 muscles which are both neck and shoulder muscles: the Levator scapulae and the Trapezius ; both lift up the shoulder, but the Levator scapulae is a deep muscle,   responsible for the posture “shoulder up and forward “ and works with the Splenius  in turning the head to the same side (the left Levator Scapulae will contribute with the left Splenuis to the rotation of the head to the left, )

The Trapezius is a superficial muscle and can contribute to the rotation of the head to the opposite side, working together with the SCM (the right Trapezius will contribute with the right SCM to the rotation of the head to the left).

These muscles are the most frequent targets for Botulinum toxin injections to control the dystonic rotation of the head. The palpation of these muscles is important, as dystonic muscles feel more bulky under the fingers.

It may sound complex but looking at the drawing should make it simpler to grasp…

Marie-Helene Marion

London BTX centre

 

Cervical dystonia: what does the examination look for?

Cervical dystonia: what does the examination look for? Dr Marion tells you how the clinical examination is important to optimise the Botox treatment.

Cervical dystonia: what does the examination look for?

 Patients with cervical dystonia described at onset an intermittent feeling of pulling in the neck muscles; over the months, the head take an abnormal posture. Torticollis is defined by the head (the chin) turned to one side; laterocollis by the head tilt toward one shoulder; retrocollis by the head pulled backward in extension, chin up; antecollis by the  head  flexed downward, chin down to the chest. These abnormal postures are due to the involuntary movement of the neck on the trunk. There is also the possibility of abnormal movement of the head on the neck, the head going forward like a goose or going backward giving a double chin posture.

The diagnosis of cervical dystonia is made on the involuntary movement and the abnormal posture of the head, and often delays by many years from the onset of symptoms. They are other rare causes of abnormal posture of the head that a neurologist can exclude by a neurological examination and investigations.

 But like the BSP, every patient is different and need to be examined carefully to document precisely the abnormal dystonic posture to know which muscle is pulling too much! Then these muscles, which are responsible of the pulling, will be the one to inject with Botulinum toxin.  The difficulty comes from the action of the neck muscles which are often mixed (rotating the head on one side and tilting on the other side), resulting in mixed abnormal posture of the head (predominant rotation with a degree of tilt and extension).

It’s best to see the patient at his worst!

The patient is asked to walk, to stand up, to write or to lie down depending of the triggering factors. Usually the worst posture is achieved standing, eyes closed. The fixation of the eyes on an object helps the person to keep the head straight; when closing the eyes, the head lost the visual cue and shift to its maximal abnormal posture. Then to write down the degrees of the rotation, tilt, extension and flexion to be able at the next visit to assess the improvement under treatment.

It’s also important to see the patient at his best!

I ask the patient if he has a “geste antagoniste” (French expression also used by the Anglo-Saxons neurologists!); for instance stopping the pulling in rotation by touching with one finger the cheek without exerting an opposing force to the movement. What’s count is the improvement of the pulling by simply touching a part of the head or neck. It’s also called sensory trick and it’s a hallmark of the dystonic phenomenon.

Then when the posture is clearly documented, identifying which are the leading muscles behind, is based on surface anatomy (palpation) and functional anatomy (which muscle is doing what!).