Magritte – The False Mirror, 1928
Mental imagery, visualisation and focal dystonia retraining
Magritte – The False Mirror, 1928
Mental imagery, visualisation and focal dystonia retraining
Mental imagery is already used in high level sports competition, and athletes are trained to rehearse their race in their mind, to increase their performance.
Could dystonic patients benefit from mental imagery focusing on their motor
There are scientific facts, and anecdotal reports from dystonic patients to suggest that it may be very helpful on the long term.
Real and mentally stimulated movements rely upon largely overlapping networks. In another words, writing or imagining writing involved common networks in our brain. Studies have shown that the mental imagery of a movement in patients with dystonia follows the same difficulties than the execution of the dystonic movement.
A study by Fioro, 2006 has looked at the mental rotation of body part (hands, feet) in which the subjects imagine moving their body part, from their actual posture into that seen on a picture to recognise which side is belonged in patients with writer’s cramp. Writer’s cramp patients are slower than controls in mentally rotating hands but not feet; it suggests that the mental rotation of body parts reflects the anatomical constraints of real hand movements.
Could the mind reshape the brain?
Neuroplasticity is a normal process by which the brain develops new connections at different levels, following interaction with environment, emotions, behavior. Dystonia is understood to be a condition characterized by an excessive neuroplasticity of the brain leading to abnormal learning of motor program. To be able to influence this brain plasticity It’s important to create an environment for positive learning and recovery. Mindfulness can be helpful in patients with focal dystonia to minimise stress and increase well being before embarking for retraining.
Retrain your brain, not your muscles!
The visual and mental imagery training will encourage you to imagine successful, normal execution of tasks, which the dystonia prevents you to do..
Remember the time when you could perform the movement normally, and how easy it was to do it and the pleasure, which come with it.
It will be best performed after the Botox treatment has already controlled the dystonic spasm
in the affected body part and together with sensory retraining.
Try daily to visualize yourself free of the dystonia, walking eye opened, turning your head freely looking around you, writing a page with our favorite pen or chewing a delicious meal.
Also music and melody can help you to IMAGINE…
You may say I’m a dreamer, But I’m not the only one, I hope someday
you’ll join us, And the world will live as one (John Lennon)
Meditation refers to a family of self -regulation practices that focus on training attention and awareness in order to bring mental processes under greater voluntary control and thereby foster general well-being and development and/or specific capacities such as calm, clarity and concentration.…( Walsh and Shapiro, 2006, quoted in Wikipedia on meditation http://en.wikipedia.org/wiki/Meditation
Several recent studies have shown the influence of mindfulness meditation on brain morphology. In particular, Britta et al (Soc Cogn Affect Neurosci. 2010; 5: 11–17) has shown the influence of an 8-week mindfulness-based stress reduction intervention on the changes in amygdaloid gray matter density, which is a part of the brain involved in response to stress.
Patients with dystonia have all experienced the worsening of their dystonic symptoms with stress and Henry Meige at the beginning of the 20th century adviced his dystonic patients to have a regular, calm life to avoid fluctuations in the severity of the cervical dystonia.
The dystonia itself is source of great frustration and stress for the patients, who are limited in their daily tasks (walking, reading, eating, speaking, writing) by the dystonics spasms. In addition, professional and family life can bring a lot of joy , but can be also emotionally challenging.
Can meditation help patients with dystonia? There is no scientific study on that topic but I want to share with you the testimony of Anne, a lady with blepharospasm who has been involved in teaching meditation to groups and practices mediation regularly for her well being.
Testimony of Anne
“I have had Blephoraspasm for 7 years, for me the most difficult things to come to terms with were
Ø Loss of independence
Ø Loss of career
Ø Not being able to drive when I wanted
Ø Learning to use Public Transport alone
Ø Fear of travelling alone
Ø Decrease in social activities
I went through a period of becoming almost house bound only going out with my son and friends.
Having worked as a senior Nurse in Mental Health for over 40 years I was very aware of the symptoms of stress and anxiety but had not fully appreciated just how much these symptoms were affecting my Dystonia, I had spent years as a CPN teaching patients and carers Anxiety Management but had not recognised the tell-tale signs in myself
First I had to accept that I had this disabling disorder and that I had to learn to manage the symptoms, I soon became more and more aware that any sort of negative stress or anxiety made the symptoms a great deal worse. It could be something really trivial and my eyes would start closing.
To assist me with relaxation I tried many different complementary therapies some helped some didn’t, we are all individuals, what will help one person won’t another. I also used anxiety management techniques to help, particularly when I went out i.e. shopping.
I also tried to develop new activities/hobbies that I could do rather than dwell on those that I had lost [not easy]
I had been interested in Meditation for many years and although I had practised this, it had not been in a very disciplined way, now I aim to sit for 30 minutes once or twice daily.
There are many different types of meditation and many definitions.
Meditation for me is about stilling the mind and looking within, facilitating a sense of peace and calmness
Simple meditation exercise.
The following is a simple method that I use with the aim of reducing stress, identifying tension in various parts of the body and assisting me in controlling negative thoughts and generally aiding relaxation
Preparation for meditation
Ø Wear comfortable clothing
Ø Use a space for this purpose, a spare room or a corner of a bedroom whatever works for you importantly the space needs to be conducive to sitting quietly with an even temperature
Ø Attempt to sit at the same time each day, this will help to establish a routine that will be easier to adhere to.
5 to 10minutes is fine to begin with. Don’t beat yourself up if you cannot achieve this.
Sit comfortably on a chair with your back supported, feet flat on the floor [use a cushion for your feet if they don’t reach the floor] hands on your lap.
Close your eyes if this is comfortable.
Focus on your breath both the inhalation and exhalation [it is important to breathe normally not too deeply] Some people think of the word Relax as they exhale.
You will find that to begin with there are many distracting thoughts going round and round in your mind, this is normal, don’t worry about them let them come and go, just gently bring your attention back to your breath, this may be difficult to begin with but with practise it becomes easier.
It is impossible to think about 2 things simultaneously, as you focus on the breath the distracting thought will disappear at least for that moment.
You may feel fidgety at first, your body and mind need time to adjust to not worrying and rushing to do all the normal daily tasks, practise will help.
As you become more expert in the exercise you will observe which muscles are tenser than others. Gradually you will be able to sit for a longer period leaving you feeling more relaxed. If it is preferable, quiet gentle background music could be played. Most types of meditations start with this type of exercise how long you sit and how deeply you go within yourself is a matter of personal choice
It will be interesting to hear the voices of dystonic patients from India for instance, where meditation is part of a long cultural tradition to know if they find it helpful.
Of course, I am not suggesting that meditation is a treatment of dystonia, or that meditation is good for everybody, but it may be a coping strategy for some dystonic patients when the stress in their life has a negative impact on the severity of their muscle spasms.
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
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…
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
Jean Pierre Bleton : Role of the physiotherapist in the treatment of dystonia