The beginning of April I started working with a client who has been suffering from dystonia for 12 years. This client has opened my eyes to the difficulty this disorder can have oneself, their career, their family, and quality of life. Every client deserves due diligence and best quality of care. I have been asking my colleagues about their treatment plans with clients diagnosed with dystonia. They did not have the confidence to even tell me what they would do. This blog is to help other clinicians and clients to understand and have the steps to build their own plan of care.
Dystonia as defined by the Mayo Clinic is a movement disorder in which the muscles contract involuntarily, causing repetitive or twisting movements. This definetion sounds simple enough right? WRONG! Dystonia affects every person differently. Most muscular issues begin in a single extremity and develops to physical disabilities functionally, visually, and swallowing. These disabilities can lead to increased anxiety and stressed. We all know what increased stress and anxiety lead to decline in physical and mental function. Dystonia is complicated to diagnosis leading to transient or even permanent mis-classification secondary to varying symptoms. Common misdiagnosis are Parkinson's, essential tremors, myoclonus, tics, psychogenic movement disorder, headaches or even scoliosis. Current diagnostic tools are blood/urine tests to reveal toxins; MRI/CT scan to revel abnormalities, lesions, stroke; EMG to reveal unusual electrical activity within muscles. Plan of treatment for dystonia at this time is just managing symptoms. From a medication stand point they target neurotransmitters in the brain ie. Cardidopa-levodopa, Trihexyphenidyl and benztropine, tetrabenazine, and diazepam. These are complicated medications and not the focus of this post. Feel free to do your own research on these medications. Surgical interventions include implanting electrodes in specific areas to decrease muscle contractions, or cutting nerves to specific muscles to also decrease muscle contractions. Now for the "important" treatment THERAPY. Physical, occupational and speech therapy to help with improving function and dystonia if affects the voice.
Day 0: This client was referred to me for torticollis of the neck that had exacerbated over the past couple of months with a chronic diagnosis of Dystonia. Upon on introduction the first thing that stood out was forward flexed cervical spine with compensation of scrunching of the frontalis muscle (forehead muscle). Client had noticeable fatigue from scrunching her forehead and has history of chronic migraines which could be secondary to this compensation. Making me think right off the bat that we need to strengthen the posterior cervical spine muscles to assist with holding her head up, but also realizing that engaging those muscles will also triggering the torticollis which is currently her primary complaint (already going to be a complicated treatment without considering the dystonia). We went through all the muscle testing and her strength was overall 5/5 especially the right upper and lower extremities because that is the side that almost all of her spasms happen. Clients bilateral hip flexors,abductors, and gastrocs came in at 4/5. I am not one to judge based on the 1-5 standard scale because imbalance and weakness I think is relative, but including the standard out of respect for the profession. Right hip flexion, right single leg heel raise, right hamstring curl, and right inversion of the ankle all triggered a spasm which she called "club foot" because it look like a golf club when it was triggered. This club foot includes right hip flexion and internal rotation, right knee flexion, right ankle dorsiflexion/inversion, and all five distal phalanges (toes) contracting. Postural alignment was forward flexed upper trunk, right lateral side bend, right lower extremity internally rotated and decreased right knee extension. Client is able to perform all functional tasks (ADLs,IADLs, ambulation, household choirs) with increased time and frequent rest breaks. Clients goal is to be able to stand up straight for at least 4-8 hours a day and ambulate without a single point cane. Clients current plan of care is medications of levadopa, rotating Botox injections in certain muscles her and her neurologist have deemed hyperactive, and semi-consistent yoga training.
After discussing what the clients goals were and my approach of strengthening as most important part of any treatment plan but also the belief of alignment with appropriate muscle length and range of motion we began passive range of motion and stretches. Beginning with easy hamstring, piriformis, quadriceps, and iliacus stretches to improve postural alignment. Educated client on how to perform tasks on her own to allow patient independence with her own treatment. Her cervical spine and mobility was a different story. After lower extremity stretches and range of motion went to her neck. Any stretching of upper trapezius, sternocleidomastoid, levator scapulea triggered the torticollis and club foot spasm. After effluerage (fancy word for gentle massage) of said muscles her range of motion improved with decreased triggering of spasms.
Before leaving we reviewed corner stretch, chin-tucks, bilateral upper trapezius stretch, and hamstring stretches to be performed daily to improve alignment and strength of the neck. For daily strengthening exercises prescribed lateral step downs from her stair with finger support for balance, standing heel raises, supine bridges, and sidelying hip abduction.
This is the start of the treatment. I will follow up with summary every couple of weeks. If you have any questions leave a comment or email me at firstname.lastname@example.org.