The effectiveness of physiotherapy for patients with isolated cervical dystonia: an updated systematic review and meta-analysis.

BACKGROUND: Cervical dystonia is a movement disorder typically characterized by a patterned and twisting movement of sustained or intermittent muscle contractions. Recently, new clinical trials are emerging, highlighting the potential benefit of physiotherapy (PT) on disease outcomes. Thus, the objective of this review is to update the effectiveness of PT on cervical dystonia disease outcomes and subsequently perform a meta-analysis. METHODS: Interventional studies published in English with adult patients with isolated cervical dystonia following a physiotherapy program were included. Relevant articles were searched in PubMed (MEDLINE), Web of Science, and Scopus. Cochrane and Joanna Briggs Institute risk of bias checklists were used for quality reporting. Meta-analysis was done using Review Manager 5.3 statistical software and a pooled mean difference for pain was presented. RESULTS: Fourteen articles were included in the review and two articles were included in the meta-analysis. The meta-analysis revealed that PT intervention had a significant effect on pain reduction scale (-5.00, 95% CI -6.26, -3.74) when used as an additional therapy with botulinum toxin (BoNT) injection. Additionally, findings indicate a possible positive effect of PT disease severity, disability, and quality of life. CONCLUSIONS: Physiotherapy in addition to BoNT is recommended to decrease pain. The findings suggest a reduction of disease severity, disability, and improvement in quality of life. The variety in the type and duration of PT interventions did not allow a clear recommendation of a specific type of PT.

The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis.

BACKGROUND: In patients with frequent migraine, prophylactic treatments are used. Patients often request non-pharmacological alternatives. One treatment option can be aerobic exercise. The value of aerobic exercise as prophylactic treatment however needs to be determined. METHODS: A systematic review and meta-analysis was performed to investigate the result of aerobic exercise on the number of migraine days, duration and pain intensity in patients with migraine. After screening three online databases, PubMed, Cochrane library and Web of Science, using predefined in- and exclusion criteria, six studies were retained. Pooling of data was performed when possible. RESULTS: Significant reductions in the number of migraine days after aerobic exercise treatment were found with a mean reduction of 0.6 ± 0.3 migraine days/month. Other outcomes were too variable to pool due to heterogeneity of outcome measurements. Unpooled data revealed small to moderate reductions in attack duration (20-27%) and pain intensity (20-54%) after aerobic exercise intervention. Various exercise intensities are applied. CONCLUSION: There is moderate quality evidence that in patients with migraine aerobic exercise therapy can decrease the number of migraine days. No conclusion for pain intensity or duration of attacks can be drawn. Effect sizes are small due to a lack of uniformity. For future studies, we recommend standardized outcome measures and sufficiently intense training programs. TRIAL REGISTRATION: CRD42018091178 .

Outcome for dizzy patients in a physiotherapy practice: an observational study.

BACKGROUND: Dizziness is a common reason for referral to physiotherapy. Additional information on clinical characteristics, treatment effect and prognostic indicators in physiotherapy practice are needed. METHODS: A retrospective observational study. Based on a standardised clinical evaluation patients were labelled as having Benign Paroxysmal Positioning Vertigo (BPPV) or not (no-BPPV). BPPV was treated with repositioning manoeuvres and exercises. In no-BPPV, treatment was based on additional clinical tests. Treatment was provided once per week and considered successful when the patient was free of symptoms confirmed by negative positional tests. RESULTS: From 148 referred patients, 88 were labelled as having BPPV, 60 as no-BPPV. The symptom of a short-lasting spinning sensation provoked by head movements was highly suggestive of BPPV. On average, in BPPV treatment was completed after 2.27 ± 1.68 treatments, in no-BPPV this was after 4.91 ± 3.46 treatments. The delayed outcome was related to higher 'age' and 'concomitant neck pain' in BPPV and with higher 'age' only in no-BPPV. Favourable outcome was related to the feature 'dizziness provoked by movements in the horizontal plane' in BPPV. CONCLUSIONS: Clinical evaluation and treatment in physiotherapy practice can be an effective and safe option for patients with dizziness. Several clinical variables with prognostic values were identified.Key messagesClinical evaluation and treatment in physiotherapy practice can be part of low threshold care for dizzy patients.Despite prior medical screening, one-third of patients without signs of BPPV were sent back for further evaluation, illustrating the need for interdisciplinary collaboration.Based on the description of the dizziness symptom (vertigo rather than light-headedness), provocation of the dizziness by movements, and a short duration of the dizziness attack, and positive clinical vestibular tests, BPPV treatment could be initiated.

ICF domains covered by the Tinnitus Questionnaire and Tinnitus Functional Index.

PURPOSE: Tinnitus frequently causes disability as it affects daily living, which is objectified using several tinnitus questionnaires. To what extent they cover domains of the International Classification of Functioning, Disability and Health (ICF) is currently unknown. Therefore, this study aims to investigate which ICF domains are measured by two questionnaires and to describe the health status of somatic tinnitus patients in ICF terms. MATERIALS AND METHODS: All questions of the Tinnitus Questionnaire (TQ) and Tinnitus Functional Index (TFI) were linked to the ICF using linking rules. A count-based method was used to link all individual answers of 80 tinnitus patients, to the ICF categories. RESULTS: Most of the linked questions concerned "body functions". TFI covered more categories of "activity and participation" than TQ. Patients reported severe impairments in "mental functions", "sensory functions and pain", and "sleep functions". Additionally, severe limitations were scored in "focusing attention". CONCLUSIONS: The TFI and TQ measure distinct domains but can be used complementary or solely, depending on the research question. The TFI identifies a broad spectrum of problems, where the TQ focuses on the psychological impact of tinnitus. Somatic patients in our study reported impairments and disabilities in all covered domains, especially in "onset of sleep" and "sound detection".Implications for RehabilitationThe Tinnitus Functional Index (TFI) and the Tinnitus Questionnaire (TQ) cover different domains of the International Classification of Functioning, Disability and Health.The TFI identifies problems in "body functions" and "activity and participation".The TQ focuses on the psychological impact of tinnitus.

Brainstem evoked auditory potentials in tinnitus: A best-evidence synthesis and meta-analysis.

Introduction: Accumulating evidence suggests a role of the brainstem in tinnitus generation and modulation. Several studies in chronic tinnitus patients have reported latency and amplitude changes of the different peaks of the auditory brainstem response, possibly reflecting neural changes or altered activity. The aim of the systematic review was to assess if alterations within the brainstem of chronic tinnitus patients are reflected in short- and middle-latency auditory evoked potentials (AEPs). Methods: A systematic review was performed and reported according to the PRISMA guidelines. Studies evaluating short- and middle-latency AEPs in tinnitus patients and controls were included. Two independent reviewers conducted the study selection, data extraction, and risk of bias assessment. Meta-analysis was performed using a multivariate meta-analytic model. Results: Twenty-seven cross-sectional studies were included. Multivariate meta-analysis revealed that in tinnitus patients with normal hearing, significantly longer latencies of auditory brainstem response (ABR) waves I (SMD = 0.66 ms, p < 0.001), III (SMD = 0.43 ms, p < 0.001), and V (SMD = 0.47 ms, p < 0.01) are present. The results regarding possible changes in middle-latency responses (MLRs) and frequency-following responses (FFRs) were inconclusive. Discussion: The discovered changes in short-latency AEPs reflect alterations at brainstem level in tinnitus patients. More specifically, the prolonged ABR latencies could possibly be explained by high frequency sensorineural hearing loss, or other modulating factors such as cochlear synaptopathy or somatosensory tinnitus generators. The question whether middle-latency AEP changes, representing subcortical level of the auditory pathway, are present in tinnitus still remains unanswered. Future studies should identify and correctly deal with confounding factors, such as age, gender and the presence of somatosensory tinnitus components. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021243687, PROSPERO [CRD42021243687].

Is perception of visual verticality intact in patients with idiopathic cervical dystonia?

Idiopathic cervical dystonia (CD) is a focal dystonia characterized by an abnormal tilted or twisted head position. This abnormal head position could lead to a distorted perception of the visual vertical and spatial orientation. The aim of this cross-sectional study was to investigate whether the perception of the visual vertical is impaired in patients with CD. The subjective visual vertical test (SVV) was measured in 24 patients with CD and 30 controls. The SVV test is conducted in a completely darkened room. A laser bar is projected on an opposing white wall, which is deviated from the earth's gravitational vertical. Participants were seated with their head unrestrained and were instructed to position this bar vertically. The deviations in degrees (°) are corrected for the side of laterocollis in order to measure the E-effect. We found that patients were able to position the laser bar as equally close to the earth's gravitational vertical as controls (+ 0.67° SD ± 2.12 vs + 0.29° SD ± 1.08, p = 0.43). No E-effect was measured. Notwithstanding the abnormal position of the head, the perception of the visual vertical in patients with idiopathic CD is intact, possibly because of central neural compensatory mechanisms.

The effect of a single botulinum toxin treatment on somatosensory processing in idiopathic isolated cervical dystonia: an observational study.

BACKGROUND: Patients with idiopathic cervical dystonia (CD) experience involuntary neck muscle contractions, abnormal head position and pain accompanied by dysfunctions in somatosensory processes such as postural control, cervical sensorimotor and perception of visual verticality. First-line treatment is injection with botulinum toxin (BoNT). It remains unclear whether this affects sensorimotor processes. AIM: To investigate the effect of first-line care on deficiencies in somatosensory processes. METHODS: In this observational study, 24 adult patients with idiopathic CD were assessed three times over a treatment period of 12 weeks following a single treatment with BoNT. Disease severity was assessed by a disease-specific questionnaire, rating scale and the visual analogue scale. Seated postural control was assessed with posturography, cervical sensorimotor control was assessed by the joint repositioning error with an eight-camera infrared motion analysis system during a head repositioning accuracy test and perception of visual verticality was assessed with the subjective visual vertical test. RESULTS: Disease symptoms significantly improved following BoNT injections and deteriorated again at 12 weeks. This improvement was not accompanied by improved postural control, cervical sensorimotor control and perception of visual verticality. A trend toward improvement was seen; however, it did not reach the level of the control population. CONCLUSION: The peripheral and central treatment effects of BoNT have little to no effect on postural and cervical sensorimotor control in CD. Further research may explore whether sensory training or specialized exercise therapy improves somatosensory integration and everyday functioning in patients with CD.

Measuring Disability in Patients With Cervical Dystonia According to the International Classification of Functioning, Disability and Health.

Cervical Dystonia (CD) is a rare movement disorder characterized by an abnormal head position. This cross-sectional study describes the health status and severity of disability using an internationally agreed language by applying the International Classification of Functioning, Disability and Health (ICF). Two disease-specific rating scales were administered to 30 patients with CD. By linking the individual answers to the ICF model, the frequency and severity of reported impairments and restrictions were estimated using a count-based method. Results showed that patients most frequently reported impairments linked to "neuromusculoskeletal and movement-related functions" and "mental functions." Most restrictions in activities were related to "interpersonal interactions and relations," "major life areas," and "community, social, and civic life." One third of the reported impairments can be labeled as severe disability. The findings show that CD causes disability in multiple levels of a patients' functioning in life, well beyond the cervical area.

Cervical sensorimotor control in idiopathic cervical dystonia: A cross-sectional study.

OBJECTIVES: Patients with idiopathic adult-onset cervical dystonia (CD) experience an abnormal head posture and involuntary muscle contractions. Although the exact areas affected in the central nervous system remain uncertain, impaired functions in systems stabilizing the head and neck are apparent such as the somatosensory and sensorimotor integration systems. The aim of the study is to investigate cervical sensorimotor control dysfunction in patients with CD. MATERIAL AND METHODS: Cervical sensorimotor control was assessed by a head repositioning task in 24 patients with CD and 70 asymptomatic controls. Blindfolded participants were asked to reposition their head to a previously memorized neutral head position (NHP) following an active movement (flexion, extension, left, and right rotation). The repositioning error (joint position error, JPE) was registered via 3D motion analysis with an eight-camera infrared system (VICON ® T10). Disease-specific characteristics of all patients were obtained via the Tsui scale, Cervical Dystonia Impact Profile (CDIP-58), and Toronto Western Spasmodic Rating Scale. RESULTS: Patients with CD showed larger JPE than controls (mean difference of 1.5°, p < .006), and systematically 'overshoot', i.e. surpassed the NHP, whereas control subjects 'undershoot', i.e. fall behind the NHP. The JPE did not correlate with disease-specific characteristics. CONCLUSIONS: Cervical sensorimotor control is impaired in patients with CD. As cervical sensorimotor control can be trained, this might be a potential treatment option for therapy, adjuvant to botulinum toxin injections.

The effectiveness of physiotherapy for cervical dystonia: a systematic literature review.

Cervical dystonia is a form of adult-onset, focal dystonia characterized by involuntary contractions of the neck muscles, leading to a disabling, abnormal head posture. CD has a great impact on the activities of daily living (ADL) and quality of life. Currently, the most widely used and recommended first line treatment is botulinum toxin type A (BoNT/A) injections. Physiotherapy is a potentially useful adjuvant, but little is known about its effectiveness. Consequently, our objective was to investigate the effectiveness of physiotherapy alone or as an adjuvant treatment to BoNT/A injections in cervical dystonia (CD) by means of a systematic literature review. Two online databases, PubMed and Web of Science, were searched for articles describing the effectiveness of physiotherapy treatment for CD. After screening, based on predefined in- and exclusion criteria, 16 studies were retained. Their methodological quality was assessed according to Cochrane guidelines. The methodological quality of most studies was low. Examples of shortcomings are small sample sizes, lack of randomization or blinding, and diversity in therapeutic techniques and outcome measures. Only seven studies were clinical trials; the remaining were either case reports or case series. The reported physiotherapy treatments included EMG biofeedback training, muscular elongation, postural exercises and electrotherapy. Improvements in head position, pain, cervical range of motion, quality of life and ADL have been reported, which is promising. Cautious interpretation on the effectiveness of physiotherapy as an adjuvant therapy is required. Before firm conclusions can be drawn, additional high quality trials are needed.