Dystonia

What is the evaluation of Phalen's test?

Push back of hands together for one minute. Checks carpal tunnel irritation through compression- positive test if patient experiences pain or tingling.

What are peripheral nerve lesions?

-Carpal Tunnel -Ulnar nerve

What is testing protocol?

-Cessation of abnormal movements -Sensory retraining -Mental rehearsal of the movement without overt body movement. In monkeys, this treatment protocol was shown to normalize the somatosensory hand representation in the cortex and reduce dystonic movements. In humans with focal hand dystonia, this treatment protocol returned performance to normal or near-normal.

What is carpal tunnel syndrome?

-Compression of the median nerve due to increased pressure in the carpal tunnel (wrist) -Caused by inflammation or swelling of tendons, crushing injuries, and fluid retention -Symptoms consist of numbness, burning, or tingling of one or more of the fingers

What is mental rehearsal in sensory retraining?

-Imagine you are healthy and have full normal control of the affected part. -Imagine how the body is healing itself. -Imagine using the part as you use to use it. -Mentally review how each of the components of the part are working normally. -Recapture the excitement of using the affected part normally. -Mental rehearsal should be performed at least 30-60 min per day. From MRI studies, there is evidence that sensory and motor representations of the body part are activated with mental rehearsal.

What is focal hand dystonia?

A movement disorder characterized by involuntary sustained contractions of muscles of the hand. It affects people who perform attended stereotypical repetitive movements of the fingers and hands. -Performing artists (pianists, flautists, cellists, violinists, according players, etc). -Artists. -Athletes - tennis players, golfers. -Assembly line workers who use their hand muscles. -Business executives who type at a keyboard. There may be a genetic predisposition to the disorder combined with performance of highly repetitive movements.

What is dystonia?

A movement disorder characterized by sustained involuntary contractions of muscles that lead to repetitive, patterned, abnormal twisting movements and postures that are sometimes painful.

What is the pathophysiology of dystonia?

Abnormality of the basal ganglia (subcortical structures involved with movement). Many times opposing muscles are activated. May be a decrease in dopamine activity in the putamen (GABA and ACh have also been implicated). Symptoms are due to contraction or spasms of antagonistic muscle groups.

Where is the origin of focal hand dystonia?

Although a dysfunction in the basal ganglia is commonly assumed to be at the origin of focal hand dystonia, it is obvious that the whole sensory-motor network is affected.

What is the basal ganglia?

Composed of the putamen, globus pallidus and substantia nigra. Involved in sequencing muscular movements and regulating muscle tone and muscle force.

What is a joint disorder?

Degeneration of joint: Abnormal passive mobility of joint -Osteoarthritis

What is occurring in the brain during desensitization?

Desensitization is thought to involve habituation of the sensory system. With prolonged desensitization techniques, permanent, structural changes are thought to occur in the sensory system. Decreased synaptic strength (decrease in the release of glutamate and perhaps internalization of synaptic receptors).

What does dystonia not affect?

Dystonia does not affect cognition or intelligence. Dystonia generally does not affect life expectancy.

What is etiology of dystonia?

Dystonia has a genetic component - researchers have identified 3 genes and the location of 4 more. Physical trauma, stroke, tumor or disease that affects the basal ganglia. Exposure to drugs or toxins that affect the basal ganglia. Focal dystonia is seen in people whose work involves frequent repetitive movements (musicians, writers, typists, athletes, etc). Patients report that involuntary muscle movements interfere with performance.

What are two examples of UE diagnoses?

Focal Hand Dystonia and Carpal Tunnel Syndrome There are many different evaluations and interventions needed to address the different diagnoses.

What is desensitization?

Following traumatic brain injury or with certain psychiatric disorders, some patients are hypersensitive to touch. -They respond negatively when touched or when they touch an object. Desensitization therapy is used to normalize this behavior. -The rationale is habituation of the sensory system.

What are symptoms of dystonia?

In generalized dystonia, involuntary twisting postures of the limbs and trunk Deteriorating handwriting Foot cramps Neck turning Tendency of one foot to pull up Voice and speech difficulties Rapid eye blinking, involuntary closure of the eyelids Pain, as the disease progresses (Initially the symptoms may be very mild and occur after exertion, stress, fatigue. The symptoms worsen over time and can spread to other areas of the body)

What is sensory retraining?

Involves stimulation of skin mechanoreceptors and thermoreceptors as well as proprioceptors in muscles, tendons and joints. -Identify objects by feel, without looking at them. -Identify objects that have been placed on the skin as being warm or cold. -Identify how the body part is oriented when someone manipulates and holds it. -Match pairs of objects without looking at them. -Learn Braille. -Identify numbers and letters that someone draws on your skin. -Use small weights to increase the tension on muscles. -Assemble small puzzles by feeling the pieces, not looking at them. The stimulation should be active and passive. The retraining tasks should increase in difficulty. All areas of the affected part should be stimulated (i.e. finger tips, sides of fingers). The retraining tasks should be performed in different contexts (i.e. under water, in a box of rice or sand). The retraining tasks should be performed for at least 1- 1.5 hrs per day.

What is occurring at the brain?

Learning a new motor task alters the motor homunculus to represent the greater involvement of previously unused muscles. There is evidence to indicate that learning a new motor task also affects the sensory homunculus. Monkeys were trained to produce fast, repetitive movements of the hand until they developed dystonia. The somatosensory cortex initially showed enlarged representations of the fingers used. -With time the representation of the hand shrank and representations of the fingers and hand were blurred. -The same may occur in humans. -This is because the finger movements are so fast they're nearly simultaneous and the brain can't distinguish and represent the overused fingers distinctly and precisely. -And, since sensory information is needed for motor control, blurring of the fingers in the somatosensory cortex eventually results in loss of motor coordination.

What is desensitization therapy?

Lightly touch or tap the part repeatedly (with your fingers or neutral object). With time, increase the pressure of the touch or tap. Have the patient touch the floor, the bed railings, etc. Have the patient dig in sand or rice. Move from distal to proximal on the body. Move from the exterior to the interior of the body. Gradually increase the intensity of the stimulus.

Who and what does dystonia affect?

May affect one part of the body (such as the legs, arms, neck, face, eyes, vocal cords; called focal dystonia) or the entire body (called generalized dystonia). Affects 300,00 people in North America. Affects males and females equally. Can affect children as well as adults, but average age of onset is 45 years.

What are some exercises for UE disorders?

Median Nerve Gliding -Begin by making a fist with your wrist in the neutral position -Straighten your fingers and thumb -Bend your wrist back and move your thumb away from your palm -Turn your wrist palm up -Use your other hand to gently pull your thumb farther away from your palm. Tendon Gliding- wrist flexion -Start with your fingers straight -Make a hook fist and then return to a straight hand -Make a straight fist and then return to a straight hand -Make a full fist and then return to a straight hand.

What are treatments for focal hand dystonia?

Medication Botox Splinting -Digit extension splints (dynamic) Adaptive environment/ equipment -Different keyboard position -Different mouse shapes

What is the treatment for dystonia?

No cure. Treatment is may be difficult. Many patients are advised to reduce their activity. Individualized drug treatment, using medications that decrease or increase dopamine; decrease ACh; increase GABA. Botox injections into the affected muscles. The results are good. Treatment effects wear off and injections may be required every 3 months. Deep brain stimulation - Electrical stimulation of the basal ganglia (to help correct the abnormal firing of neurons and relieve abnormal movements and postures). Usually tried in patients who are unresponsive to drugs.

What do you look for during an evaluation for UE disorders?

Occupational limitations? Decreased performance skills? -Pain -Involuntary Muscle Movement -Cramping -Sensory Abnormalities

What are musculo-tendinous disorders?

Over use, cumulative trauma. Non-inflammatory: -Decreased strength, decreased dexterity and difficulty in coordinating finger movements i.e.: Poor posture resulting in back pain Inflammatory: -Swelling i.e.: Tendonitis of hand, wrist and forearm

What are treatment for UE disorders?

Rest Splinting (immobilization to provide rest) Surgery Exercises after surgery

What is functional dystonia?

Results from rapid repetitions of the same movement. -Involuntary movement, Spasms, Pain i.e. Writer's Cramp, Musician's Cramp

What happens when neuroplasticity goes wrong?

The brain had rewired itself but lost resolution.

What is the diagnosis of dystonia?

There is no single diagnostic test for dystonia. The physician must rule out other conditions that present with similar symptoms (differential diagnosis). Dystonic symptoms can be seen with many other diseases and conditions. The best person to diagnose dystonia accurately is a movement disorder neurologist.

Desensitization can normalize hypersensitivity to touch (true or false).

True

Sensory information is necessary for accurate control of movements (true or false).

True

The sensory and motor systems are intimately linked (true or false).

True

What do you look for during an evaluation for someone with Typist's Cramp?

What occupations are limited due to cramping? Do certain hand/arm positioning make the cramps worse? What performance areas are limited due to hand cramps? Handwriting test: -Holds pen tightly -Tight flexed fist -Hyperextended DIP of 2nd digit