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Analyse og forståelse

Fysioterapibehandlingen er baseret på en omhyggelig analyse og forståelse af det dystone mønster. I tilfælde af igangværende BoNT-injektioner bør denne analyse udføres i umiddelbar nærhed eller i direkte forbindelse med dem, for ikke at blive vildledt af muskelaktivitet som er påvirket af injektionerne .Undersøgelsen identificerer de forskellige komponenter i mønsteret:

  • Torticollis/caput: halsen/hovedet drejer til højre eller venstre.
  • Laterocollis/-caput: hals/hoved vipper til højre eller venstre.
  • Anterocollis/-caput: nakke/hoved bøjer fremad.
  • Retrocollis/-caput: nakke/hoved bøjes bagud.
  • Lateroshift: hovedet forskydes sideværts til højre eller venstre.
  • Anteroshift: hovedet er forskudt fremad.
  • Skulderløft: højre eller venstre.
  • Tremor: ja-ja, nej-nej, grov eller fin, regelmæssig eller uregelmæssig.
  • Kompensatorisk kropsholdning.

I de fleste tilfælde er der ikke kun én komponent af mønsteret, men en kombination af flere komponenter, såsom en tonisk laterocollis venstre, laterocaput højre,  venstre skulderløft og tremor. Mønsteret inspiceres i siddende, stående, gående og liggende stilling. Derudover undersøges den aktive bevægelse i alle retninger af halsen, både kvalitets- og kvantitetsmæssigt. Reduceret bevæglighed eller sværhedsgrad i én retning kan styre identifikationen af ​​mønsteret, da bevægelse i den modsatte retning af den dystone normalt er begrænset. Overløbsaktivitet (overflow) og mulig reduktion eller forøgelse af rysten i de forskellige retninger kan ses.

Hvis gensidige armbevægelser korrigerer patientens hovedstilling og reducerer eventuel rysten, kaldes dette "stabil dystoni", og hvis dystonien forværres af armbevægelserne, kaldes det "ustabil dystoni". Ved stabil dystoni kan armbevægelser bruges til at dæmpe dystonien og korrigere hovedstillingen. Ved ustabil dystoni bør dette ikke bruges som behandling, men over tid bør patienten gradvist trænes i at lave rolige armbevægelser uden forværring.











 



















                
    Begreber at kende til for håndtering og brug af platformen



                    
    

  • Agonister: de dystone, overaktive muskler.
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  • Antagonister: de modsatte, korrigerende muskler.
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  • Motorisk og postural kontrol: at træne kontrol i bevægelse og kropsholdning.
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  • Tonusreduktion: for at reducere tonus- og dystonirelaterede spændinger.
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  • Antagonisttræning: at aktivere/styrke antagonisterne.
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  • Udstrækning: øvelser, der involverer strækning/forlængelse af agonister i mønsteret eller sekundært spændte muskler.
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    Basic principles of treatment and training of a patient with cervical dystonia



                    
It is good to start training in the positions where the dystonic activity is calmest or absent, and gradually challenge in the more difficult positions. Mirror in front is recommended whenever possible, to provide feedback and increased body awareness. With an oblique position of the head for extended periods of time, it is easy to lose perception of what is straight and what is oblique. The patient is guided to motor control by distraction from the neck, and the patient is encouraged to follow the hand (their own or the therapist's) with the gaze/face.


Trunk rotations are a good tool for tonus suppression, reduction of secondary obliques and tension, and distraction from the neck. For those with stable dystonia, tonus is very effectively dampened by sweeping-swinging-oscillating arm movements, dancing and by using ball and balloon.


Training should be in the opposite direction to the dystonia. Thus, if the patient has a left torticollis, preferential motor control is trained in the right direction (sometimes right, left and then right) and, when activating antagonists, only in the right direction. In the case of right torticollis, the situation is the opposite.


When training the middle position, this is done with reference to the opposite arm in relation to the direction of the dystonia; for example, in left torticollis, middle position training is done with reference to the right arm. Help to achieve the middle position can also be provided by various types of head support or, in the case of stable dystonia, by various reciprocal arm movements.


Tremor is treated according to the direction of the tonic components and the way the tremor occurs during movements and mid-position, but can usually be treated with uprighting exercises, support for the back of the head or, in the case of stable dystonia, with reciprocal arm movements.


Stretching helps to relieve pain, reduce dystonic twitching and tremor and increase mobility. It is important not to stretch against a concurrent dystonic pull, but to find a relaxed position or appropriate support/reference to calm the activity before stretching is performed.


It is important to try to prevent irreversible joint impairment and to maintain passive mobility through various exercises, designed for the individual patient. In cases where there is underlying joint hypermobility, the need to stabilise may be greater, and not to go out of position.


Posture is included in the training/treatment of the neck, partly in order to reduce the compensatory tendency and the general postural deviations, and partly as a diversion to reach the neck. Sometimes there are musculoskeletal postural abnormalities that are not related to dystonia, but can trigger/exacerbate dystonia. For example, increased thoracic kyphosis can exacerbate a dystonic tremor or anteroshift. In this case, it is useful to work on thoracic straightening and mobility to reduce the triggering of dystonia.


It is sometimes difficult for the patient to find appropriate forms of physical activity, and in these cases the physiotherapist should provide guidance and advice. The same applies to resting positions in everyday life and for those who have problems settling down for sleep.



                
    Kontraindikationer



                    
Der er metoder, som risikerer at forværre dystoni, hvorfor de frarådes. De er følgende: 


    

  • Styrketræning af overkroppen ved hjælp af maskiner eller håndvægte
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  • Nakke-skulder massage
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  •  Manipulationer af nakke
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  • Halskrave
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    Referencer



                    
    

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