Physiotherapy treatment is based on a careful analysis and understanding of the dystonic pattern. In the case of ongoing BoNT injections, this analysis should be done in close proximity or in direct conjunction with them, so as not to be misled by any BoNT-expressed muscles.

The study identifies the different components of the pattern:

• Torticollis/caput: the neck/head twists to the right or left.
• Laterocollis/-caput: neck/head tilts to the right or left.
• Anterocollis/-caput: neck/head bends forward.
• Retrocollis/-caput: neck/head bends backwards.
• Lateroshift: the head is shifted sideways to the right or left.
• Anteroshift: the head is displaced forward.
• Shoulder raise: right or left.
• Tremor: yes-yes, no-no, coarse or fine, regular or irregular.
• Compensatory trunk posture.

In the majority of cases there is not only one component of the pattern, but a combination of several components, such as a tonic laterocollis left, laterocaput hay, height left shoulder and tremor. The pattern is inspected in sitting, standing, walking and lying position.  In addition, the active movement in all directions of the neck is examined, in terms of both quality and quantity. Reduced range or difficulty in one direction may guide the identification of the pattern, as movement in the opposite direction to the dystonic one is usually limited. Overflow activity and possible decrease or increase of the tremor in the different directions are noted. 

If reciprocal arm movements correct the patient's head position and reduce any tremor, this is called "stable dystonia", and if the dystonia is exacerbated by the arm movements, it is called "unstable dystonia". In stable dystonia, arm movements can be used to dampen the dystonia and correct the head position. In unstable dystonia, this should not be used as a treatment, but over time the patient should be gradually trained to make calm arm movements without aggravation. 

• Agonists: the dystonic overactive muscles.
• Antagonists: the opposing, corrective muscles.
• Motor and postural control: to train control in movement and posture.
• Tone reduction: to reduce tone and dystonia-related tension.
• Antagonist training: to activate/strengthen the antagonists.
• Stretching: exercises involving stretching/elongation of agonists in the pattern or secondarily tense muscles.

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.

There are methods, which risk aggravating dystonia, which is why they are discouraged. They are the following:

• Strength training of the upper body using machines or dumbbells.
• Neck-shoulder massage.
• Neck manipulations.
• Neck collar

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