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Dystonia

From Wikipedia, the free encyclopedia
Not to be confused withdystopia.

Dystonia
A person with medication-induced dystonia
SpecialtyNeurology
Complicationsphysical disabilities (contractures,torticollis),[1]pain and fatigue[2]
Causeshereditary (DYT1); birth injury; head trauma; medication; infection; toxins
Diagnostic methodgenetic testing,electromyography,blood tests,MRIorCT scan
Treatmentmedication, physical therapy,botulinum toxininjection,deep brain stimulation
Medicationanticholinergics,dopamine agonists

Dystoniais aneurologicalhyperkineticmovement disorderin which sustained or repetitive muscle contractions occur involuntarily, resulting in twisting and repetitive movements or abnormal fixed postures.[3]The movements may resemble atremor.Dystonia is often intensified or exacerbated by physical activity, and symptoms may progress into adjacent muscles.[4]

The disorder may behereditaryor caused by other factors such asbirth-relatedor otherphysical trauma,infection,poisoning (e.g.,lead poisoning) or reaction topharmaceutical drugs,particularlyneuroleptics,[3]or stress. Treatment must be highly customized to the needs of the individual and may include oral medications, chemodenervationbotulinum neurotoxininjections, physical therapy, or other supportive therapies, and surgical procedures such asdeep brain stimulation.

Classification

[edit]

There are multiple types of dystonia, and many diseases and conditions may cause dystonia.

Dystonia is classified by:

  1. Clinical characteristics such as age of onset, body distribution, nature of the symptoms, and associated features such as additional movement disorders or neurological symptoms, and
  2. Cause (which includes changes or damage to the nervous system and inheritance).[4]

Physicians use these classifications to guide diagnosis and treatment.

Types

[edit]

Generalized dystonias

[edit]

For example, dystonia musculorum deformans (Oppenheim, Flatau-Sterling syndrome): [6]

  • Normal birth history and milestones
  • Autosomal dominant
  • Childhood onset
  • Starts in lower limbs and spreads upwards

Also known astorsion dystoniaor idiopathic torsion dystonia (old terminology "dystonia musculorum deformans" ).

Focal dystonias

[edit]
Main article:Focal dystonia

These most common dystonias are typically classified as follows:

Name Location Description
Anismus muscles of therectum Causes painful defecation,constipation;may be complicated byencopresisorfecal incontinence.
Cervical dystonia (spasmodic torticollis) muscles of theneck Causes the head to rotate to one side, to pull down towards the chest, or back, or a combination of these postures.
Blepharospasm muscles around theeyes The patient experiences rapid blinking of the eyes or even their forced closure causing functional blindness.
Oculogyric crisis muscles of eyes and head An extreme and sustained (usually) upward deviation of the eyes often with convergence causingdiplopia(double vision). It is frequently associated with backward and lateral flexion of the neck and either widely opened mouth or jaw clenching. Frequently a result ofantiemeticssuch as theneuroleptics(e.g.,prochlorperazine) ormetoclopramide.Can be caused byChlorpromazine.
Oromandibular dystonia muscles of the jaw andmuscles of tongue Causes distortions of the mouth and tongue.
Spasmodic dysphonia/Laryngeal dystonia muscles of larynx Causes the voice to sound broken, become hoarse, sometimes reducing it to a whisper.
Focal hand dystonia (also known as musician's orwriter's cramp). single muscle or small group of muscles in the hand It interferes with activities such as writing or playing a musical instrument by causing involuntary muscular contractions. The condition is sometimes "task-specific", meaning that it is generally apparent during only certain activities. Focal hand dystonia is neurological in origin and is not due to normal fatigue. The loss of precise muscle control and continuous unintentional movement results in painful cramping and abnormal positioning that makes continued use of the affected body parts impossible.

The combination ofblepharospasmodic contractionsandoromandibular dystoniais called cranial dystonia orMeige's syndrome.

Genetic/primary

[edit]

Symbol OMIM Gene Locus Alt Name
DYT1 128100 TOR1A 9q34 Early-onset torsion dystonia
DYT2 224500 HPCA 1p35-p34.2 Autosomal recessive primary isolated dystonia
DYT3 314250 TAF1 Xq13 X-linked dystonia parkinsonism
DYT4 128101 TUBB4[7] 19p13.12-13 Autosomal dominant whispering dysphonia
DYT5a 128230 GCH1 14q22.1-q22.2 Autosomal dominant dopamine-responsive dystonia
DYT5b 191290 TH 11p15.5 Autosomal recessive dopamine-responsive dystonia
DYT6 602629 THAP1 8p11.21 Autosomal dominant dystonia with cranio-cervical predilection
DYT7 602124 unknown 18p (questionable) Autosomal dominant primary focalcervical dystonia
DYT8 118800 MR1 2q35 Paroxysmal nonkinesigenic dyskinesia
DYT9 601042 SLC2A1 1p35-p31.3 Episodic choreoathetosis/spasticity (now known to be synonymous with DYT18)
DYT10 128200 PRRT2 16p11.2-q12.1 Paroxysmal kinesigenic dyskinesia
DYT11 159900 SGCE 7q21 Myoclonic dystonia
DYT12 128235 ATP1A3 19q12-q13.2 Rapid-onset dystonia parkinsonism andalternating hemiplegia of childhood
DYT13 607671 unknown, near D1S2667[8] 1p36.32-p36.13 Autosomal dominant cranio-cervical/upper limb dystonia in one Italian family
DYT14 See DYT5
DYT15 607488 unknown 18p11[9] Myoclonic dystonianot linked to SGCE mutations
DYT16 612067 PRKRA 2q31.3 Autosomal recessive young onset dystonia parkinsonism
DYT17 612406 unknown, near D20S107[10] 20p11.2-q13.12 Autosomal recessive dystonia in one family
DYT18 612126 SLC2A1 1p35-p31.3 Paroxysmal exercise-induced dyskinesia
DYT19 611031 probablyPRRT2 16q13-q22.1 Episodic kinesigenic dyskinesia 2, probably synonymous with DYT10
DYT20 611147 unknown 2q31 Paroxysmal nonkinesigenic dyskinesia 2
DYT21 614588 unknown 2q14.3-q21.3 Late-onset torsion dystonia
DYT24 610110 ANO3[11] 11p14.2 Autosomal dominant cranio-cervical dystonia with prominent tremor

There is a group calledmyoclonic dystoniawhere some cases are hereditary and have been associated with amissense mutationin thedopamine-D2 receptor.Some of these cases have responded well to alcohol.[12][13]

Other genes that have been associated with dystonia includeCIZ1,GNAL,ATP1A3,andPRRT2.[14]Another report has linkedTHAP1andSLC20A2to dystonia.[15]

Signs and symptoms

[edit]
Hyperglycemia-induced involuntary movements, which, in this case, did not consist of typicalhemiballismusbut rather ofhemichorea(dance-like movements of one side of the body;initial movements of the right arm in the video) andbilateraldystonia (slow muscle contraction in legs, chest, and right arm) in a 62-year-old Japanese woman withtype 1 diabetes

Symptoms vary according to the kind of dystonia involved. In most cases, dystonia tends to lead to abnormal posturing, in particular on movement. Many individuals with the condition have continuous pain, cramping, and relentless muscle spasms due to involuntary muscle movements. Other motor symptoms are possible including lip smacking.[16]

An accurate diagnosis may be difficult because of the way the disorder manifests itself. Affected individuals may be diagnosed as having similar and perhaps related disorders includingParkinson's disease,essential tremor,carpal tunnel syndrome,temporomandibular joint disorder,Tourette's syndrome,conversion disorderor other neuromuscular movement disorders. It has been found that the prevalence of dystonia is high in individuals withHuntington's disease,where the most common clinical presentations are internal shoulder rotation, sustained fist clenching, knee flexion, and foot inversion.[17]Risk factors for increased dystonia in patients withHuntington's diseaseinclude long disease duration and use ofantidopaminergicmedication.[17]

Causes

[edit]

Primary dystoniais suspected when the dystonia is the only sign and there is no identifiable cause or structural abnormality in the central nervous system. Researchers suspect it is caused by a pathology of thecentral nervous system,likely originating in those parts of thebrainconcerned with motor function—such as thebasal gangliaand the GABA (gamma-aminobutyric acid) producingPurkinje neurons.The precise cause of primary dystonia is unknown. In many cases it may involve some genetic predisposition towards the disorder combined with environmental conditions.[18]

Meningitis and encephalitis caused by viral, bacterial, and fungal infections of the brain have been associated with dystonia. The main mechanism is inflammation of the blood vessels, causing restriction of blood flow to the basal ganglia. Other mechanisms include direct nerve injury by the organism or a toxin, or autoimmune mechanisms.[19]

Malfunction of thesodium-potassium pumpmay be a factor in some dystonias. TheNa+
-K+
pump has been shown to control and set the intrinsic activity mode ofcerebellarPurkinje neurons.[20]This suggests that the pump might not simply be a homeostatic, "housekeeping" molecule for ionic gradients; but could be a computational element in thecerebellumand thebrain.[21]Indeed, anouabainblock ofNa+
-K+
pumps in the cerebellum of a livemouseresults in it displayingataxiaand dystonia.[22]Ataxia is observed for lower ouabain concentrations, dystonia is observed at higher ouabain concentrations. A mutation in theNa+
-K+
pump (ATP1A3gene) can cause rapid onset dystonia parkinsonism.[23]Theparkinsonismaspect of this disease may be attributable to malfunctioningNa+
-K+
pumps in thebasal ganglia;the dystonia aspect may be attributable to malfunctioningNa+
-K+
pumps in the cerebellum (that act to corrupt its input to the basal ganglia) possibly inPurkinje neurons.[20]

Cerebellum issues causing dystonia is described by Filip et al. 2013: "Although dystonia has traditionally been regarded as a basal ganglia dysfunction, recent provocative evidence has emerged of cerebellar involvement in the pathophysiology of this Enigma tic disease. It has been suggested that the cerebellum plays an important role in dystonia etiology, from neuroanatomical research of complex networks showing that the cerebellum is connected to a wide range of other central nervous system structures involved in movement control to animal models indicating that signs of dystonia are due to cerebellum dysfunction and completely disappear after cerebellectomy, and finally to clinical observations in secondary dystonia patients with various types of cerebellar lesions. It is proposed that dystonia is a large-scale dysfunction, involving not onlycortico-basal ganglia-thalamo-cortical pathways,but the cortico-ponto-cerebello-thalamo-cortical loop as well. Even in the absence of traditional "cerebellar signs" in most dystonia patients, there are more subtle indications of cerebellar dysfunction. It is clear that as long as the cerebellum's role in dystonia genesis remains unexamined, it will be difficult to significantly improve the current standards of dystonia treatment or to provide curative treatment. "[24]

Treatment

[edit]

Various treatments focus on sedating brain functions or blocking nerve communications with the muscles via drugs, neuro-suppression, or selectivedenervationsurgery.[25]Almost all treatments have negative side-effects and risks. Ageste antagonisteis a physical gesture or position (such as touching one'schin) that temporarily interrupts dystonia, it is also known as asensory trick.[26]Patients may be aware of the presence of a geste antagoniste that provides some relief.[27]Therapy for dystonia can involve prosthetics that passively simulate the stimulation.[28]

Physical intervention

[edit]

While research in the area of effectiveness ofphysical therapyintervention for dystonia remains weak,[29]there is reason to believe that rehabilitation can benefit dystonia patients.[30]Physical therapy can be utilized to manage changes in balance, mobility and overall function that occur as a result of the disorder.[31]A variety of treatment strategies can be employed to address the unique needs of each individual. Potential treatment interventions include splinting,[32]therapeutic exercise, manualstretching,soft tissue andjoint mobilization,postural training and bracing,[30]neuromuscular electrical stimulation,constraint-induced movement therapy,activity and environmental modification, andgait training.[31]

Recent research has investigated further into the role of physiotherapy in the treatment of dystonia. A recent study showed that reducing psychological stress, in conjunction with exercise, is beneficial for reducing truncal dystonia in patients withParkinson's disease.[33]Another study emphasized progressive relaxation, isometric muscle endurance, dynamic strength, coordination, balance, and body perception, seeing significant improvements to patients' quality of life after 4 weeks.[34]

Since the root of the problem is neurological, doctors have explored sensorimotor retraining activities to enable the brain to "rewire" itself and eliminate dystonic movements. The work of several doctors such as Nancy Byl andJoaquin Fariashas shown that sensorimotor retraining activities and proprioceptive stimulation can induceneuroplasticity,making it possible for patients to recover substantial function that was lost due to Cervical Dystonia, hand dystonia, blepharospasm, oromandibular dystonia, dysphonia and musicians' dystonia.[35][36][37][38][39]

Due to the rare and variable nature of dystonia, research investigating the effectiveness of these treatments is limited. There is nogold standardfor physiotherapy rehabilitation.[33]To date, focal cervical dystonia has received the most research attention;[31]however, study designs are poorly controlled and limited to small sample sizes.[29]

Baclofen

[edit]

Abaclofenpump has been used to treat patients of all ages exhibiting muscle spasticity along with dystonia. The pump delivers baclofen via a catheter to the thecal space surrounding the spinal cord. The pump itself is placed in the abdomen. It can be refilled periodically by access through the skin. Baclofen can also be taken in tablet form[40]

Botulinum toxin injection

[edit]

Botulinum toxininjections into affected muscles have proved quite successful in providing some relief for around 3–6 months, depending on the kind of dystonia. Botox or Dysport injections have the advantage of ready availability (the same form is used for cosmetic surgery) and the effects are not permanent. There is a risk of temporary paralysis of the muscles being injected or the leaking of the toxin into adjacent muscle groups, causing weakness or paralysis in them. The injections must be repeated, as the effects wear off and around 15% of recipients develop immunity to the toxin. There is a Type A and a Type B toxin approved for treatment of dystonia; often, those that develop resistance to Type A may be able to use Type B.[41]

Muscle relaxants

[edit]

Clonazepam,abenzodiazepine,is also sometimes prescribed. However, for most, their effects are limited and side-effects like mental confusion, sedation, mood swings, and short-term memory loss occur.

Ketogenic diet

[edit]

One complex case study found that aketogenic type dietmay have been helpful in reducing symptoms associated withalternating hemiplegia of childhood(AHC) of a young child. However, as the researchers noted, their results could have been corollary in nature and not due to the diet itself, though future research is warranted.[42]

Surgery

[edit]
Schematic representation of a patient with cervical dystonia, with deep brain stimulation (DBS) electrodes implanted in the internal globus pallidus (GPi)

Surgery, such as the denervation of selected muscles, may also provide some relief; however, the destruction of nerves in the limbs or brain is not reversible and should be considered only in the most extreme cases. Recently, the procedure ofdeep brain stimulation(DBS) has proven successful in a number of cases of severe generalised dystonia.[43]DBS as treatment for medication-refractory dystonia, on the other hand, may increase the risk of suicide in patients. However, reference data of patients without DBS therapy are lacking.[44]

History

[edit]

The ItalianBernardino Ramazziniprovided one of the first descriptions of task-specific dystonia in 1713 in a book of occupational diseases, The Morbis Artificum.[45] In chapter II of this book's Supplementum, Ramazzini noted that "Scribes and Notaries" may develop "incessant movement of the hand, always in the same direction… the continuous and almost tonic strain on the muscles... that results in failure of power in the right hand". A report from the British Civil Service also contained an early description of writer's cramp. In 1864, Solly coined the term "scrivener's palsy" for this condition. These historical reports usually attributed the etiology of the motor abnormalities to overuse. Then, dystonia were reported in detail in 1911, whenHermann Oppenheim,[46]Edward Flatauand Wladyslaw Sterling described some Jewish children affected by a syndrome that was retrospectively considered to represent familial cases of DYT1 dystonia. Some decades later, in 1975, the first international conference on dystonia was held in New York. It was then recognized that, in addition to severe generalized forms, the dystonia phenotype also encompasses poorly-progressive focal and segmental cases with onset in adulthood, such as blepharospasm, torticollis and writer's cramp. These forms were previously considered independent disorders and were mainly classified among neuroses. A modern definition of dystonia was worded some years later, in 1984. During the following years it became evident that dystonia syndromes are numerous and diversified, new terminological descriptors (e.g., dystonia plus, heredodegenerative dystonias, etc.) and additional classification schemes were introduced. The clinical complexity of dystonia was then fully recognized.[47]

See also

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References

[edit]
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