Restriction of neck movements, pain, decrease in participation in activities of daily
living and decrease in quality of life are common complaints in patients with cervical
dystonia.Botulinum toxin injections are indisputably one of the most preferred methods in
the treatment.There are debates about the contribution of exercise to treatment in these
patients with functional limitation and pain.It is thought that the exercise program
after botulinum toxin injection may be effective in reducing the patient's complaints and
increasing the quality of life. Exercise programs can be planned as supervised or
self-executed. However, although the effectiveness of supervised exercises is higher due
to better patient compliance, it also brings a burden to both patients and the health
system as it requires the patient to come to a center.
In this study, patients with cervical dystonia who received botulinum toxin type A
injection will be divided into study group and control group.The patients in the study
group will be given stretching, strengthening, breathing and rhythmic coordination
exercises for the muscles involved. (Personalized exercise program) In the control group,
only breathing and rhythmic coordination exercises will be given and the two groups will
be compared.Thus, it is aimed to investigate the effect of a personalized exercise
program on clinical findings and the patient's quality of life.
Dystonia is involuntary movements characterized by postural abnormalities or repetitive
movements as a result of continuous or intermittent simultaneous contractions of opposing
muscle groups.Dystonic movements are twisted and twisted in a certain pattern. Dystonia
can be focal, segmental, multifocal, generalized or hemidystonia according to its
distribution in the body.It is classified as primary (idiopathic) and secondary according
to the etiology. Cervical dystonia is the most common form of focal dystonia and can be
defined as involuntary postural movements of the head in normal upright posture.There are
different types of cervical dystonia such as torticollis, laterocollis, anterocollis and
retrocollis. These forms can be seen individually as well as in combination. The dystonic
position can be intermittent or continuous. It may also be accompanied by
tremor.Idiopathic cervical dystonia has a prevalence of 5-9 per 100,000. The mean age of
onset is 42 years, and it is seen in relatively young individuals. It is seen 1.5-1.9
times more in women than in men. Pain is seen in approximately 70% of patients and is
closely related to involuntary contractions of neck muscles and impaired neck posture.
Fatigue, anxiety, depression, decreased self-efficacy and limitation in daily living
activities due to limitation in neck movements are the main causes of disability in
patients with cervical dystonia. Before starting treatment in patients followed up with a
diagnosis of dystonia, it is necessary to make sure that the distinction between primary
and secondary dystonia is made correctly. Because secondary dystonias can occur due to
many reasons and elimination of the cause constitutes the first step of
treatment.Discontinuation of treatment in drug-induced dystonias, and treatment of the
disease primarily in metabolic diseases can be given as examples. With symptomatic
treatment in cervical dystonia, it is aimed to improve the quality of life by reducing
symptoms such as muscle contractions, abnormal head and neck posture, pain and tremor,
and to prevent secondary complications such as myelopathy, radiculopathy and dysphagia.
Treatment options in cervical dystonia can be examined under three headings. These are
pharmacological treatments, surgical treatments and chemodenervation (botulinum toxin
injection application) options. In some cases, it may be necessary to combine these
options.
Patients who meet the inclusion criteria after botulinum toxin injection application due
to cervical dystonia in the Department of Neurology, Department of Neurology, Ankara
University will be invited to the study. Before the study, patients will be asked to
review the informed consent form and give their consent to the study. Socio-demographic
information (name-surname, gender, age, education level, marital status, occupation,
contact information, file numbers) of all patients who accepted to participate in the
study will be recorded. Additional diseases, medications used, total number of botulinum
toxin administered for cervical dystonia, date of diagnosis and symptoms of cervical
dystonia will be questioned in the history of the patients. After this stage, patients
will be randomized into two groups as study and control groups. Patients in both the
study and control groups will consist of patients with a diagnosis of cervical dystonia
and botulinum toxin injections. The patients in the study group will be given exercise
videos prepared in the Department of Physical Medicine and Rehabilitation of Ankara
University Faculty of Medicine. These exercise videos will be selected in accordance with
the patient's cervical dystonia type (Torticollis, laterocollis, retrocollis,
anterocollis). During the exercises, stretching exercises will be applied to the muscle
groups that cause dystonia, and isometric strengthening exercises will be applied to the
contralateral muscle groups. Videos including breathing exercises and rhythmic
coordination exercises will also be given to all patients in the study and control
groups. Patients will be asked to do these exercises for 10 repetitions, three times a
day, five days a week. Patients will be asked to mark after each exercise on the exercise
chart prepared to determine continuity and compliance with exercise. Patients will be
called and followed up on a weekly basis with the exercise chart given to the patients
and by telephone.
The primary outcome measure will be a change from baseline of at least 5 units in the
torticollis pain scale, a subscale of the Toronto Western Spasmodic Torticollis Rating
Scale (TWSTRS), with 12 weeks of exercise.
The calculation of the sample size will be based on the primary dependent variable.
Using the G-Power program version 3.1.9.2, an alpha error of 5%, a ß error of 20%, and a
patient loss rate of 20% were determined, and 17 volunteers were recruited to the study
group and control group at 80% power.
Statistical Package for the Social Sciences(SPSS) 11.5 package program will be used in
the evaluation of the data.
Frequency (percentage) for the variables obtained by counting, mean (standard deviation)
for the variables obtained by measurement will be given as descriptive statistics.
In intergroup comparisons, t-test will be used in independent groups for variables
obtained by measurement, and chi-square test will be used for variables obtained by
counting.
Analysis of variance will be used in repeated measurements to examine the trend of
time-dependent change in groups.
p<0.05 will be considered statistically significant.