Neurorehabilitation dystonia

We are at the beginning of our journey to better understand the origins of cervical dystonia and better formulate an individualized comprehensive treatment program for each person.

In this and subsequent ST/Dystonia bulletins, I will highlight some of the key elements from the program presented by Dr Joaquin Farias at our Chattanooga ST/ Dystonia symposium and from his e-book :  Limitless . This will then be correlated with what other researchers have discovered about the cause and treatment of dystonia.   

Much of the impetus of exploring this new vista of therapy has been through the vision and research of Dr. Farias from Toronto .   At the symposium in Chattanooga, he outlined his principles of promoting neuroplasticity for rehabilitation of dystonia.  It has been through his over 20 years of research and personal observations of those with dystonia that he has developed a program  to promote  cerebral neuroplasticity for rehabilitation of focal dystonia .

Please read carefully the spectacular article in this bulletin by Sheri Caruso on the text of the discussion by Dr Farias.  She has captured the key points that he made that were difficult for those in attendance to assimilate at the time due to the amount of information presented and logistics of the room.  As you can see, this is going to be an ongoing study of these difficult concepts that will result in great rewards for those suffering with dystonia who are willing to commit the time and effort to do so.

It is becoming increasingly clear that the underlying basis for cervical and other forms of focal dystonia is a disruption of the balance between the excitatory and inhibitory circuits in the brain. It is the intent of the therapy for dystonia to precisely stimulate neuroplasticity  of the pre-frontal cortex in such a way to reactivate the inhibitory circuits that will result in rebalancing of the energy outflow to the muscles.

It is a natural phenomena that our brains operate every moment in a highly precise system of activating the  muscle function that is needed for a specific task while suppressing other movement that is not necessary.  It appears that in the brain of a person with dystonia, localized inhibitory circuits have been suppressed leading to an excessive amount of energy being delivered to specific groups of muscles by the unchecked excitatory circuits.  The specific muscles  that are abnormally activated and the degree of activation can be unique to each individual.

This disruption in cerebral outflow balance appears to have occurred because of neuroplasticity gone wrong.  Neuroplasticity is defined as the brain’s ability to reorganize itself by forming new neural connections in order to adjust its function and structure in response to life experiences.  For years I have spoken at our ST/dystonia symposiums and written in the Bulletin about what a person can do to stimulate neuroplasticity for therapy for dystonia and for brain health.  I have emphasized the need to do this through  physical exercise and exercise for positive  thought and attitude.  In a sense we are trying to reprogram the brain with good neuroplasticity to overcome the bad neuroplasticity that caused the dystonia in the first place.  The origin of dystonia may be that the susceptible  brain developed a  plastic response to some stimulus  that caused a dysfunction in the inhibitory circuits.

This is consistent with the conclusions from other dystonia researchers. It is the position of the Dystonia Medical Research Foundation that  “brain maladaptive plasticity is at the core of dystonia pathology.”   

Dr. Mark Hallet  is one of the leading researchers of dystonia at the  NIH.  He spoke at our ST/Dystonia symposium a few years ago on the complexity of cerebral circuitry abnormalities in dystonia.  He recently wrote that “there are abnormalities of central nervous system inhibition in dystonia.  The problem lies in the brain’s ability to appropriately apply the brakes to functions that must be suppressed for normal movement to occur.”

Through his 20 years of research on dystonia, it has been the conclusion of Dr Farias that it is in the prefrontal cortex where this loss of inhibition occurs.  It is the prefrontal cortex  of the brain that is the  primary target of this form of therapy.  The prefrontal cortex is the region that puts limits on motor function and emotions. The prefrontal cortex is located at the very front of the brain right behind our forehead.  The prefrontal cortex can be considered to be the control center of the brain that regulates our behavior and our movements..  It is through the prefrontal cortex that impulsive socially inappropriate actions are inhibited. It helps us make appropriate decisions for our behavior and movement. Fear can cause the loss of the controlling ability of the prefrontal cortex producing impulsive thoughts and actions. Dr. Farias commented in his lecture that fear is a common emotion in those with dystonia.

This control by the prefrontal cortex happens both consciously and more often without our awareness when it comes to controlling the precision of our movements.  This  process in our heads is a phenomenon that is continually occurring every moment in time and  results in the inhibition of movements that are not needed and activation of the muscle activity that is  needed to produce the most efficient and precise movement of our bodies .  Unfortunately, in those of us with dystonia, this inhibitory process has lost some precision resulting in an excessive amount of motor energy being delivered to individual muscle groups.

The secret  for us to discover is what each individual person needs to do to regain this balance to result in a cure or at least a better control of your focal dystonia. It is the approach of Dr.  Farias to regain this balance by promoting neuroplasticity changes at the prefrontal cortex level that is the source of the dystonia pathology and regaining the normal inhibitory action.

It is the approach of most other practitioners treating dystonia to treat the end result of dystonia by suppressing the excessive excitation of the muscles through medications that modify the
excitatory chemicals (such as glutamate) or through deep brain stimulation to modulate the excitatory impulses or through injecting botulinum toxins at the muscle level to suppress the over activity.  It is certain that each of these will continue to be a necessary part of the treatment of dystonia but we can take it a step farther.

It is the approach of Dr. Farias and it has always been my approach that the best results are achieved by a comprehensive program of dystonia treatment  that also utilizes the power of what a person can do for themselves through properly designed exercises , positive attitude and exercises of healthy thinking that promote the neuroplastic changes at the very source of the dystonia pathology.
Dietary factors are also of utmost  importance ( see the article in this bulletin by Joan Hogan RD on diet suggestions for a healthy brain.)

In my 35 years of treating people with dystonia and 27 years of treating people with botulinum toxins, I have learned that the people with dystonia who do a demanding form of exercise and have a positive attitude toward life respond better to standard treatment of dystonia and cope better with the disorder.  It has been more recently recognized that these benefits are occurring through the basis of neuroplasticity of the brain.

It has been difficult for many treating dystonia to accept these concepts because that was not the way they were taught in their training.  As Dr Farias points out in his book, Albert Einstien once said ‘The greatest impediment to my learning is my education.”  It is the hope that everyone can learn to  accept that there is much to learn by  blending the treatment approaches from all credible research disciplines.  

You have already been practicing some of the key tasks along the way to promote pre-fontal cortex plasticity if you have been following the “10 steps to optimal dystonia treatment “ that I have lectured on at the ST/Dystonia symposiums and are listed on the web sites for ST/ Dystonia ( www.STDystonia.org    ) and Puget Sound Neurology (www.psneurology.com)  .

These principles have also been enhanced by the rejuvenating yoga practice for dystonia as demonstrated by New York Yogi Patrick Hogan at each of the Sunday yoga sessions  at  our annual symposiums and on his DVD “The journey of Mind and Body Integration” available by joining ST/Dystonia.

The exercises promoted by Mikki Townshend PhD RPT in her articles and at our symposiums have been of great help to the many that make them a part of their life.

Dancing for dystonia has been promoted by Dr Farias and has been a successful program for many of my
patients but that far too few take advantage of.

Discovering your inhibitory stimuli that have been called “sensory tricks”  and using them for treatment will also become an integral part of the therapeutic reprogramming program .  I invite anyone who has discovered unusual sensory tricks to send me a note  describing what you have observed: Hoganpsn@aol.com

We will now be embarking on a personal journey to putting these skills to work for neurorehabilitation of your dystonia. I will further elucidate in subsequent articles in our quarterly bulletins on more specifics on what you can do and what Dr Farias has discovered for rehabilitation of dystonia.  This will all be in preparation for our  ST/Dystonia symposium at Providence, Rhode Island next Fall when Dr Farias and others will hold another pre-symposium work shop to advance our knowledge in these concepts another step forward.

HoganPSN@aol.com

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