Ferreira_EU Neurology 10/03/2010 10:38 Page 74
Cervical Dystonia
Pain and Quality of Life in the Treatment of Cervical Dystonia
Miguel Coelho,
1
Anabela Ferreira Valadas,
2
Tiago Mestre
2
and Joaquim J Ferreira
1
1. Attending Neurologist; 2. Resident in Neurology, University Hospital of Santa Maria, and
Neurological Clinical Research Unit, Institute of Molecular Medicine, Lisbon
Abstract
Cervical dystonia (CD) is a chronic movement disorder characterised by abnormal postures of the neck. Although muscle contractions represent
the most visible disease feature, associated symptoms such as pain are frequent and relevant contributors to disability. At the same time, pain
constitutes one of the most important factors in terms of poor quality of life (QoL) and is one of the more affected QoL domains in CD patients.
However, the mechanism underlying the pain associated with CD remains unclear. There are no therapeutic controlled trials that have evaluated
pain or QoL as primary outcomes, but the available data suggest that therapeutic interventions that improve dystonia also alleviate pain and
have a beneficial effect on QoL. The management of CD should incorporate problems such as pain, depression and anxiety in order to achieve
a significant decrease in the burden of disease.
Keywords
Cervical dystonia, pain, quality of life, botulinum toxin
Disclosure: Miguel Coelho is a consultant for Allergan. Anabela Ferreira Valadas and Tiago Mestre have no conflicts of interest to declare. Joaquim J Ferreira is a consultant
for Allergan, Grunenthal, Ipsen, Merz and Solstice.
Received: 4 February 2010 Accepted: 22 February 2010
Correspondence: Joaquim J Ferreira, Centro de Estudos Egas Moniz, Faculdade de Medicina de Lisboa, Av. Prof. Egas Moniz, 1649-028 Lisboa, Portugal.
E:
joaquimjferreira@net.sapo.pt
Support: The publication of this article was supported by an educational grant from Eisai Europe Limited. The views and opinions expressed are those of the authors and
not necessarily those of Eisai Europe Limited.
Dystonia is a neurological syndrome characterised by involuntary, classically described as being slightly more prevalent in females, both
sustained, patterned and repetitive contractions of opposing muscles, genders seem to be equally affected according to a European
leading to twisting and repetitive movements or abnormal postures of epidemiological study.
8
Clinically, the predominant direction of the
the body part involved.
1–4
Dystonic movements must be distinguished muscle twisting allows the identification of four core patterns of CD:
from other hyperkinetic involuntary movements such as chorea, rotation or torticollis (horizontal turning of the head), which is the
myoclonus, tremor or tics. Dystonias can be classified according most common; laterocollis (lateral flexion or tilt of the head);
several factors: age at onset, body distribution and aetiology. retrocollis (posterior extension of the head); and anterocollis (forward
Dystonias in which symptoms typically begin after 26 years of age are flexion of the head).
9
In a series of 300 CD patients, Jankovic et al.
classified as adult-onset dystonias, whereas dystonias beginning identified torticollis in 82%, laterocollis in 42%, retrocollis in 29% and
earlier are generally called young-onset dystonias.
4,5
Focal dystonias anterocollis in 25%.
9
In a limited number of cases, the head may be
involve a single body area, segmental dystonias affect contiguous shifted forward (forward shift) or off the midline (lateral shift).
body parts and generalised dystonias involve at least one leg, the Nevertheless, Jankovic et al. found that the majority of patients (66%)
trunk and another body part.
1–5
Multifocal dystonias (two or more non- had a combination of these patterns (complex CD).
9
Head tremor
contiguous body parts) and hemidystonias (one side of the body) are (dystonic tremor) was found in 62% of patients, whereas hand
less frequent body distributions.
6
As for aetiology, primary dystonias tremor was present in 23%.
3
are those in which dystonia (± tremor) is the only sign and symptom
and no secondary cause or neurodegeneration is found. Conversely, Stress or fatigue may exacerbate CD, while factors such as relaxation,
secondary dystonias include a structural or a metabolic cause.
1,2,7
In sleep and sensory manoeuvres usually improve it.
10–12
The use of a
turn, the primary dystonias can be either sporadic or inherited.
1,2,7
sensory trick, or geste antagoniste, to temporarily alleviate the
dystonia is used by up to 90% of patients.
10–12
In a series of 50 patients,
Cervical dystonia (CD), or spasmodic torticollis, affects the muscles of sensory tricks were found to induce a greater than 30% reduction in
the neck and often the shoulders. It is the most common form dystonia in 82%.
13
Touching the chin, face or the back of the head are
of adult-onset focal dystonia, with an estimated prevalence of classic examples of sensory tricks in CD. In contrast to the temporary
5.7/100,000 in Europe.
6
CD usually presents in the fifth decade of life, relief induced by sensory tricks, a long-lasting and spontaneous
although it can affect individuals at any age.
6
Although CD is remission of CD is less frequent, with reported rates ranging between
74
© TOUCH BRIEFINGS 2009
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132