How 30 years of Botulinum toxin treatment  has shaped the physiotherapy for cervical dystonia. Dr Marie-Helene Marion

I was privileged to treat cervical dystonia before the era of Botulinum toxin, when working on both side of the channel, first with Professor Rondot in Paris and then with the late Professor Marsden in London, before Botulinum toxin revolutionised the treatment of CD. Physiotherapy had at that time a central place in the treatment of cervical dystonia.

I would like to review the evolution of physiotherapy for cervical dystonia over the years.

At the beginning of the 20th century (1), the treatment of cervical dystonia was based on scopolamine, an anticholinergic drug (Barre, 1929), and psycho-motor retraining by Meige, (2) who pioneered physiotherapy for cervical dystonia. Already it was felt that cervical dystonia required an urgent treatment in the first few weeks after onset and that the “nervosity” of the patient should be treated.

illustrated by Dr Marion, blog

illustrated by Dr Marion, blog

Then the treatment evolved in the 80s and Jean-Pierre Bleton, a physiotherapist, in Paris, working with Professor Rondot, (3) developed a technique of retraining (4), which has inspired a lot of recent studies, aiming to retrain the antagonist muscles and to increase the control of the dystonic spasms.


Bleton JP, et al. Spasmodic Torticollis Ed: Frison Roche, 1988

Bleton JP, et al. Spasmodic Torticollis Ed: Frison Roche, 1988

Then Tsui et al (5) published the first study of Botulinum toxin injections for the treatment of CD in 1985. Since, Botulinum toxin treatment has shown its efficacy in improving quality of life, disability, and pain and maintaining people in employment. Long-term studies over 10 and 20 years have shown also that the treatment is well tolerated and keeps its efficacy over the years in the majority of patients.

Does physiotherapy still have a role to play in the treatment of cervical dystonia, considering the dramatic therapeutic effect of the Botulinum toxin?

A second generation of physiotherapy programs (6,7), as an add-on treatment to Botulinum toxin injections, were compared to a no exercise groups and consisted of short (from 2 to 6 weeks) and intense (3 to 7 sessions a week) programs of motor learning exercises and mobilisation techniques and were associated with improvement in pain and disability (8). A trial (9) comparing specific versus non-specific exercises did not show any difference between the 2 groups as all patients improved but the outcome measures in all these studies (9,10) were done at the peak effect of the Botulinum toxin injections.

A modified approach has been recently published (6), comparing the standardised physical therapy, tailored to functional need of each patient in his or her daily life versus a regular physical therapy program. This standardised program is inspired from the JP Bleton French school, but with an emphasis on the importance of self-management. The patients also are assessed at the end of a12 week interval following the injections. The results are not yet published.

Do new advances in the understanding of dystonia influence a new generation of physiotherapy?

The importance of the non motor signs in the disability of cervical dystonia (10) such as fatigue, anxiety and pain, supports the use of an integrated approach to treatment such as a bio-psycho-social model used in the treatment of chronic pain and more recently in functional movement disorders (11).

-Also as self-efficacy is the best predictor of disability (10) in cervical dystonia, it emphasises the importance of the education of the patient with a self-management program to keep the patient as active as possible in his daily life and at work.

“Perceived self-efficacy is not a measure of the skills that an individual possesses, but a belief in what he or she can do under certain conditions and when influenced by taxing circumstances, e.g. adverse physical symptoms; Therefore, self-efficacy beliefs may explain why some individuals with severe motor symptoms report low disability and other individuals with mild symptoms report severe disability.” (quote from Zetterberg, 10).

-The understanding of dystonia as a motor circuit disorder with abnormal plasticity (12) suggests the possibility of retraining the dystonic brain to a “normal” automatic movement using mindfulness, motor imagery, and visualisation like an athlete optimising his physical performance in preparation for a competition!

Dr Marie-Helene Marion, Consultant Neurologist,Chair of the British Neurotoxin Network (BNN)

MH Marion, BNN Oxford 2015

MH Marion, BNN Oxford 2015

References :

  1. Séance du Mardi 4 Juin 1929. Revue Neurologique T1, n6, Juin1929;
  2. Treatment of spasmodic torticollis by a psycho-motor retraining:
  3. Rondot P. Le torticolis spasmodique: rapport de Neurologie présenté au Congrès de psychiatrie et de neurologie de langue française, LXXIXp-s session, Colmar, 29 juin au 4 juillet 1981.
  4. Bleton JP, et al. Spasmodic Torticollis Ed: Frison Roche, 1988
  5. Tsui JK, et al. Can J Neurol Sci 1985;12(4):314–
  6. Delnooz et al, Mov Disord 2009, 2187-98
  7. Van den Dool J, et al. BMC Neurol 2013;13:85
  8. Tassorelli C, et al. Mov Disord 2006;21(12):2240–3
  9. Counsell C, et al, Parkinsonism Relat Disord. 2016 Feb;23:72-9.
  10. Zetterberg L, et al. J Rehabil Med 2012;44(11):950–4
  11. Nielsen G, et al. J Neurol Neurosurg Psychiatry 2015;86:1113–9.
  12. Pierre Burbaud (2012). Dystonia Pathophysiology: A Critical Review, Dystonia – The Many Facets, Prof. Raymond Rosales (Ed.), ISBN: 978-953-51-0329-5, InTech, Available from: