Patient story: “My neck just won’t listen”

Your new patient describes a stubborn, twisting pull of the head—some days a tremor, other days a painful clamp-down. They can briefly “reset” it by touching their chin or the back of the head, but the relief fades. That’s the clinical feel of cervical dystonia (CD): involuntary, patterned neck muscle contractions that drive abnormal postures or movements, often with pain and functional limits. It’s the most common adult-onset focal dystonia, with prevalence estimates typically in the 5–30 per 100,000 range. UpToDate

What is cervical dystonia?

Cervical dystonia (a.k.a. spasmodic torticollis) is a movement disorder of sensorimotor control. Patients show one or more stereotyped postures—torticollis (rotation), laterocollis (side-bend), anterocollis (flexion), retrocollis (extension)—which can be constant or intermittent and are frequently painful. “Sensory tricks” (geste antagoniste)—like lightly touching the chin or cheek—may transiently reduce symptoms, hinting that altered sensory integration is part of the disorder. Dystonia Medical Research Foundationshrs.uq.edu.au

Why does it happen? (A quick, practical pathophysiology)

CD isn’t just “tight muscles.” Converging evidence points to network-level dysfunction across basal ganglia–thalamo–cortical and cerebellar circuits, with three recurring themes:

1. Impaired sensorimotor integration (mismatch between sensory input and motor output)

2. Reduced inhibitory control across CNS levels

3. Abnormal plasticity/maladaptive learning

Together, these alter how the system selects and stabilizes movement, letting “noisy” patterns through and reinforcing them over time. SpringerLink

How is it treated? (Medical & interventional overview)

• Botulinum neurotoxin (BoNT) injections are the first-line evidence-based treatment for CD. Choice of product (ona/abo/inco BoNT-A or BoNT-B), muscle selection, dosing, and guidance (EMG/US) drive outcomes. Note that units are not interchangeable across brands. UpToDateDysport®

• Oral medications (e.g., anticholinergics, benzodiazepines, baclofen) may help selected patients, but tolerability often limits use; most guidelines still center BoNT for focal CD. UpToDate

• Deep brain stimulation (DBS) of the globus pallidus internus (GPi) (and sometimes STN) is an option for BoNT-refractory cases, with sustained improvements (motor, disability, and often pain) reported in meta-analyses and long-term cohorts. SpringerLinkBioMed Central

PT framework: what to assess and train

1) Map the dystonic pattern & “trick”

• Identify the dominant posture(s) and document a reliable sensory trick (touch to cheek/chin/occiput). Use the trick deliberately during early practice to improve movement quality, then gradually fade the cue. shrs.uq.edu.au

2) Address sensorimotor control (not just strength)

The cervical system’s position sense, oculomotor coupling, and postural control are commonly altered in neck disorders; targeted training can improve accuracy and steadiness. JOSPT

• Joint-position error (JPE) retraining

  • Set a midline target on the wall. From neutral, rotate ~30°, then return to perceived neutral, using a head-laser or wall target to get external visual feedback. Start slow, prioritize accuracy, then add speed/complexity. 6–10 reps each direction, 1–2 sets. JOSPT

• Head–eye coordination

  • Smooth pursuit: keep the eyes on a moving target while the head stays still; then reverse (eyes fixed on a dot, head performs small, smooth excursions). Progress to combined patterns.

• Postural stability with cervical control

  • Static stance → tandem → unstable surface, while maintaining neutral head alignment to a visual reference (e.g., laser on a target line). Add dual-task (countbacks, category naming) to simulate real-world demands.

3) Mobility & selective activation

• Gentle dose-controlled stretching for shortened/posturing muscles (e.g., ipsilateral upper trap/levator/splenius depending on pattern).

• Antagonist activation/strengthening in short, frequent bouts—focus on quality of alignment over load.

• Breathing/relaxation drills to reduce co-contraction and pain-related guarding.

4) Task-specific practice with external focus

Motor learning literature supports external focus and visual targets for performance and retention—key for durable change. Use clear targets (dots, shapes, grids), mirrors, or laser-guided traces to make “good reps” visible. JOSPT

5) Dosage & progression tips

• Short, frequent sessions (5–10 min, 2–4×/day) beat long, fatiguing blocks.

• Start with the patient’s sensory trick to reduce dystonia, then titrate exposure to movement without it.

• Layer speed/complexity only after accuracy is consistent.

Why Laser-Guided Feedback Works

• External focus of attention: improves motor learning and retention compared to internal “think about your neck” cues.

• Real-time performance feedback: patients see their head’s trajectory and can self-correct, building awareness.

• Objective tracking: clinicians can identify asymmetry, drift, tremor, or inability to stabilize that might be hidden without visual feedback.

• Engagement: turning exercises into “visual games” keeps patients motivated.

Phase 1 (Weeks 1–2): Calm and Calibrate

Goals: Reduce pain, build awareness of neutral, introduce simple visual feedback.

Laser-Integrated Drills:

1. Neutral Hold with Laser Dot

   • Affix the Motion Guidance laser to the headband.

   • Project laser in center of flag (midline, 4–6 feet away).

   • Patient practices holding head steady for 10–20s, minimizing dot drift. Every 10-20 seconds, take a 5 second break, repeating for 2 minutes total.

   • Use patient’s sensory trick (e.g., light finger touch to face) initially if needed.

2. Return-to-Target (Joint Position Error retraining)

   • With the laser pointed at center red dot close eyes.

   • Fully rotate head left or right, then attempts to return to center.

   • Opens eyes to see how close to the center red dot you landed.

   • 6–8 reps each direction; prioritize accuracy > speed.

3. Laser Breathing Reset

   • Hold laser dot on target while practicing slow diaphragmatic breathing.

   • This encourages relaxation and reduces co-contraction.

   • Every 10 seconds, move the laser to a new red dot the flag. For instance, do all 6 dots along the blue butterfly shape on the tracking grid.

Phase 2 (Weeks 2–4): Control and Integrate

Goals: Expand range and accuracy, integrate eyes and head, improve smoothness.

Laser-Integrated Drills:

1. Smooth Line Tracking

   • Start with the vertical and horizontal lines on the tracking grid

   • Patient slowly traces line with laser (up/down, left/right) maintaining smoothness.

   • Practive for 2 minutes and slow controlled speeds.

2. Head–Eye Coordination with Laser

   • Eyes fixed on center red dot targetwhile head traces the butterfly with the laser: do each butterfly 3 times clockwise and 3 times counterclockwise, all while trying to keep EYES still on center target.

   • Then reverse: have the laser fixed on center red dot target while making your eyes dart to different red dots on the flag.

3. Shape Tracing

   • Trace the butterfly on the tracking grid clockwise, and counter clockwise.

   • Progress from slow & accurate → faster with dual-task (count backwards, word recall).

   • Progress from the small yellow butterfly shape to the large blue butterfly shape

4. Asymmetry Mapping

   • Identify direction most affected by dystonia (e.g., excessive rotation left).

   • Use laser feedback to practice controlled excursions toward the non-preferred side, aiming for smooth, centered return. For example: if your head tends to drift Down and Left, practice slowly going up to the dot in the UPPER RIGHT corner of the tracking grid, then returning. Also practice the portion of the butterfly ONLY in the UPPER RIGHT quadrant, over and over agian.

Phase 3 (Weeks 4–6): Complexity and Confidence

Goals: Build endurance, adaptability, and functional transfer.

Laser-Integrated Drills:

1. Reactive Targeting

   • Hang the flag, and use a parner to call out tasks.

   • Parner calls out/randomizes which target to hit (for example, calling out numbers on the clock, such as "12!, 3! 4! 8!...") You could also say "Clockwise Yellow!" or "CounterClockwise Blue!"

   • Patient quickly moves laser to each number, or traces each buttefly shape, maintaining control.

2. Dual-Task Balance + Laser

   • Patient balances in tandem stance or on foam.

   • Traces butterfly patterns with laser while holding posture.

   • Progress: add mental task (spelling, counting, etc).

   • Progress to doing butterfly tracing with head/neck, while doing slow controlled squats

3. Asymmetry Challenge Progression

   • Practice longer-duration holds or faster tracking into non-dystonic direction.

   • Add stroboscopic glasses (MotionGuidance Vision-Pro) for advanced sensorimotor challenge via manipulating visual field.

   • Progress to doing butterfly tracing with head/neck, while walking left and right slowly, or in a figure 8 pattern.

Clinician Tips for Success

• Short bouts (5–10 minutes, 2–4×/day) improve carryover more than long sessions.

• Start with larger, slower movements → narrow and speed up as control improves.

• Always anchor drills to a visible external target (line, dot, shape).

• Track progress by measuring dot deviation, accuracy, and smoothness.

• Integrate into post-BoNT window for maximum neuroplastic reinforcement.

Example Weekly Progression

• Week 1–2: Neutral hold, return-to-target, line tracing (short reps, frequent practice).

• Week 2–4: Add shape tracing, eye–head coordination, asymmetry mapping.

• Week 4–6: Build into reactive, dual-task, and functional simulations.

✨ With Motion Guidance, you transform “invisible” motor control drills into visible, measurable training. Patients aren’t just told to “keep your head steady”—they see it, self-correct, and stay engaged.

Example 4–6 week clinic/home program (adapt as needed)

Phase 1 (Weeks 1–2): Calm and calibrate

• Pain modulation (heat/ice as preferred), breathing, gentle mobility

• JPE drills with head-laser to midline target (eyes open, low speed)

• Sensory trick-assisted neutral head holds (10–20 sec)

• 3–5 min, 3–4×/day

Phase 2 (Weeks 2–4): Control and integrate

• JPE drills to multiple targets (midline + 30° each side)

• Head–eye coordination (eyes fixed / head moves; head fixed / eyes track)

• Antagonist activation (isometrics in corrected alignment)

• Balance progression (wide → narrow → tandem), maintain laser on line

• 6–10 min, 3×/day

Phase 3 (Weeks 4–6): Complexity and confidence

• Faster JPE returns with accuracy threshold (e.g., ≤2–3 cm error)

• Dual-task balance (cognitive load), short reactive reaches to wall targets

• Functional tasks (reading/computer/ADLs) with planned micro-breaks and visual cueing

• 8–12 min, 2–3×/day

Tip: If the patient receives BoNT, schedule PT intensification in the post-injection window when tone is reduced, then maintain gains as the effect tapers. assets.bmctoday.net

Safety notes and clinical pearls

• Expect good days/bad days; track what makes it better (sleep, stress, task context) and deliberately practice under those favorable conditions before challenging contexts.

• Encourage self-efficacy: short home sessions, visible targets for feedback, and quick wins.

References (selected)

• Sensorimotor control & neck disorders: Kristjansson & Treleaven, JOSPT 2009. JOSPT

• PT for cervical dystonia: Toxins 2022 systematic review; BMC Neurology 2024 meta-analysis; RCT (2019). MDPIBioMed CentralPubMed

• BoNT guidance & first-line status: UpToDate treatment topic; product unit non-interchangeability. UpToDateDysport®

• DBS outcomes: 2020 pooled analysis; 10-year GPi cohort. SpringerLinkBioMed Central

• Epidemiology range: UpToDate epidemiology/diagnosis. UpToDate

This article is for educational purposes and is not medical advice. Treatment should be individualized and coordinated with the patient’s neurologist/MD/Physical Therapist.