Category Archives: Dystonia

New thinking in dystonia

New thinking in dystonia

New thinking in dystoniaWe need new thinking in dystonia because the treatment of this very troubling condition must improve. This means that people suffering dystonia feel that they are getting better. The same can be said for all conditions that are viewed as persistent, as our understanding moves forward, creating new approaches that must be based upon science. One areas of particular interest that I believe will be highly influential, is the science of consciousness — what is it to be conscious? What is it to be like something?

The patient’s lived experience is something we seek to gain insight into as clinicians so that we can shape a forward trajectory characterised by less suffering. I would argue that this is an approach that we should be taking for all conditions. We may have an injury, a pathology, a disease or a pain yet we can always seek to reduce suffering in a number of ways by taking a broader perspective and look at the causes of suffering that are not directly related to the condition. This could be termed a whole person approach or a sociopsychological approach with a minor contribution from the biological dimensions — is it useful to understand the molecular biology of pain or to know what action to take to feel better? I would argue the latter. To feel better we may need to foster relationships, communicate, move, create a new habit, consider financial or occupational matters, just to name a few. Being able to determine which receptor is being activated is not particularly helpful in this light.

Once a person is diagnosed with dystonia, they may be offered botulinum toxin injections. In some locations, physiotherapy may be recommended but the content of the treatment programme tends to vary. There is no standard set of treating principles resulting in mixed results borne out in the literature. However, as far as I am aware there is scant attention given to sensorimotor training according to the latest understanding of ‘how we work'; a unification of action-perception-cognition, our experiences are our brain’s best guess about the possible causes of sensory information for which we seek confirmation with action.

Exercises alone are not enough. The understanding, the engagement with the programme (meaning), the expectation (what you are thinking will happen as a result of the training in that moment — the tape you play of what will happen with your embodied mind; a prediction) and the focus are all important. The complete programme must incorporate these elements as the person living the dystonia (the twists, the pulls, the tension, the jerks, the imprecision, the inconvenience, the pain, the second arrow that is the way you think about yourself and the condition) needs to be able to coach themselves in any given moment, day to day in order to be successful. There are a number of simple ways of facilitating this mindset.

Identifying with one’s strengths, those characteristics that have led to successes in the past, and employing them in this arena results in resilience, self-motivation and the necessary perseverance. Practice is key in creating new habits of body awareness, movement control and sense of self. Alongside a focus on strengths, one learns to manage weaknesses and distractions so that the direction of travel remains toward the desired outcome. Creating a clear vision of that desired outcome is an important start point to which one can check orientation.

Remaining open with a broad mindset tends the individual towards greater feelings of satisfaction and happiness. It is the the moment to moment emotions that cultivate how we feel and hence to purposefully notice positive emotions and triggers of our positive emotions both maintain a steer towards feeling open. When we are open, we experience the full opportunity that life presents, engaging with people and activities far more effectively, which in turn promotes more consistent positive emotional states. Both of these simple skills form a strong foundation for the sensorimotor training necessary to develop precision of movement, a core change needed to feel better and closer to how one feels one should be feeling in this moment. A further practice is that of mindfulness, which is being aware of what you are feeling, thinking and doing right now in this moment; being present, which by definition removes the suffering caused by our thoughts drifting into the past or future. In so doing, we are robbed of what is really happening right now.

As we understand ‘how we work’ more and more with the unfolding story of the science of the sense of self — who we are, how we function (move and act), how these unify into the lived experience, and how we can reduce suffering by creating the right context for healthy action-perception-cognition with a comprehensive training programme that addresses the lived experience. That is our role as clinicians.


Sensorimotor training programme | t. 07518 445493


Back pain

Cervical dystonia and anxiety

Cervical dystonia and anxietyVarying degrees of anxiety are usually described by the person who suffers cervical dystonia and there are a number of understandable reasons. Firstly, anxiety about the condition itself — what is it? What does it mean for me? Will it get better? What can I do? Can anyone help me? Secondly, the person suffering dystonia often has had a tendency to worry in life, frequently feeling anxious, over-thinking things, ruminating and over-focusing on unhelpful thoughts. These are all habits of thought but experienced as that story we tell ourselves, the inner dialogue, that can be so impacting on our reality and perception. Combining these, there is usually an attentional bias towards the feelings of dystonia, the pulls, the tension or spasm, and at these times, the symptoms are worse. Conversely, when distracted or engaged in something more interesting or meaningful, the symptoms ease. And when we are not aware, in essence it is not happening!

When we feel anxious it is because of the meaning with give to those familiar feelings in our body — tingling in the tummy, tension etc. The meaning we have attributed to the causes of those sensations is something threatening and consequently we act by preparing to deal with that threat. This is the same biology as used to face a threat in the wild: fright or flight. Part of the way the body/we deal with threat is to get ready to run away or fight, both of which need mobilisation of resources to our muscles, which is why they tense up in readiness. But, in dystonia there is already overactivity and unwanted movement, so the additional preparation as described can only add to this experience and put out attention on the sensations.

One of the issues in cervical and facial dystonia is altered body sense and sense of self. It seems that when we have an altered body sense, which means that there is a mismatch between what is happening (sensory input) versus what the brain expects (or predicts). This creates a threat and hence the biology that is responsible for detecting and acting upon this state is active in creating a fright or flight response that the person then predicts as anxiety. The same happens in persistent pain states when body sense and sense of self changes; not permanently, but it needs training. This is one of the reasons why exercise and movement reduce anxiety because we improve our body sense.

A significant part of the re-training programme for both dystonia and pain is body sense based. Body sense, ‘where I am’ and ‘what I am doing’, is really a unification of internal sense, external sense and proprioception somewhat threaded together by the narrative that I tell myself. Ironically, when we feel ourselves, we don’t really think about our body! So this is the desired outcome: not thinking too much about our body and in fact using our body to help us focus on the job in hand; e.g. when walking, we don’t normally think about how we are walking, we just walk; the body is thinking for us — aka ‘embodied cognition’. When the person says to me, ‘I feel myself again’, then I know that they are reaching or have reached their desired outcome.

Pain Coach Programme and Dystonia Coach Programme | t. 07518 445493

Mindful commuting

Cervical dystonia and body sense

Cervical dystonia The main focus of cervical dystonia is usually the neck yet in my experience it is not just the neck where body sense changes. A simple balance test identifies a poor ability to remain upright in an economical fashion in most cases and there are several reasons for this feature: altered body sense and the fact that with cervical dystonia, the involuntary movements ensure that the world appears to be constantly moving and thereby the person is perpetually correcting their position relative to the environment. We are all doing this, but in dystonia when there is spasm, this is amplified and hugely troublesome for the person, often the cause of great suffering.

Many people with cervical dystonia tell me that their awareness of the movements increases when they are walking. Walking involves transferring weight from side to side, in effect re-balancing over and over as you move forwards. Without precise body sense this becomes a challenge. I use oversteer as an analogy when playing an arcade driving game, as I turn the wheel too much one way and then the other with compensation after compensation. Continue update and correction is exhausting, so no wonder people with dystonia often feel tired. Heads are heavy and with all the extra muscle activity, fatigue sets in and often hurts if not the cause of stiffness and tension alone.

This being the case, improving one’s overall body sense is an important part of improving cervical dystonia. This is done simply with balance exercises set up in such a way that the position is precise thereby creating an effective learning opportunity. What we do now impacts on the next movement or position, so practicing best quality is key. This is why when balancing, some support is important so that the person can hold best posture, feel it and see it in the mirror; i.e./ learn.

There are a couple of other important points about walking and an increase in symptoms that I will not be going into details about here, but they are part of the bigger picture. Firstly we can have an attentional bias, which means that the person will regularly focus on the feelings (pulls, twists, spasms etc.). Secondly, there can be an expectation or anticipation that this is what happens when I walk down the road, even before you do it. This primes and an association builds — i.e./ it becomes a habit. But, habits can be replaced.

Training a better body sense locally is a key part of changing dystonia and improving movement quality. We cannot move normally without experiencing a normal body sense — where I am, my position, speed of movement, when to stop, where I am in relation to the environment etc. So in cervical dystonia, learning where your head is positioned and re-training normal muscle activity when you are using your arms and hands is key, as is an overall body sense.


Cervical and facial dystonia training programme | t. 07518 445493 — call us now to start your programme


Physiotherapy Dystonia Network Meeting

Last week was the Physiotherapy Dystonia Network Meeting in Birmingham, attended by physiotherapists who work with people suffering dystonia who wish to engage in conversations to further our understanding and impact upon this condition. Chaired by Dr Marie-Helene Marion, it was a day of engaging conversations, led by pertinent, short talks that shared knowledge and experience. One aim is to develop the network, which would further the awareness of dystonia and create opportunities for clinicians to build their skills and knowledge together.

I was asked to talk about my approach to cervical dystonia (see my slides here: Similar to the way in which I approach persistent pain, the programme is neuroscience-based coaching and treatment for cervical dystonia.

Beginning with how Dr Marion and I met, and how we shared stories of chronic pain and dystonia before realising that there was significant overlap in the characteristics and hence approach that could be taken, I then provided some background as to why I do what I do with people suffering cervical dystonia. I emphasised the over-arching need to consider the whole-person, their story and how their narrative fits within their life as a lived experience.

Cervical dystonia is a condition that sits at the root of the sense of self. We face the world with our bodies and the way in which we move, posture and gesture communicates with others. Yet this moving and posturing is affected by the way we feel, where we are, who we are with, what we have been doing, what we may do in the future moments (and we may not be aware of what that will be in any given environment), and hence the final product of movement is the brain’s best guess as to what we should be doing in the light of the current evidence, based on past experience. And the brain does not always get it right! Of course we are not separate from our brain; we are our brain, our body, our mind and our reality as created by the sum of these within a particular environment.

Despite this seeming complexity and perhaps departure from the classic model of mind-body separation, a moment’s thought and we soon realise with some simple examples that embodied cognition is a useful way of thinking about the way we exist. Where do you feel anxious? Usually in your abdomen or chest although anxiety would be considered a ‘mental’ experience. Trying to separate body and mind does no justice to our lived experience and reduces the impact of any treatment programme.

Having briefly covered this, I described some of the training methods that include motor imagery, visualisation, sensory discrimination training, proprioception and motor training. None of these are discreet but instead are moulded together in the form of a comprehensive programme to create new learning experiences towards a more normally functioning sensorimotor system, but remembering that this ‘system’ works closely with emotional, attentional and motivational areas of the brain, that is of course part of the whole person, residing within their reality and perception of life to date. Nothing happens in isolation. We seek to restore a sense of self; who we feel we should be.

My talk was brief and hence only able to scrath the surface of some important considerations, especially the need to set the scene for training by helping the person develop their thinking and self-coaching skills. The aim now is to expand this talk into a day long learning experience that looks at each area and how they tie together into an approach. Keep an eye on the website and twitter for updates (@painphysio). There will also be a series of blogs, considering some of the key issues in cervical dystonia to follow.

If you would like any further information, please do get in touch: 07518 445493

Useful links:

The British Neurotoxin Network

The Dystonia Society


Keoni Cabral |

Cervical dystonia

Keoni Cabral |

Keoni Cabral |

Cervical dystonia (CD) is a movement disorder that is characterised by unwanted and involuntary spasms of the muscles in the neck and shoulder region. It can also affect the facial muscles. There is a genetic aspect to cervical dystonia but frequently, people who come for the treatment and re-training programme will describe a period of stress when the problem really took off.

It is not uncommon to hear that the diagnosis eventually came some years after the problem began. Typically a neurologist will diagnose dystonia, although an informed GP or physiotherapist may also identify it from the twitching, pulling and sometimes writhing movements that are cleary involuntary.

Cervical dystonia can be a distressing condition for a number of reasons: the pain and discomfort from the constant tugging, the continuous battle between opposing muscles and attempted conscious corrections, the awareness of others looking, the way that the movement patterns and body sense affects how you feel and your sense of self, your self-esteem and confidence in social situations, perhaps hopelessness in the face of the persisting symptoms; all impact on the condiiton itself and your hopes and expectations.

In conversation with people with CD, we usually identify certain traits such as perfectionism, obsessiveness and a lack of compassion towards oneself (self-critical). In addition, there can be a heightened awareness towards the body, including aesthetically–how do I look? Combining the desire to look a certain way with the manifestations of CD and there is a great deal of angst created.

Modern treatment is often led medically, once diagnosed, 3 monthly injections of botulinum toxin are typical. With the right dose and careful placement of the injections, this creates a great opportunity for sensorimotor re-training. Whilst the training is the mainstay of improving movement, there are a number of other considerations, the so-called non-motor factors. These must be addressed within a treatment and training programme. Merely focusing on the senses and movements is simply not enough, and indeed when we purely attend to a problem at the expense of all else, it will increasingly dominate our thinking. So in a way, to treat a problem, we should not always treat the problem!

Sensorimotor training develops normal body sense and movement, the two being absolutely interrelated. Without good body sense, you cannot move with normal precision, and when we move abnormally, or what is deemed abnormal by the motor system, then our bodies can feel different. When our bodies feel different, the way in which we engage with the world changes and so on. Specific exercises and techniques are used on a ‘little and often’ basis, which are simple and do not require equipment except a mirror on occasion. They necessitate practice like any training that is designed to improve performance, in this case precise movements for everyday life.

Where there has been and is on-going tension from overactive muscles, these body tissues and the underlying joints that are limited in movement by the tension, require nourishment with easy and regular movements. This often works best after a period of relaxation from breathing exercises or mindfulness, both of which promote better blood flow and oxygen delivery. I call this ‘motion is lotion’, a term that I did not coin but use with everyone I see to encourage healthy movement, whether for chronic pain, dystonia or both.

The way we move and the way that our brains plan movement based on predicting what we may do in a given environment, is affected by many factors: e.g./ how you are feeling, what you are thinking, who you are with, what you have been doing, how tired you are, what you plan to do, what your brain predicts that you may do, what you have done before in that environment, to name but a few. You will not be aware of many of these, but you’ll be aware that your spasm or pulling worsens or eases depending on certain circusmstances. Identifying these circumstances and situations allows you to begin dissolving these associations and habits, creating new patterns of movement. Remember that we are designed to learn and change, with opportunities to do so existing at all times.

Spending some time doing something that is meaningful to you is a great way of focusing on something else. Many people with dystonia find that when they are in full flow, the spasm and pulling ease off. This can be when painting, speaking, reading or listening to music. Even if during a meaningful activity you notice the symptoms, you can practice and improve, acknowledging the symptoms and returning your attention to the favoured activity. The pleasure that you gain and the realisation that you can attend elsewhere is part of overcoming the problem.

Mindfulness practice and relaxation play a significant role in changing the brain state, immune state and dampen down other systems that work to protect us including the sensorimotor system. When we perceive a threat, the muscles tense up in readiness to fight or run away. This is a basic biological function that does not help the already overactive muscles of dystonia. Mindfulness is not a spiritual or religious practice but rather a practical way of looking your thinking rather than becoming embroiled in thoughts and living out the past or future in your head. The techniques are simple and can be practiced anywhere.

This is a brief insight into both the condition and some of the ways that we go about changing your experience with a training and treatment programme. As ever, it is the person who needs treatment as they are living the experience of dystonia (it is not the neck experiencing dystonia), much like it is the person who feels hunger, not their stomach that feels hunger. Thinking widely and individually is key to successfully changing the unwanted movement patterns and easing the symptoms, allowing for the resumption of a meaningful life.

For more information or to book an appointment, call 07518 445493

Lateral view of neck by Double-M

Dystonia coaching programme

Lateral view of neck by Double-M

Lateral view of neck by Double-M

The dystonia coaching programme that I have developed over the past few years is based on similar thinking to that of persisting and complex pain. In fact, the reason why I started working with people experiencing dystonia is because of a conversation with Dr Marie-Helene Marion (the movement disorder specialist).

We were discussing biology, people and influences, thinking that we were talking about the same thing, but in fact I was talking about persisting pain and Dr Marion was talking about dystonia! From thereon it was clear that there are significant parallels in what we see and who we see, leading to an innovative approach based on the latest neurosciences. I was fortunate enough to talk about this at The Dystonia Society meeting and The British Neurotoxin Network conference.

Most cases of dystonia that I see are cervical. This is a troubling condition in many ways, including the social aspect that is commonly forgotten. By this I mean how dystonia impacts upon the person’s social interactions due to the way it can make them feel about themselves. This is such an important part of the problem, as the way we think and feel affects our sense of self and how we move. With a movement disorder, this is highly pertinent. Our thoughts and feelings can frequently be impacted upon by the way we think others see us, potentially driving behaviours such as avoidance and protective posturing, both of which affect quality of life.

There are several other notable consistent findings. An altered sense of body position that underpins the imprecision of knowing where your body is in space and the movement imprecision that is the classic sign. In fact, it is the sensorimotor function that is a problem as a whole, influenced by a range of factors such as thoughts, emotions, the environment. As with pain, dystonia is a whole person problem and as such requires whole person thinking behind the treatment and training programme.

Botox treatment often has good effects when used at the right dosages. Commonly people become engrained in thinking that they must have injections every 3 months, with this expectation influencing behaviours and outcomes. In my dystonia programme we immediately aim to develop this thinking into how we can gap out the need with specific training but also challenging unwarranted expectations. It is exciting to think that drugs are affected by the way we think as it opens the door to great possibilities.

Much like the Pain Coach Programme for persisting pain, the dystonia programme targets the person: their thinking, emotions, movements, sensations as a whole. There are specific training exercises that take advantage of our ability to develop (commonly called neuroplasticity) and learn, and a range of strategies that target the influences upon the way we move and face the world including stress, anxiety, thoughts, other people and the environment. Our understanding of ‘how we work’ is ever-growing and this is cause for great optimism as we see people overcome chronic pain and dystonia in theor own individual way.

For more details or to book an appointment, call now 07518 445493


Dystonia — facing the world

Dystonia — the term used to describe uncontrollable and sometimes painful muscle spasms caused by incorrect signals from the brain. It is estimated to affect at least 70,000 people in the UK; Dystonia Society — has varying impact upon the individual. By this I refer to the way in which it makes the person view themselves, their sense of self, and how the world sees them.

Our physical persona, the way we represent ourselves to the world via body language, posturing and movement to an extent defines us and how we feel. This is bi-directional as we will respond physically to how we are feeling and what we are thinking as much as noticing how our body feels to then ascribe an emotion; for example, butterflies in the stomach will typically trigger thoughts that we must be anxious.

Having spoken to many people with dystonia, this significant part of the experience is rarely addressed. It must be. On a practical level, understanding that movement is affected by a number of influences such as where we are, who we are with, how we are feeling, where we are and what we have been doing, helps to cope and deal with the unwanted motion on several different levels. Further, to know that the brain is constantly predicting what actions will be required next and planning how to use the body, provides insight into how certain involuntary movements can be initiated.

In dystonia, the way in which the brain perceives the body is altered as is the way movements are planned and executed. A loss of precision means that there is unwanted and uncontrolled actions in both a sensory and motor context. This is why training must be multisensory and embrace the sensorimotor system as a whole, from a planning stage through to actual movement.

How we face the world and whether we choose to face the world will be dependent upon how we feel. Being able to cope with this will impact upon the extent to which socialisation continues or is voluntarily curtailed. Cultivating skills in dealing with the thought processes and being able to intervene independently has a positive effect, reducing and minimising the impact. This is also a key skill to use in optimising the outcome of the training programme, by changing the way that the brain is functioning in a motor sense, so that the focus and quality is of a high level. Practice is key.

Focused attention training or mindfulness should form part of a comprehensive treatment programme. It can be thought of as setting the scene, creating a brain state of calm and readiness for the actions that are required to re-train precision of movement and body sense. It is a state that can be cultivated that means troubling thoughts do not get played through the body (tension, altered movement, involuntary movement).

There are many healthy, physical and mental benefits of mindful practice, tackling the so significant non-motor factors that are barely mentioned, yet play such a huge role in the individual’s suffering. We are understanding the brain changes associated with this practice as neuroscientists study the effects upon the wiring — a crude analogy of the brain’s function — and how this translates into a positive experience of life.

Stand alone, mindfulness practice can change our interface with the world. Combined with specific sensorimotor training and the creation of new habits, the potency is magnified. On a practical note, mindfulness can be used at all stages of dystonia, acute through chronic. The sensorimotor training often requires a degree of quiescence and hence will usually begin after botox treatment. The design of any treatment and training programme will depend very much on the individual need and circumstance.

As I have argued recently in writing and speaking at several conferences (Dystonia Society DayBritish Neurotoxin Network meeting 2013) , to address dystonia — and chronic pain — we must consider the biology of the condition but also the biology of the influencing factors that are such a significant part of the narrative.

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Dystonia Society

Dystonia Society meeting | Talk on sensorimotor training for cervical dystonia

Dystonia SocietyThe ‘Living with Dystonia’ Day, organised by the Dystonia Society, was held in London in November. This was an opportunity to talk to neck dystonia sufferers and their carers about the sensorimotor training programme that I am using in conjunction with botox treatment — see here.

We have an understanding of how the brain plans and then executes movement. This is based upon a blend of prediction, feedback from the body’s sensory systems and what has been learned (i.e. prior experience). Tests in the clinic can identify an altered sense of body, a common finding in both cases of chronic pain and dystonia, that impacts upon the precision with which we would normally move. It is an issue of ‘threat’ when the movement that actually occurs does not match with the expected pattern or blueprint that exists in the brain. Any sense of threat can be enough for protective measures to be taken by the brain, e.g./ pain, guarding. This is the neurobiology of movement, and involves many parts of the brain including the motor centres, the basal ganglia and the cerebellum.

A key point that I made during the talk, and one that I make to patients, is that not only do we need to think about how the neurobiology of movement or the pain that is manifesting, but we also must consider the array of influences upon this biology. Those that we know well include stress, anxiety, prior experience, beliefs, the environment, the context, who we are with and what we are thinking about. All of these affect movement that is an expression of our ‘self’ at any given moment — what we are doing, thinking and feeling.

Our posturing or body language represents an interface between our sense of self and the outside world. When our movement changes, so does our relationship with the World. Certainly in neck dystonia, almost all of those who come to see me will talk about how it makes them feel to experience involuntary movements whilst in public places. Many will avoid going out if possible.

The involuntary movements, the lack of control and body awareness are all manifest and emergent characteristics of ‘re-wiring’ in the brain; the dark side of neuroplasticity. To improve motor control in these cases, we need to start at the level of planning rather than practicing actual movements. However, it is not just about the movement but also the sensory aspects that inform the brain. Hence the training is ‘sensorimotor’ that develops a better body sense to then normalise how it moves. The two are so interlinked in my view, that they are in fact one and the same; an overall mechanism of expression or function.

There are specific training strategies used for improving sensorimotor action including motor imagery and tactile discrimination exercises. Concurrently we look at the individual’s lifestyle influences: stressors, thoughts that cause anxiety and other non-motor factors that impact upon the movements and muscle activity.

Tension in muscles that persists can cause pain as the blood flow changes, acids build up and nerve endings that sample the tissues become sensitised. The messages sent to the brain about the tension and chemicals can result in a pain experience and often does in neck dystonia. Imagine performing bicep curls all day, every day. It would begin to hurt. With increased muscle activity due to involuntary movements and imprecise control, this is exactly what is happening. Reducing muscle tension by developing better control of movement and using techniques that are known to promote restorative activity are effective ways of re-programming how the body is working. Mindfulness or focussed-attention training are the methods of choice.

It is a very exciting time as we better understand movement and pain from a neuroscience perspective. The research must continue as we continually seek to improve the way in which we treat dystonia. The approach, as I described, must be comprehensive in addressing the physical, cognitive and emotional dimensions of the problem. In doing so we are offering a route forward via sensorimotor training, best applied in conjunction with botox treatment that both changes the muscle activity and eases pain.

For further information or to book an appointment, please contact us on 07932 689081



Keble coll

Tackling dystonia | British Neurotoxin Network Conference 2013 | Keble College, Oxford

Keble collIt was a pleasure to speak at the British Neurotoxin Network conference this week, a meeting for specialists in dystonia who use botulinum toxin as a form of treatment. Held at Keble College in Oxford, the surroundings were perfect for meeting, discussion and the sharing of ideas.

BNN Conference Programme here

Before dining in the magnificent hall, the audience was entertained by a talk from Dr. Marion on facial expressions, referring to Duchenne, Darwin and the work of Paul Ekman. Much of our communication relies on body language with facial expression revealing much about the emotional state. This is useful to communicate effectively, to demonstrate empathy and to determine threat—i.e. an angry face. Equally, a loss of facial expression due to cosmetic Botox treatment or facial paralysis affects one’s ability to show genuine emotion. A lesser known feature is that we can change our expression to alter our emotion. A simple technique to improve one’s mood is to grip a pencil between your teeth thereby forcing a smile. The feedback from the face to the brain persuades it it sense something good and hence our mood alters.

The focus of my talk was upon the reconceptualisation of pain, looking at whether this process can be considered as a way to progress the rehabilitation of dystonia. The slow move away from a biomedical model to the comprehensive biopsychosocial model has changed both the way we think about and tackle the problem of pain. Understanding that pain is multidimensional (physical, cognitive and emotional) means that there are a number of considerations that are unique to the patient. This makes it key to address the person as much as the condition.

In addition to the tissue based therapies that play role in the treatment of chronic pain, the modern brain based techniques are becoming increasingly recognised as part of a comprehensive programme. Discussing these therapies for pain in the light of what we know about the underlying mechanisms, it has been apparent that they could apply in dystonia and other movement disorders. The cortical reorganisation that we understand in both pain and dystonia is an important focus of a training programme. Graded motor imagery, tactile discrimination training and other brain targeted strategies not only seek to ‘re-organise’ but also to desensitise. Pain is all about a perceived threat by the brain, so any change or learning that reduces the threat can change pain and also movement.

With movement being an expression of who we are, how we are feeling, what we are doing and what we intend to do (we may not realise this fully), when we have difficulty because of pain or a lack of voluntary control, this impacts upon the way we feel. Our movement and posturing interface with the World, so reflect the situation that we are in as much as how we feel about that situation. The bidirectional nature of this interface offers different ways of changing our emotional state and retraining normal movement.

The science based talks focused upon genes (Dr Sean O’Riordan, Consultant Neurologist), cortical reorganisation, the effects of vibration (Dr Richard Grunewald) and deep brain stimulation (Mr Alex Green, Neurosurgeon), all of which are ‘neuroimmune’ lines of thought. Tying this basic science with what we can do therapeutically is a key way in which we can seek to move forward and cultivate new ideas. Clearly we need further research to look at all of these paradigms and develop our knowledge but we are in an excellent position to use some of the existing pain therapies that target the central nervous system to improve body sense and motor control via sensorimotor congruence.

Thanks to Dr Marion and Mondale Events for a great two days.

Here is some information on our treatment, training and coaching for dystonia



Chronic pain to #dystonia: how physiotherapy can target cortical reorganisation – speaking this week at BNN Conference

I am delighted to be speaking at the British Neurotoxin Network conference this coming week, giving an opportunity to talk about how we can target the higher centres with wise action and therapy for dystonia. The more recent literature has identified functional changes in a widespread network (e.g./ cerebral cortex, basal ganglia, cerebellum), cortical reorganisation and the importance of non-motor factors. In essence, a biopsychosocial look at this hugely impacting condition.

With a background in pain neuroscience it is fundamental to consider the physical, cognitive and emotional dimensions of any condition. The integrated nature of these dimensions are often key points and areas to target with education, therapy and strategies that seek to create the conditions for change and development, i.e. the treatment and training.

Dystonia is not about the basal ganglia as much as pain is not about damaged tissue. It is about an individual with a conscious experience that has evolved as a consequence of the combination of genes and the life story so far (epigenetics). To seek to change the experience we must consider the biology of the condition such as changes in the neuronal activity, the way in which the person thinks about their problem and the emotional responses. In comprehensively tackling the individual’s situation we can make headway by tapping into our neuroplastic mechanisms that underpin learning and adaptation but for the better. This equally applies for both chronic pain and dystonia, the similarities of which I will be discussing and drawing upon to provoke thought and advancement of the treatment for the latter.

Dystonia Clinic in London

Next: Interesting matters arising from the BNN Conference