Treatment for Dystonia
Treatment for dystonia may include medication, injections, and surgery. In some cases, patients are able to use "sensory tricks" (sometimes called geste antagoniste) to help alleviate symptoms or at least make them more manageable. By touching the affected area (or one close to it) in a particular way, the contractions subside.
For example, some patients place a hand on their chin, on the back of their head, or on the side of their face to help with neck muscle spasms. Others find that touching their eyebrows helps alleviate contractions in the eyelids. Orthopedic devices have been developed to perform some sensory tricks so that the patient does not have to perform them.
Medications can be used to affect neurotransmitters in the nervous system and control movement. Often, a combination of medicines is prescribed and patients are started on a low dosage. The medication can be gradually increased as needed, and may be discontinued slowly over time.
Types of medication that may be used to treat dystonia include the following:
- Anticholinergics (e.g., benztropine mesylate [Cogentine], biperiden [Akineton], diphenhydramine [Benadryl], trihyxyphenidyl [Artane])
- Benzodiazepines (e.g., diazepam [Valium], clonazepam [Klonopin])
- Baclofen (muscle relaxant and antispastic medication)
- Dopamine agonists (e.g., bromocriptine [Parlodel], pergolide [Permax])
These medications should not be discontinued abruptly. Side effects may include dizziness, drowsiness, fatigue, lack of coordination and balance (ataxia), nausea, and vomiting.
Injections can help focal (i.e., located in one area of the body) dystonias. The most common procedure uses botulinum toxin (e.g., BOTOX, Myobloc) to hinder the brain-body communication problems that cause dystonia. Botulinum toxin injections for dystonia must be repeated every three months.
Phenol/alcohol injections also may be used. These treatments, which are less expensive than botulinum toxin injections, usually last for six months. However, only certain types of nerves can be treated, and the procedure must be performed very carefully.
If medications and injections are unsuccessful, surgery may be considered. However, most types of dystonia are not treated surgically, and the results may be only temporary.
In deep brain stimulation (DBS), an electrode (lead) is inserted through a small incision in the skull and is implanted in the targeted area of the brain that control movement. An insulated wire (extension) is then passed under the skin in the head, neck, and shoulder, connecting the lead to the neurostimulator, which is surgically implanted in the chest or upper abdomen.
The stimulator emits an electrical pulse that is picked up by the electrode, calming the nerves that cause contractions and blocking nerve signals that trigger abnormal movement. However, the results are not consistent and deep brain stimulation is still being investigated and developed to make it more reliable.
Side effects of deep brain stimulation include the following:
- Bleeding at the implantation site
- Impaired muscle tone
- Loss of balance
- Slight paralysis (paresis)
- Slurred speech (dysarthia)
- Tingling (parethesia) in the head or the hands
For severe dystonias that affect the neck, certain nerves can be severed. Another surgical procedure (called ablative surgery) locates, targets, and destroys (ablates) the clearly defined area of the brain that produces chemical or electrical impulses that cause abnormal movements (i.e., the thalamus).
In this surgery, a heated probe or electrode is inserted into the targeted area. The patient remains awake during the procedure to determine if the problem has been eliminated. A local anesthetic is used to dull the outer part of the brain and skull. The brain is insensitive to pain, so the patient does not feel the actual procedure. In some cases, it may be difficult to estimate how much tissue to destroy and the amount of heat to use.
Ablative surgery for dystonia carries risks. The thalamus is very close to another part of the brain used for speech and if that area is disturbed, the patient may experience speech impediments following the procedure. Adverse effects of surgery often cannot be reversed and they may result in permanent disfigurement.