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Dystonia and Chiropractic Neurology

IT REALLY IS ALL CONNECTED

Part of the reason I decided to study neurology was my fascination with the brain as “mission control” of the human body. Many of us forget that most events in our body, from the vaguest memory to muscle movement, begin with the brain. But the brain can be intimidating study material particularly for those who have not studied the body in the past. It is so complex that to discuss it is often overwhelming. It is the complexity, though, that is key to understanding how different areas of the brain affect different functions in the body.

Dystonia is defined as a neurological syndrome where the patient experiences muscle spasms that can cause involuntary movements, tremors, pain or abnormal posture. Many of you are well aware of the basal ganglia and know that they are structures deep in the brain that are involved in muscle movement. Did you know they are also involved in processing emotions? Many areas of the brain perform more than one function. Here, we will look beyond the basal ganglia to illustrate the interwoven aspects of the brain and how many areas can affect movement in everyday life. These topics and this anatomy will be new to many of you and it is not light reading, but I trust that the new insight you are about to gain will help explain the many secondary symptoms dystonia patients often experience. Equally important, you will learn how brain-based therapies, such as specific music, metronome timing exercises, visual stimulation, etc. can retrain the brain and help dystonia patients. 

The table shows the different areas of the brain, their primary “job,” and secondary functions. The numbers on the table match those on Fig. 2, the Brain Association Areas diagram. It is important to note where the areas are, which areas are neighbors and what each area does. Some areas cross over in their involvement further establishing the interconnectedness of the brain. The act of moving a muscle is more complicated than it might seem.  Generally, the process is as follows: Area #1 (Prefrontal Association Cortex) decides what we want to move, Area #2 (Premotor Cortex) decides how we should move, Area #3 (Primary Motor Cortex) initiates movement, Area #4 (Primary Somatic Sensory Cortex) senses how the movement happened.  It is not just coincidence that these areas are neighbors and rely on each other. What happens when one area starts to malfunction? The neighboring areas act as “back-up” for the primary areas. When the brain or body experiences injury, trauma or dysfunction, it tries to find a new way to accomplish the task.  For better or worse, we have the ability to learn to do things right or to learn to do them wrong. When we learn to do things wrong it can result in a “miswiring” of the brain. This “miswiring” is now the brain’s new “normal.”  The goal in brain-based rehabilitation is to retrain the brain and the body from “miswired” back to their “original wiring.” Brain-based rehabilitation takes time. Just like when one learns a new language or a new instrument, it takes repetition, patience, time and effort.

To find a chiropractic neurologist in your area, visit www.acnb.org and search the referral listings by state. You can find more information about chiropractic neurology online at www.carrickinstitute.com , www.acnb.org and  www.dendrites.com

Now that we have established that areas of the brain are connected to and affected by neighboring areas, how is it apparent to you, the patient?  Many with movement disorders experience seemingly disconnected symptoms such as: depression, lack of concentration, poor memory function, incontinence, constipation, dizziness, trouble sleeping, difficulty coordinating the left and right sides of the body, vertigo, difficulty reading (even without having a tremor), visual fatigue, etc.  Referring back to the table, do you notice which areas of the brain might be malfunctioning or miswired to cause these other symptoms? It is not unusual for dystonic patients to report some or many of these secondary symptoms and rarely do they attribute them to their dystonia. Diaschisis, or spreading of misfired brain patterns often causes secondary symptoms beyond dystonic muscles. Think of it as a chain reaction. Once one brain area is not functioning properly, other areas have to pick up the slack. That compensation can only go on for so long before other areas of the brain are overworked and start functioning less than optimally. I would expect that most dystonics did not have all of the symptoms they experience today at the beginning of their dystonia. This is logical as the brain will work very hard to continue functioning “normally” as long as possible. Gradually, systems fatigue and begin to fail resulting in more symptoms, perhaps in multiple systems (sight, sound, emotional, focus/attention, etc.)  

So, what does one do? We have learned that treating only the bodily area of pain or tightness will not usually change the neurology behind the muscle spasm. Symptom management is still important but it will not correct the dysfunctioning brain. If your dystonia is not pathological, meaning there have not been positive test results indicating a disease process, retraining of dysfunctioning/miswired brain areas may be a possibility.

If you understand the concept of physical exercise or physical therapy, brain-based physical rehabilitation is somewhat similar.  Instead of focusing only on the body, the doctor must examine function of all possible brain areas that control body movement. Once we have determined which neuropathways and brain areas are not working so well, we apply various exercises and therapies to retrain those brain areas. The goal: as the brain “rewires” and strengthens, it can relearn how to control and coordinate dystonic muscles.  This will in turn affect overall brain function and may simultaneously address the secondary symptoms so many dystonia patients report.

Most patients want to know how their dystonia started. Rarely are we able to pinpoint the reason.  Instead, let’s look at how the dystonic brain might have learned to control muscles. For most patients with non-pathologic dystonia, somewhere along the way, a neurologic wrong turn was made. Over time, the brain has accommodated and learned the wrong turn as “normal.” The brain needs to relearn the “correct” way of processing neurologic messages. Often, patients report a symptom (we’ll use lack of balance as our example here) and we are able to make an immediate improvement upon application of the appropriate stimulation or therapy. That improvement does not usually last more than a few minutes initially, but it does indicate that a change can be made to that particular “wrong turn” which has caused the lack of balance. This is called plasticity and it is the brain’s ability to establish new connections to improve function. The next step is to determine the appropriate exercises for the brain to learn the “right turn” without tiring it out. Slowly, over time, the brain will learn the “right turn” as normal and the symptom should lessen and movement improve.

Think of the complexity of learning a new instrument for example. One must learn the mechanics of the instrument by teaching their hands, mouths and sometimes feet to perform the action of playing. One must also learn to see and recognize notes on a page, learning to read new symbols like a language, utilize their hearing to help determine correct pitch and notes and call upon their sense of timing and rhythm. Vision, hearing, body sensation (proprioception), muscle movement, coordination, timing and rhythm are all elements that must come together for an individual to play music. Similarly, all of these elements must also come together in order to move our body easily each day. Brain-based physical rehabilitation for dystonia is much like learning a new instrument integrating all aspects of brain function.

Here is a chart that lists a few examples of exercises/stimulations that may be utilized for brain-based physical rehabilitation in a chiropractic neurologist’s office. Also listed are the primary brain areas being exercised/stimulated and examples of correlating physical goals.

Example: Slow tempo non-vocal music (such as nature sounds) played in the left ear stimulates the right brain which can improve signals to muscles on the left side of the body. This is because sounds excite the auditory cortex (#9), then the parietal-temporal-occipital association cortex (#8) decides what that sound means and sends information to the prefrontal association cortex (#1) to plan your muscle movement in response to the sound. This example clarifies how a doctor might use visual (colored light) and auditory (sound) stimulation to help the brain control muscle movements and decrease muscle spasms.  

It is very important to note that these therapies are typically performed unilaterally, or only on one side of the body. This is because it is rare that both sides, or hemispheres of the brain, are malfunctioning with equal severity. In other words, one half of the brain usually has more “miswirings” than the other. This is known as brain hemisphericity. Consequently, it makes good sense that all therapies must be specific to the weaker brain hemisphere with a goal of balanced right/left brain function. This is the brain hemispheric model of care. The body diagram demonstrates the general connections between the right and left sides of the body, cerebellum and brain hemispheres.  For example, a stretch, adjustment or exercise using the left arm will stimulate the left cerebellum and the right brain hemisphere. Remember, each patient has different brain “miswiring” patterns and must be treated specifically as an individual. Though the common diagnosis is dystonia, the order and type of retraining therapies on the road to improved function is very different for every patient. This is not a one-size-fits-all approach, nor should any treatment be. Each patient’s brain and body respond differently to similar therapies. Consequently, therapies need to be updated regularly to insure optimal outcomes for each individual patient. Another major difference between physical therapies and brain-based therapies is that brain-based rehabilitation should never push the nervous system beyond fatigue. There is no benefit from doing twice the number of exercises prescribed and in some cases, exercising beyond the point of fatigue can be detrimental. 

The human brain has an amazing ability to adapt to constantly changing circumstances.  That ability to adapt and change (plasticity) gives hope to patients with dystonia for it tells us there is potential to retrain those misfiring pathways.  Because so many brain areas are involved in orchestrating body movement, dystonia is a complex puzzle. Paying attention to the big picture of the brain and the body is essential to making progress. Thanks to vast new brain research, we understand more about brain function than ever before. Because of this, new therapies are emerging and with them new ways toward symptom relief and restoration of muscle movements. Thanks to the brain’s interconnectedness and association areas, there are many opportunities to evoke a positive change in how our brain moves our body. Brain-based physical rehabilitation is a serious option for those with dystonia and other neurological difficulties.  

 ©2004
Scott Theirl, DC, DACNB
Board Certified Chiropractic Neurologist