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BMJ Clin Evid. 2008; 2008: 1211.
Published online 2008 September 5.
PMCID: PMC2907934

Dystonia

Ailsa Snaith, Systematic Reviewer# and Derick Wade, Consultant and Professor in Neurological Rehabilitation#

Abstract

Introduction

Dystonia is usually a lifelong condition with persistent pain and disability. Focal dystonia affects a single part of the body; generalised dystonia can affect most or all of the body. It is more common in women, and some types of dystonia are more common in people of European Ashkenazi Jewish descent.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments, surgical treatments, and physical treatments for focal, and for generalised dystonia? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 13 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review we present information relating to the effectiveness and safety of the following interventions: acetylcholine receptor inhibitors, acupuncture, anticholinergic drugs, anticonvulsants, atypical antipsychotic drugs, benzodiazepines, biofeedback, botulinum toxin, chiropractic manipulation, deep brain stimulation of thalamus and globus pallidus, dopaminergic agonists and antagonists, gamma-aminobutyric acid (GABA) inhibitors, microvascular decompression, myectomy, occupational therapy, osteopathy, pallidotomy, physiotherapy, selective peripheral denervation, serotonergic agonists and antagonists, speech therapy, and thalamotomy.

Key Points

Dystonia is characterised by involuntary muscle contractions, resulting in abnormal postures and twisting of body parts.

  • It is usually a lifelong condition, with persistent pain and disability.
  • Focal dystonia affects a single part of the body; generalised dystonia can affect most or all of the body.
  • It is more common in women, and some types of dystonia are more common in people of European Ashkenazi Jewish descent.

Botulinum toxin is effective in relieving cervical dystonia symptoms in adults.

We don't know whether any other drug treatments (benzodiazepines, GABA inhibitors, atypical antipsychotics, anticonvulsants, dopaminergic agonists and antagonists, and serotonergic agonists and antagonists) are effective for either focal or generalised dystonia.

We don't know whether any surgical interventions (thalamotomy, pallidotomy, deep brain stimulation of thalamus and globus pallidus, selective peripheral denervation, or myectomy) are effective for either focal or generalised dystonia.

Most people will see a physiotherapist after diagnosis, but there is no consistent approach to treatment.

About this condition

Definition

Dystonia is a neurological disorder characterised by involuntary, abnormal muscle contractions that result in sustained abnormal postures, twisting, or both, and repetitive movements of body parts. It arises from dysfunction of the motor control system within the central nervous system. Dystonia is most simply classified by location: focal dystonia involves a single body part; multifocal dystonia involves two or more unrelated body parts; segmental dystonia affects two or more adjacent parts of the body; hemidystonia involves the arm and leg on the same side of the body; and generalised dystonia affects most or all of the body. For the purpose of this review we have classified dystonia into focal dystonia and generalised/other dystonia. However, studies in which dystonia has been classified according to other classification systems are also covered. In addition to focal and generalised dystonia, classification may also be based on age at onset (early onset or late onset), or according to the cause of the dystonia: primary dystonia where dystonia is the only sign and no cause can be identified; dystonia-plus syndrome where dystonia is associated with other pathology (e.g. dopa-responsive dystonia, and myoclonus dystonia); heredodegenerative dystonia where dystonia is a sign associated with neurological conditions, such as Parkinson's Disease and Huntington’s Disease; and secondary dystonia where a cause (usually environmental) can be identified, such as head injury or use of drugs (e.g. neuroleptic drugs and metoclopramide). Certain dystonias may also be classified as task specific; examples of task-specific focal hand dystonia include writer’s cramp, typist’s cramp, and musician’s cramp (affects pianists and flautists). Diagnosis: The clinical diagnosis of dystonia is based on the hallmark features of the abnormal, involuntary, and prolonged muscle contractions with consistent directionality that lead to an abnormal posture of the area affected. There is no definitive diagnostic test for dystonia. Investigation typically involves history and clinical examination, laboratory tests, and imaging, to establish severity and potential cause. Laboratory tests and neuro-imaging may help to rule out metabolic or structural causes. Genetic testing, electro-physiological tests, and tissue biopsy may also be considered. The goal of accurate diagnosis is to facilitate treatment choice.

Incidence/ Prevalence

Dystonia occurs worldwide, with prevalence estimates varying widely depending on study methodology. In the USA, the prevalence of focal dystonia has been reported as 30/100,000 people. Cervical dystonia (torticollis or "wry neck") is the most common adult form of focal dystonia, with a prevalence in Europe of 5.7/100,000. Other frequently occurring focal dystonias are blepharospasm (forceful eyelid closures), which affects 3.6/100,000 people, and limb dystonias (e.g. writer's cramp), which affect 1.4/100,000.In the USA, the prevalence of generalised dystonia has been reported as 0.2-6.7/100,000 population; generalised dystonia affects more people of European Ashkenazi Jewish descent. In Europe, the prevalence of primary dystonia has been estimated at 15.2/100,000.Studies identified to have rigorous methodology estimated the prevalence of early-onset (at less than 20 years of age) dystonia to be 11.1/100,000 for dystonia in Ashkenazi Jews from the New York area, 60/100,000 for late-onset (at more than 20 years of age) dystonia in the overall population of Northern England, and 300/100,000 for late-onset dystonia in the Italian population (aged 50 years or older). Dystonia occurs more frequently in women.

Aetiology/ Risk factors

The pathophysiology of dystonia remains unclear. Dystonia may occur because of abnormal neurochemical transmission in the basal ganglia, brainstem, or both, resulting in abnormal execution of motor control.Focal dystonias have been associated with loss of inhibition, abnormal plasticity in the motor cortex, and impairments in partial and temporal discrimination. There is debate on the extent to which psychological factors cause dystonia, although they can undoubtedly exacerbate it. Dystonia can be classified as primary (where underlying cause is unknown) or secondary (related to known disorders). The primary disorders may be further classified as hereditary or sporadic. Currently, 15 types of dystonia can be distinguished on a genetic basis, six of which are primary dystonias (DYT1, 2, 4, 6, 7, and 13). The remainder are secondary dystonia, dystonia-plus syndromes, and paroxysmal dystonias.

Prognosis

Dystonia is usually a lifelong disorder, although a small minority experience complete remission. Most people with dystonia have a normal life expectancy, but with continued symptoms. The presence and severity of symptoms are unpredictable, as symptoms may fluctuate over time (e.g. stressful situations may make symptoms worse), or may disappear or stabilise for a time. Regardless of the cause, dystonic contractions may have a chronic course, and may lead to severe persistent pain and disability. Also, embarrassment caused by the symptoms may lead to social withdrawal. Prognosis seems to depend on a number of factors, including age at onset, distribution, and cause. Focal dystonia may become generalised over time. Dystonia with a later age of onset has a lower likelihood of spreading compared with dystonia beginning in childhood. Similarly, dystonia starting in the neck is less likely to spread than dystonia starting in the limbs.

Aims of intervention

To improve quality of life by minimising: immediate symptoms (movement, posture, pain); limitation of activities; pain; and social consequences, with minimal adverse effects of treatment.

Outcomes

Neurological disability: In dystonia clinical trials, outcome is usually measured using disease-specific rating scales: Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), Tsui scale, Cervical Dystonia Severity Scale (CDSS), Jankovic Rating Scale (JRS), and Blepharospasm Disability Index (BSDI; see table 1 ). Quality of life; adverse effects of treatments.

Table 1
Commonly used rating scales for dystonia.

Methods

BMJ Clinical Evidence search and appraisal July 2007. The following databases were used to identify studies for this systematic review: Medline 1966 to July 2007, Embase 1980 to July 2007, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2007, Issue 2. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA), Turning Research into Practice (TRIP), and NICE. We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using predetermined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs for all interventions in any language, and also case series for physical therapies; single-blind and open studies acceptable for all, containing more than 20 people, of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ).

Table
GRADE evaluation of interventions for dystonia

Glossary

Chiropractic manipulation
These involve manipulation of the spine by a chiropractor. It is based on the theory that manipulating the vertebrae helps normal nervous system functioning and the body's ability to heal itself.
High-quality evidence
Further research is very unlikely to change our confidence in the estimate of effect.
Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Very low-quality evidence
Any estimate of effect is very uncertain.

Notes

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

Contributor Information

Ailsa Snaith, University of Aberdeen, Aberdeen, UK.

Derick Wade, Oxford Centre for Enablement, Oxford, UK.

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2008; 2008: 1211.
Published online 2008 September 5.

Acetylcholine receptor inhibitors for focal dystonia

Summary

SYMPTOM SEVERITY Botulinum A compared with placebo: Botulinum A toxin is more effective at 3–16 weeks at improving cervical dystonia as assessed by an improvement in Tsui scale, Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), physician- and patient-rated scores, and the number of people reporting pain relief ( moderate-quality evidence ). Botulinum B compared with placebo: Botulinum B toxin is more effective at 4–8 weeks at improving TWSTRS-Total score ( high-quality evidence ). Botulinum A compared with botulinum B: We don't know whether botulinum A toxin is more effective at 2–4 weeks at improving TWSTRS disease-activity rating scale ( very low-quality evidence ). High-dose compared with low-dose botulinum A: We don't know whether high-dose botulinum A toxin is more effective at increasing patient- and physician-rated improvements (very low-quality evidence). Low-dose compared with high-dose botulinum B: Low-dose botulinum B toxin may be less effective at 4 weeks at improving disease-activity TWSTRS pain subscale (moderate-quality evidence). Botulinum A compared with anticholinergic drugs: Botulinum A may be more effective at 12 weeks than trihexyphenidyl at improving TWSTRS disability scores, Tsui scale, and General Health Perception Subscale (very low-quality evidence). Botulinum B in Botulinum A-resistant adults compared with Botulinum B in Botulinum A responders: We don't know whether botulinum B toxin in botulinum A-resistant adults is more effective at 4 weeks at improving TWSTRS-Total scores (low-quality evidence). Botulinum A compared with placebo (writer's cramp): Botulinum A toxin is more effective at 8 weeks at improving symptom severity scores, writer's cramp rating scales, handwriting, and writing speed (moderate-quality evidence). FUNCTIONAL IMPROVEMENT Botulinum A compared with placebo (writer's cramp): Botulinum A toxin is no more effective at 8 weeks at improving functional status scale (moderate-quality evidence). NOTE We found no clinically important results about botulinum A toxin in the treatment of people with focal dystonia of other body sites (eyelid, larynx, and hand). We found no clinically important results about other acetylcholine receptor inhibitors in the treatment of focal dystonia.

Benefits

Botulinum A toxin versus placebo in cervical dystonia in adults:

We found one systematic review (search date 2003; see table 2 ). It found that botulinum A toxin significantly improved Tsui, and physician- and patient-rated scales at 3–16 weeks compared with placebo. The quality of the 13 trials was assessed by Jadad's scale as good. However, all trials were of short duration, and examined the effects of only one injection cycle.

Table 2
Botulinum toxin for focal dystonia.

Botulinum B toxin versus placebo in cervical dystonia in adults:

We found one systematic review (search date 2003; see table 2 ). It found that a single injection cycle of botulinum B toxin (dose 2500–10,000 U) significantly improved the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) Total score at 4 and 8 weeks by at least 20% compared with placebo, but found no significant difference at 12 or 16 weeks. The review also found that botulinum B toxin (5000–10,000 U) significantly improved Patient Global Assessment of Change, Principal Investigator Global Assessment of Change, and Patient Analog Pain Assessment at 4 weeks compared with placebo. Of the three RCTs included in the systematic review, one RCT included both people responsive and resistant to botulinum A toxin, one RCT included only people resistant to botulinum A toxin, and one RCT included only people responsive to botulinum A toxin. The quality of the three RCTs was assessed as good by Jadad's scale.

Botulinum A toxin versus botulinum B toxin in cervical dystonia in adults:

We found one systematic review (search date 2003), which identified no RCTs. We found two subsequent RCTs (see table 2 ). The first RCT found no significant difference between botulinum A toxin (up to 250 U) and botulinum B toxin (up to 10,000 U) in TWSTRS scores at 4 weeks. It also found no significant difference between botulinum A and botulinum B toxin in the median duration of effect of treatment. The second RCT found similar TWSTRS scores at 2 weeks between botulinum A (dose not reported) and botulinum B toxin (dose not reported).

High-dose (greater than 200 U Botox/960 U Dysport) versus low-dose (100 U Botox/250 U Dysport) botulinum A toxin in cervical dystonia in adults:

We found one systematic review (search date 2003; see table 2 ). It found no RCTs directly comparing high- and low-dose botulinum A toxin. However, it reported indirect meta-analyses by dose of botulinum A toxin compared with placebo. It found limited evidence that higher doses increased effect sizes for improvement of patient and physician subjective assessment (time of follow-up unclear). Indirect comparisons should be treated with caution as they lose the benefit of the randomisation in the trials they analyse. We found one additional RCT (see table 2 ). It found no significant difference in improvement in TWSTRS scores at week 4 between high- (500 U/mL) and low-dose (125 U/mL) botulinum A toxin.

Low-dose (2500–5000 U) versus high-dose (10,000 U) botulinum B toxin in cervical dystonia in adults:

We found one systematic review (search date 2003; see table 2 ). It found that significantly fewer people had improved TWSTRS pain subscale at 4 weeks with low-dose botulinum B toxin compared with high-dose botulinum B toxin. However, it found no significant difference for the same comparison in TWSTRS-Total score at 4–16 weeks.

Botulinum A toxin versus anticholinergic drugs (trihexyphenidyl) in cervical dystonia in adults:

We found one systematic review (search date 2003; see table 2 ). It found that botulinum A toxin significantly improved a number of outcomes at 12 weeks compared with trihexyphenidyl (TWSTRS disability score, Tsui scale, and number of people with at least 3-point improvement on Tsui scale, General Health Perception Subscale difference in mean improvement). The systematic review found that significantly more people had at least a three point improvement on the TWSTRS scale, but the RCT itself found no significant difference between treatments. The review also found no significant difference between treatments in the median improvement in TWSTRS pain score. The systematic review commented on some limitations of the RCT it found: there were significantly fewer people with history of progressive disease in the botulinum A toxin group than in the trihexyphenidyl group (9/33 [27%] with botulinum A toxin v 21/33 [64%] with trihexyphenidyl; P = 0.003); the short duration of the RCT may not favour trihexyphenidyl; and people were injected with botulinum A toxin at baseline and 8 weeks later, which is a shorter interval than the 12–16 week interval between injections which would generally be used in clinical practice.

Botulinum B toxin in botulinum A toxin-resistant versus respondent adults:

We found one systematic review (search date 2003; see table 2 ). It found no significant difference after botulinum B toxin in TWSTRS-Total score at 4 weeks between people resistant to botulinum A toxin and people responsive to botulinum A toxin.

Botulinum A toxin versus placebo in blepharospasm (eyelid closure):

We found one systematic review (search date 2003). It identified no RCTs of sufficient quality.

Botulinum A toxin versus placebo in spasmodic dysphonia (laryngeal dystonia):

We found one systematic review (search date 2005). The review identified one RCT that did not meet BMJ Clinical Evidence inclusion criteria (RCT included only 13 people), and so the results are not discussed further.

Botulinum A toxin versus placebo in writer's cramp:

We found one RCT (40 treatment-naive people with symptoms of idiopathic writer's cramp for at least 1 year), which compared botulinum A versus placebo. At 8 weeks, the RCT found significant improvements in symptom severity, writer's cramp rating scale, handwriting, and speed of writing with botulinum A compared with placebo (see table 2 ). However, there was no significant difference between treatments in functional status (see table 2 ). To optimise treatment effect, people were treated in two sessions: initially after baseline assessment, and then 1 month later. People expressing satisfaction with their improvement after one treatment did not receive a second injection. However, if people showed no response to treatment after one session, the dose was doubled for the second session. The primary outcome assessed was the person's response to a question on whether they wished to continue with treatment (assessed at 12 weeks). This is not one of our outcomes of interest, and so the results are not discussed further. Clinical rating scales were measured as secondary outcomes.

Harms

Botulinum A toxin versus placebo in cervical dystonia in adults:

The review found generally transient, mild to moderate or intermittent adverse effects in people taking botulinum A toxin (neck weakness, dysphagia, dry mouth/sore throat, voice changes, hoarseness, pain at injection site, drowsiness, vertigo, dizziness, diffuse weakness, asthenia, tiredness, malaise, upper respiratory infection, headache, and paraesthesias; see table 2 ). It found that significantly more people had any adverse effect (neck weakness, dysphagia, or dry mouth/sore throat) with botulinum A toxin compared with placebo (see table 2 ).

Botulinum B toxin versus placebo in cervical dystonia in adults:

The review found significantly more dry mouth and dysphagia with botulinum B toxin than with placebo (see table 2 ).

Botulinum A toxin versus botulinum B toxin in cervical dystonia in adults:

The first subsequent RCT found significantly less dysphagia and dry mouth with botulinum A toxin than with botulinum B (see table 2 ). The second subsequent RCT found no significant difference in dysphagia. It found significantly less constipation with botulinum A toxin than with botulinum B.

High-dose (greater than 200 U Botox/960 U Dysport) versus low-dose (100 U Botox/250 U Dysport) botulinum A toxin in cervical dystonia in adults:

The review found no RCTs directly comparing high- and low-dose botulinum A toxin. However, it reported meta-analyses by dose of botulinum A toxin compared with placebo (see table 2 ). It found increasing incidence of the following adverse effects with increasing dose of botulinum A toxin compared with placebo: neck weakness, dysphagia, dry mouth/sore throat, and voice changes/hoarseness. It did not find the same association for pain at injection site, malaise/upper respiratory infection, and headache. The additional RCT gave no information on adverse effects (see table 2 ).

Low dose (2500–5000 U) versus high-dose (10,000 U) botulinum B toxin in cervical dystonia:

The review found significantly less dry mouth and dysphagia with low-dose compared with high-dose botulinum B toxin.

Botulinum A toxin versus anticholinergic drugs (trihexyphenidyl) in cervical dystonia in adults:

The review found significantly fewer adverse effects (dry mouth, forgetfulness, and fatigue) with botulinum A toxin than with trihexyphenidyl (see table 2 ). It also found no significant difference between botulinum A toxin and trihexyphenidyl for other adverse events reported (blurred vision, dizziness, depression, disturbances of micturition, weight loss, dyspepsia, pain at injection site, dysphagia, and neck weakness).

Botulinum B toxin in botulinum A toxin-resistant versus respondent adults:

The review gave no information on adverse effects for this comparison.

Botulinum A toxin versus placebo in blepharospasm (eyelid closure):

The review identified no RCTs.

Botulinum A toxin versus placebo in spasmodic dysphonia (laryngeal dystonia):

We found one systematic review, which identified no RCTs meeting BMJ Clinical Evidence inclusion criteria.

Botulinum A toxin versus placebo in writer's cramp:

The RCT found that only two types of adverse effect (hand weakness and injection-site pain) were treatment related. A larger proportion of people in the botulinum A toxin group than in the placebo group reported hand weakness (see table 2 ). However, a smaller proportion of people in the botulinum A toxin group than in the placebo group reported injection-site pain (see table 2 ).

Comment

Clinical guide:

Botulinum toxin injections are the mainstay of management of cervical dystonia, and have replaced most treatments used in previous decades. It is sometimes used for other focal dystonias, but with caution, because many focal dystonias may have a primarily psychological origin. The evidence supporting botulinum toxin in focal dystonias is strong, partly because there is a strong commercial imperative to show effectiveness, but also because treatment can be localised, and because botulinum toxin is effective at reducing neuromuscular transmission. Its main limitation is that the effect wears off after 12–16 weeks, but repeated injections are usually equally effective. Invasive surgical procedures have largely been displaced by local botulinum toxin injections.

Dosage:

The two commercially available formulations of botulinum A toxin, Dysport and Botox, differ in potency, and so are not interchangeable. One crossover RCT suggested a conversion of 3 U of Dysport to 1 U of Botox, although there were differences in both beneficial outcomes and in adverse effects. The adverse effects unequivocally associated with botulinum toxin injection are those expected from its local action, and they are more common with higher doses — as one would expect from local spread from the injected muscle. The differences in beneficial and adverse effects reflect relative differences in dosage, not intrinsic differences between preparations.

Substantive changes

Botulinum toxin (focal) One RCT on the effects of botulinum A in treatment of writer's cramp added;benefits and harms data enhanced; categorisation unchanged (Beneficial). At 8 weeks, the RCT found significant improvements in symptom severity, writer's cramp rating scale, handwriting, and speed of writing with botulinum A compared with placebo. However, there was no significant difference between groups at 8 weeks in functional status.

2008; 2008: 1211.
Published online 2008 September 5.

Anticholinergic drugs for focal dystonia

Summary

SYMPTOM SEVERITY Compared with Botulinum A: Trihexyphenidyl may be less effective at 12 weeks at improving Toronto Western Spasmodic Torticollis Rating Scale disability scores, Tsui scale, and General Health Perception Subscale ( very low-quality evidence ).

Benefits

Anticholinergic drugs versus botulinum toxin A in cervical dystonia:

See benefits of botulinum toxin A versus anticholinergic drugs (trihexyphenidyl) in cervical dystonia.

Harms

Anticholinergic drugs versus botulinum toxin A in cervical dystonia:

See harms of botulinum toxin A versus anticholinergic drugs (trihexyphenidyl) in cervical dystonia.

Comment

Clinical guide:

Trihexyphenidyl is rarely used in cervical dystonia, given the effectiveness of local botulinum toxin injection, and the perception and risk of more general adverse effects from using an oral drug. High doses of the anticholinergic drug trihexyphenidyl (up to 80–160 mg/day mg/day) are sometimes used for other focal dystonias, but the evidence is limited, probably because the condition is relatively rare and not life threatening.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Anticonvulsants for focal dystonia

Summary

We found no direct information about anticonvulsants in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of anticonvulsants in people with focal dystonia.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Atypical antipsychotic drugs for focal dystonia

Summary

We found no direct information about atypical antipsychotic drugs in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of atypical antipsychotic drugs in people with focal dystonia.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Benzodiazepines for focal dystonia

Summary

We found no direct information about benzodiazepines in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of benzodiazepines in people with focal dystonia.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Dopaminergic agonists for focal dystonia

Summary

We found no direct information about dopaminergic agonists in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of dopaminergic agonists in people with focal dystonia.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Dopaminergic antagonists for focal dystonia

Summary

We found no direct information about dopaminergic antagonists in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of dopaminergic antagonists in people with focal dystonia.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

GABA inhibitors for focal dystonia

Summary

We found no direct information about GABA inhibitors in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of GABA inhibitors in people with focal dystonia.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Serotonergic agonists for focal dystonia

Summary

We found no direct information about serotonergic agonists in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of serotonergic agonists in people with focal dystonia.

Harms

We found no RCTs.

Comment

None.

Substantive changes

Serotonergic agonists (focal) New option for which we identified no systematic review or RCTs. Categorised as Unknown effectiveness.

2008; 2008: 1211.
Published online 2008 September 5.

Serotonergic antagonists for focal dystonia

Summary

We found no direct information about serotonergic antagonists in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of serotonergic antagonists in people with focal dystonia.

Harms

We found no RCTs.

Comment

None.

Substantive changes

Serotonergic antagonists (focal) New option for which we identified no systematic review or RCTs. Categorised as Unknown effectiveness.

2008; 2008: 1211.
Published online 2008 September 5.

Acetylcholine receptor inhibitors for generalised dystonia

Summary

We found no direct information about acetylcholine receptor inhibitors in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of acetylcholine receptor inhibitors in people with generalised dystonia.

Harms

We found no RCTs.

Comment

Clinical guide:

As with focal dystonia, the evidence supporting treatments for generalised dystonia is limited. Generalised dystonia is a relatively rare condition (small commercial incentive for research) that is variable both within and between people with the condition, and the effect is not easily measured. Relatively high doses (up to 80 mg/day) of the anticholinergic drug trihexyphenidyl are possibly effective. People may often see a physiotherapist after diagnosis, but no specific therapeutic manoeuvres are known. Beliefs about the usefulness of physiotherapy vary. Surgical treatments are also used, although there is little long-term evidence of either benefits or risks from surgery.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Anticholinergic drugs for generalised dystonia

Summary

We found no direct information about anticholinergic drugs in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of anticholinergic drugs in people with generalised dystonia.

Harms

We found no RCTs.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Anticonvulsants for generalised dystonia

Summary

We found no direct information about anticonvulsants in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of anticonvulsants in people with generalised dystonia.

Harms

We found no RCTs.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Atypical antipsychotic drugs for generalised dystonia

Summary

We found no direct information about atypical antipsychotic drugs in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of atypical antipsychotic drugs in people with generalised dystonia.

Harms

We found no RCTs.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Benzodiazepines for generalised dystonia

Summary

We found no direct information about benzodiazepines in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of benzodiazepines in people with generalised dystonia.

Harms

We found no RCTs.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Dopaminergic agonists for generalised dystonia

Summary

We found no direct information about dopaminergic agonists in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of dopaminergic agonists in people with generalised dystonia.

Harms

We found no RCTs.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Dopaminergic antagonists for generalised dystonia

Summary

We found no direct information about dopaminergic antagonists in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of dopaminergic antagonists in people with generalised dystonia.

Harms

We found no RCTs.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

GABA inhibitors for generalised dystonia

Summary

We found no direct information about GABA in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of GABA in people with generalised dystonia.

Harms

We found no RCTs.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Serotonergic agonists for generalised dystonia

Summary

We found no direct information about serotonergic agonists in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of serotonergic agonists in people with generalised dystonia.

Harms

We found no RCTs.

Comment

None.

Substantive changes

Serotonergic agonists (generalised) New option for which we identified no systematic review or RCTs. Categorised as Unknown effectiveness.

2008; 2008: 1211.
Published online 2008 September 5.

Serotonergic antagonists for generalised dystonia

Summary

We found no direct information about serotonergic antagonists in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of serotonergic antagonists in people with generalised dystonia.

Harms

We found no RCTs.

Comment

None.

Substantive changes

Serotonergic antagonists (generalised) New option for which we identified no systematic review or RCTs. Categorised as Unknown effectiveness.

2008; 2008: 1211.
Published online 2008 September 5.

Deep brain stimulation of thalamus and globus pallidus for focal dystonia

Summary

FUNCTIONAL IMPROVEMENT Deep brain stimulation compared with sham stimulation: Deep brain stimulation of the thalamus and globus pallidus may be more effective at 3 months at improving total movement (with imputation) and disability scores on the Burke–Fahn–Marsden Dystonia (BFMD) Rating Scale in people with primary segmental and generalised dystonia ( very low-quality evidence ). QUALITY OF LIFE Deep brain stimulation compared with sham stimulation: Deep brain stimulation of the thalamus and globus pallidus may be more effective at improving the physical component of the quality of life scores (assessed using SF-36 questionnaire) in people with primary segmental and generalised dystonia (very low-quality evidence). NOTE We found no direct information about deep brain stimulation of the thalamus in people with only focal dystonia.

Benefits

We found no systematic review or RCTs of deep brain stimulation of thalamus in people with only focal dystonia. We found one RCT (40 people aged 14–75 years with primary segmental [16 people] or generalised dystonia [24 people] for a minimum of 5 years) which compared deep brain stimulation of the internal globus pallidus versus sham stimulation.The RCT found that, at 3 months, deep brain stimulation significantly improved total movement (with imputation) and disability scores on the Burke–Fahn–Marsden Dystonia (BFMD) Rating Scale, and physical component of the quality-of-life score (assessed using SF-36 questionnaire) compared with sham stimulation (change in BFMD score from baseline for movement [possible range of scores of 0–120]: –15.8 with neurostimulation v –1.4 with sham stimulation; P less than 0.001: change in BFMD score from baseline for disability [possible range of scores of 0–30]; –3.9 with neurostimulation v –0.8 with sham stimulation; P less than 0.001: change in SF-36 physical component score [33 people assessed; possible range of scores of 0–100]: 10.1 with neurostimulation v 3.8 with sham stimulation; P = 0.02). However, there was no significant difference between groups in the mental component of the quality-of-life score (change in SF-36 mental component score [possible range of scores of 0–100]: 5.2 with neurostimulation v 0.2 with sham stimulation; P = 0.39). The RCT analysed data for all people who underwent randomisation (last observation carried forward). The RCT did not carry out a subgroup analysis of people with focal dystonia, which may affect the generalisability of the results.

Harms

The RCT found that adverse effects were primarily associated with the surgical procedure. Infection at the stimulator site was the most common adverse effect, occurring in three people (1/20 [5%] with neurostimulation v 2/20 [10%] with sham stimulation; significance not assessed; P value not reported). The RCT reported that all adverse effects resolved without permanent sequelae.

Comment

Studies with longer follow-up are required. The beneficial effects of stimulation may wear off over time, and the long-term risks and adverse effects of implantation into the brain and of brain stimulation itself are not known. We suggest that a minimum of 12 months' controlled observation (i.e. without implantation into the control group) may be required to judge effectiveness, and that a minimum of 5 years of natural history follow-up (i.e. after implantation) may be required to judge safety and long-term risk, and to confirm persistence of any beneficial effect.

Substantive changes

Deep brain stimulation of thalamus and globus pallidus in focal and generalised dystonia One RCT comparing deep brain stimulation versus sham stimulation added to both focal and generalised dystonia; benefits and harms data enhanced in both interventions; categorisation unchanged (intervention categorised as Unknown effectiveness for both focal and generalised dystonia). The RCT, which included people with primary segmental or generalised dystonia, found that, at 3 months, neurostimulation significantly improved movement and disability scores as assessed on the Burke–Fahn–Marsden Dystonia rating scale, and the physical component of quality of life (assessed using the SF-36 questionnaire), compared with placebo. However, there was no significant difference between groups in the mental component of the SF-36 questionnaire.

2008; 2008: 1211.
Published online 2008 September 5.

Myectomy for focal dystonia

Summary

We found no direct information about myectomy in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of myectomy in people with focal dystonia.

Harms

We found no RCTs.

Comment

Clinical guide:

Destructive procedures that mechanically prevent the dystonic posture (e.g. myectomy, thalamotomy, pallidotomy, and selective peripheral denervation) were once used (without supporting evidence), but their apparent ineffectiveness, coupled with the effectiveness of botulinum toxin, has led to their demise.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Pallidotomy for focal dystonia

Summary

We found no direct information about pallidotomy in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of pallidotomy in people with focal dystonia.

Harms

We found no RCTs.

Comment

See comment on myectomy under surgical treatments for focal dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Selective peripheral denervation for focal dystonia

Summary

We found no direct information about selective peripheral denervation in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of selective peripheral denervation in people with focal dystonia.

Harms

We found no RCTs.

Comment

See comment on myectomy under surgical treatments for focal dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Thalamotomy for focal dystonia

Summary

We found no direct information about thalamotomy in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs of thalamotomy in people with focal dystonia.

Harms

We found no RCTs.

Comment

See comment on myectomy under surgical treatments for focal dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Deep brain stimulation of thalamus and globus pallidus for generalised dystonia

Summary

FUNCTIONAL IMPROVEMENT Deep brain stimulation compared with sham stimulation: Deep brain stimulation of the thalamus and globus pallidus may be more effective at 3 months at improving total movement (with imputation) and disability scores on the Burke–Fahn–Marsden Dystonia (BFMD) Rating Scale in people with primary segmental and generalised dystonia ( very low-quality evidence ). QUALITY OF LIFE Deep brain stimulation compared with sham stimulation: Deep brain stimulation of the thalamus and globus pallidus may be more effective at improving the physical component of the quality of life scores (assessed using SF-36 questionnaire) in people with primary segmental and generalised dystonia (very low-quality evidence). NOTE We found no direct information about deep brain stimulation of the thalamus in people with only generalised dystonia.

Benefits

We found no systematic review or RCTs of deep brain stimulation of the thalamus in people with only generalised dystonia. We found one RCT (40 people aged 14–75 years with primary segmental [16 people] or generalised dystonia [24 people] for a minimum of 5 years) which compared deep brain stimulation of the internal globus pallidus versus sham stimulation.The RCT found that, at 3 months, deep brain stimulation significantly improved total movement (with imputation) and disability scores on the Burke–Fahn–Marsden Dystonia (BFMD) Rating Scale, and physical component of the quality-of-life score (assessed using SF-36 questionnaire) compared with sham stimulation (change in BFMD score from baseline for movement [possible range of scores of 0–120]: –15.8 with neurostimulation v –1.4 with sham stimulation; P less than 0.001: change in BFMD score from baseline for disability [possible range of scores of 0–30]; –3.9 with neurostimulation v –0.8 with sham stimulation; P less than 0.001: change in SF-36 physical component score [possible range of scores of 0–100]: 10.1 with neurostimulation v 3.8 with sham stimulation; P = 0.02). However, there was no significant difference between groups in the mental component of the quality-of-life score (change in SF-36 mental component score [33 people assessed; possible range of scores of 0–100]: 5.2 with neurostimulation v 0.2 with sham stimulation; P = 0.39). The RCT analysed data for all people who underwent randomisation (last observation carried forward). The RCT did not carry out a subgroup analysis of people with generalised dystonia, which may affect the generalisability of the results.

Harms

The RCT found that adverse effects were primarily associated with the surgical procedure. Infection at the stimulator site was the most common adverse effect, occurring in three people (1/20 [5%] with neurostimulation v 2/20 [10%] with sham stimulation; significance not assessed; P value not reported). The RCT reported that all adverse effects resolved without permanent sequelae.

Comment

Studies with longer follow-up are required (see comment in deep brain stimulation of thalamus and globus pallidus in people with focal dystonia). See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

2008; 2008: 1211.
Published online 2008 September 5.

Myectomy for generalised dystonia

Summary

We found no direct information about myectomy in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of myectomy in people with generalised dystonia.

Harms

We found no RCTs.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia and comment on myectomy under surgical treatments for focal dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Pallidotomy for generalised dystonia

Summary

We found no direct information about pallidotomy in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of pallidotomy in people with generalised dystonia.

Harms

We found no RCTs.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia and comment on myectomy under surgical treatments for focal dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Selective peripheral denervation for generalised dystonia

Summary

We found no direct information about selective peripheral denervation in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of selective peripheral denervation in people with generalised dystonia.

Harms

We found no RCTs.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia and comment on myectomy under surgical treatments for focal dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Thalamotomy for generalised dystonia

Summary

We found no direct information about thalamotomy in the treatment of people with generalised dystonia.

Benefits

We found no systematic review or RCTs of thalamotomy in people with generalised dystonia.

Harms

We found no RCTs.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia and comment on myectomy under surgical treatments for focal dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Physiotherapy for focal dystonia

Summary

We found no clinically important results about the effects of physiotherapy in the treatment of children with developmental cervical dystonia or early congenital cervical dystonia. We found no clinically important results about physiotherapy compared with myomectomy in people with focal dystonia.

Benefits

Physiotherapy in children with developmental cervical dystonia:

We found no systematic review or RCTs. We found one case series (23 children, mean age 3.8 months [range 3 weeks–10.5 months] diagnosed with developmental cervical dystonia), which examined the effect of passive cervical stretching by positioning and active strengthening of identified weak muscles (see comment below). The average number of treatments was 3.8 [range 1.0–10.0] provided over mean treatment duration of 2.9 months. At follow-up (mean age at follow-up: 18 months, range 5–49 months), the case series found that a similar number of parents reported “good” or “excellent” outcomes in their children (excellent = symmetrical head features, symmetrical facial features, passive cervical rotation of at least 75 bilaterally, passive cervical lateral flexion of at least 40 bilaterally, complete head righting, and lack of resting head tilt; good = 4–5 of these outcomes; fair = 3 of these outcomes; poor = 1–2 of the outcomes: 11/23 [48%] excellent v 11/23 [48%] good v 1/23 [4%] fair v 0/23 [0%] poor).

Physiotherapy in children with early congenital cervical dystonia:

We found no systematic review or RCTs. We found one case series (126 children with mild to severe congenital cervical dystonia seen over 30 years), which examined the effect of passive stretching exercises (PSE). Subjective physician measurement of PSE showed that PSE for early congenital cervical dystonia (less than 3 months) produced excellent results in 52/81 (65%) of cases at an average follow-up of 9 months (excellent = full rotation and no asymmetry; good = full rotation and mild asymmetry or mild limitation of rotation and no asymmetry; fair = mild limitation of rotation and mild asymmetry; poor = no improvement: 65% excellent v 27% good v 8% fair v 0% poor).

Physiotherapy versus myectomy:

We found no systematic review, RCTs, or case series.

Harms

Physiotherapy in children with developmental cervical dystonia:

The case series gave no information on adverse effects.

Physiotherapy in children with early congenital cervical dystonia:

The case series reported no serious complications of treatment. In 12/126 (10%) children, a sudden “snap” or giving way of the muscle was noticed by parents during PSE, and several children developed localised bruising (numbers not reported).

Physiotherapy versus myectomy:

We found no RCTs or case series.

Comment

Case series should be carefully interpreted, because: (1) the intervention will vary over time; (2) a number of outcomes are subjective; and (3) it is hard to determine whether the specified physiotherapy actually took place in the home setting. Also, the outcome was probably assessed by someone who was not blinded to the treatment — even by the treating therapist.

Clinical guide:

Most people will see a physiotherapist at some point after diagnosis, but there is no consistent approach to treatment, and practice can vary from place to place with no consensus on best practice.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Acupuncture for focal dystonia

Summary

We found no direct information about the effects of acupuncture in the treatment of people with focal dystonia.

Benefits

We found no systematic review, RCTs, or case series of acupuncture in people with focal dystonia.

Harms

We found no RCTs or case series.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Biofeedback for focal dystonia

Summary

We found no direct information about the effects of biofeedback in the treatment of people with focal dystonia.

Benefits

We found no systematic review or RCTs.

Biofeedback for cervical dystonia:

We found one case series (80 adults: 69 with spasmodic cervical dystonia and 11 with focal dystonia). It found that sensory feedback therapy using electromyogram improved 45/80 (56%) of people at 8–12 weeks. The improvements ranged from a sustained response after feedback was withdrawn, to the person being able to maintain control of head movements for extended periods without feedback. Changes were seen in range of motion, control of oscillation and activities of daily living.

Harms

The case series did not report on adverse effects.

Comment

Clinical guide:

The aim of biofeedback is to re-establish a more normal posture and pattern of muscular activity. While it seems a reasonable approach, it needs to be tested using well-designed RCTs.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Chiropractic manipulation for focal dystonia

Summary

We found no direct information about chiropractic manipulation in the treatment of people with focal dystonia.

Benefits

We found no systematic review, RCTs, or case series of chiropractic manipulation in people with focal dystonia.

Harms

We found no RCTs or case series.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Occupational therapy for focal dystonia

Summary

We found no direct information about occupational therapy in the treatment of people with focal dystonia.

Benefits

We found no systematic review, RCTs, or case series of occupational therapy in people with focal dystonia.

Harms

We found no RCTs or case series.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Osteopathy for focal dystonia

Summary

We found no direct information about osteopathy in the treatment of people with focal dystonia.

Benefits

We found no systematic review, RCTs, or case series of osteopathy in people with focal dystonia.

Harms

We found no RCTs or case series.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Speech therapy for focal dystonia

Summary

We found no direct information about speech therapy in the treatment of people with focal dystonia.

Benefits

We found no systematic review, RCTs, or case series of speech therapy for focal dystonia.

Harms

We found no RCTs or case series.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Acupuncture for generalised dystonia

Summary

We found no direct information about acupuncture in the treatment of people with generalised dystonia.

Benefits

We found no systematic review, RCTs, or case series of acupuncture in people with generalised dystonia.

Harms

We found no RCTs, or case series.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Biofeedback for generalised dystonia

Summary

We found no direct information about biofeedback in the treatment of people with generalised dystonia.

Benefits

We found no systematic review, RCTs, or case series of biofeedback in people with generalised dystonia.

Harms

We found no RCTs or case series.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Chiropractic manipulation for generalised dystonia

Summary

We found no direct information about chiropractic manipulation in the treatment of people with generalised dystonia.

Benefits

We found no systematic review, RCTs, or case series of chiropractic manipulation in people with generalised dystonia.

Harms

We found no RCTs or case series.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Occupational therapy for generalised dystonia

Summary

We found no direct information about occupational therapy in the treatment of people with generalised dystonia.

Benefits

We found no systematic review, RCTs, or case series of occupational therapy in people with generalised dystonia.

Harms

We found no RCTs or case series.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Osteopathy for generalised dystonia

Summary

We found no direct information about osteopathy in the treatment of people with generalised dystonia.

Benefits

We found no systematic review, RCTs, or case series of osteopathy in people with generalised dystonia.

Harms

We found no RCTs or case series.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Physiotherapy for generalised dystonia

Summary

We found no direct information about physiotherapy in the treatment of people with generalised dystonia.

Benefits

We found no systematic review, RCTs, or case series of physiotherapy in people with generalised dystonia.

Harms

We found no RCTs or case series.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence

2008; 2008: 1211.
Published online 2008 September 5.

Speech therapy for generalised dystonia

Summary

We found no direct information about speech therapy in the treatment of people with generalised dystonia.

Benefits

We found no systematic review, RCTs, or case series of speech therapy in people with generalised dystonia.

Harms

We found no RCTs or case series.

Comment

See comment on acetylcholine receptor inhibitors for generalised dystonia.

Substantive changes

No new evidence


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