Elsevier

Gait & Posture

Volume 55, June 2017, Pages 55-61
Gait & Posture

Full length article
Impairments of balance, stepping reactions and gait in people with cervical dystonia

https://doi.org/10.1016/j.gaitpost.2017.04.004Get rights and content

Highlights

  • People with cervical dystonia (CD) displayed deficits in balance, gait and stepping reactions compared to controls.

  • People with dystonia had lower falls self-efficacy.

  • Reduced cervical ROM was correlated with poor balance and mobility and increased stepping reaction time in people with CD.

  • Limitations of function and activity must be considered in the management of CD.

Abstract

Background

Impaired balance is common in neurological disorders. Cervical dystonia is a neurological movement disorder affecting the neck. The effect of this aberrant head posture on physical function is unknown.

Objectives

To compare balance, mobility, gait and stepping reactions between ten people with cervical dystonia and ten control adults.

Methods

Spatiotemporal gait parameters and walking speed were assessed using a computerised walkway. Step length and time, time in double support and gait variability were calculated, then normalised to gait speed. Centre of pressure path length was assessed with eyes open and eyes closed to calculate a Romberg Quotient. Simple and choice reaction times were measured using customised apparatus while mobility was assessed by the timed up and go. Cervical spine range of motion was measured using a head mounted goniometer. Self-reported scales included Falls Self Efficacy Scale and Dystonia Discomfort Scale.

Results

There was a difference between groups for most outcome measures. The timed up-and-go and walking speed was slower (both P< 0.005) and the Romberg Quotient lower (P = 0.046) in cervical dystonia. People with cervical dystonia had lower falls self-efficacy (P = 0.0002). Reduced cervical range of motion was correlated with balance, stepping reaction time and mobility (all P < 0.05). Timed up and go was positively associated with stepping reaction time (P < 0.01). Dystonia discomfort did not impact function.

Conclusions

People with cervical dystonia displayed deficits in balance, gait and stepping reactions, and expressed higher fear of falling. Studies to further elucidate functional limitations and their impact on activity and participation in daily life are required.

Introduction

Dystonia is a poorly understood but relatively common neurological movement disorder; the third most prevalent movement disorder after Parkinson’s disease and essential tremor [1]. Cervical dystonia (CD) is an isolated dystonia characterised by sustained and involuntary contractions of neck muscles, resulting in non-functional neck and head postures [2], [3]. The pathophysiology of CD involves multiple brain structures, including sensorimotor cortex, basal ganglia, cerebellum, trigeminal and vestibular nuclei and is considered a brain network disorder [4], [5], [6], [7]. People living with neurological movement disorders commonly display poor postural control, impaired mobility and balance when walking, turning and transferring and delayed stepping reactions [8], [9], [10], [11]. Impairments in balance are known to influence gait and slow walking speed [12], [13], [14] and may lead to falls in those with neurological disorders and in older adults [15], [16].

Clinically people with CD often report that fear of falling curtails their physical activity [17]. To date there is little understanding as to whether people with CD experience balance and gait deficits, even though they are known to have issues with proprioceptive and vestibular function [18], [19], [20], [21] and impaired vision secondary to the twisted head posture. Growing evidence for the involvement of the cerebellum in CD suggests there may be an impact on balance and function given the importance of the cerebellum in motor coordination and gait. People with CD are known to walk at slower speeds than healthy controls [22], have low falls self-efficacy and balance confidence [17], [22]. The primary aim of this study was to compare balance, gait and stepping reactions in people with CD with control adults. Secondary aims were to explore if abnormal head posture, dystonia severity or fear of falling impacted on function.

Section snippets

Methods

This study was a point in time observational study of people diagnosed with CD by a neurologist, and of age and sex matched healthy adults. Participants provided written informed consent and the study was approved by the local Human Research Ethics Committee. Participants were included whether or not they underwent regular treatment with botulinum toxin injections and, as we did not specify a specific time point in their treatment cycle, time (weeks) since the last injections was recorded. To

Results

Ten people with CD (9 female, mean age 53.9 ± 12.6 years) and 10 gender and age matched controls (mean age 52.8 ± 12.2 years) were included in the study. Seven of the people with CD had a cervical tilt bias to the left. The average duration of disease from diagnosis was 12.1 ± 9.7 years. Eight of the ten participants were undergoing treatment by botulinum toxin injections at the time of the study; the average time post-injection on the day of the study was 5.9 ± 2.8 weeks. No participants

Discussion

Functional measures of mobility, gait, reaction time and balance were compared in ten people with CD and ten healthy adults. There were several new findings with relevance for understanding functional limitations in people with CD. People with CD walked more slowly, took longer steps, spent more time in double leg support during gait when gait speed was taken into account, and demonstrated differences in gait variability to healthy control adults. People with CD also had slower stepping

Conflicts of interest

None.

Authors’ roles

Christopher Barr PhD

  • (1)Conception and design of the study, acquisition of data and analysis and interpretation of data

  • (2)drafting the article and revising it critically for important intellectual content

  • (3)final approval of the version to be submitted

Rhiannon Barnard MSc

  • (1)acquisition of data and analysis and interpretation of data

  • (2)drafting the article

  • (3)final approval of the version to be submitted

Lauren Edwards MSc

  • (1)acquisition of data and analysis and interpretation of data

  • (2)drafting the

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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