. Author manuscript; available in PMC: 2025 Aug 25.

Published in final edited form as: Dystonia. 2025 Aug 22;4:14695. doi: 10.3389/dyst.2025.14695

Table 2.

Exercise/Stretching/Relaxation/Biofeedback therapy for dystonia.

Exercise/Stretching/Relaxation/Biofeedback (n = 33)
Author	Study design	Participant characteristics				Intervention		Assessment outcomes	Results	AAN class
Author	Study design		Active group	Control group		Active	Control	Assessment outcomes	Results	AAN class
Focal Cervical Dystonia
Useros-Olmo et al., 2020⁵⁶ Spain	Case-control	N	15	12	Treatment	Relaxation technique programs	Observation	SF-36, VAS, TWSTRS (subjective, pain, severity)	Significant improvements in all outcomes	III
		M/F	1/14	4/8	Details	Aquatic Watsu therapy, autogenic training
		Age (y)	47 ± 14	54 ± 12	Frequency/Duration	Supervised: 1 session/w + Home: 30min/day, 4w
Boyce. et al., 2013⁵³ Australia	RCT	N	9	11	Treatment	Semi-supervised active exercise program	Relaxation	TWSTRS, BDI (severity, depression)	Both groups significantly improved dystonia severity & depression. No significant difference between groups	II
		M/F	6/14		Details	Exercise to correct dystonic head position, relaxation
		Age (y)	57 ± 7		Frequency/Duration	Supervised: 30 min session/w, 8w + Home: daily, 12w
Zetterberg. et al., 2008⁵² Sweden	Pre-post	N	6		Treatment	Supervised PT	NA	TWSTRS, CDQ24, pain scale (severity, pain, subjective)	Significant improvement in all outcomes	III
		M/F	2/4		Details	Progressive muscle relaxation, isometric muscle endurance, dynamic strength
		Age (y)	48 (30–59)		Frequency/Duration	45 min/session, 36 session, 4 w
Smania. et al., 2003⁵⁵ Italy	Cross-over	N	4		Treatment	Supervised PT	Standard biofeedback program	Head realignment, questionnaire, VAS (function, subjective, pain)	Both groups significantly improved pain & head-trunk alignment. No significant difference between groups	III
		M/F	1/3		Details	Postural reeducation exercises, passive elongation of myofascial cervical structures
		Age (y)	41.7		Frequency/Duration	1 hr/session, 5 d/w, 5 w
Duddy. et al., 1995⁵⁴ UK	RCT	N	6	5	Treatment	Biofeedback training	Television monitored relaxation only	EMG, speech evaluation (physiological study, subjective)	Both groups significantly improved subjective symptoms No significant difference between groups	II
		M/F	5/6		Details	EMG biofeedback, television monitored relaxation
		Age (y)	33–66		Frequency/Duration	2 session/w, 4 w
Spencer. et al., 1991⁵¹ USA	Case report	N	1		Treatment	Supervised PT	NA	Subjective, head posture, EMG (subjective, function, physiological study)	Improvement in ROM & head posture	IV
		M/F	M		Details	Strengthen antagonists, correction of head posture with mirror
		Age (y)	29		Frequency/Duration	7 sessions, 20 w
Leplow. et al., 1990⁵⁷ Germany	Pre-post	N	10		Treatment	Biofeedback training	NA	Subjective symptoms	Significant improvement	IV
		M/F	6/4		Details	EMG biofeedback, relaxation, stress-management, counselling
		Age (y)	42–61		Frequency/Duration	45 min/session, 14–25 sessions
Jahanshahi. et al., 1990⁶¹ UK	RCT	N	6	6	Treatment	EMG biofeedback + relaxation	Relaxation	ROM, EMG (function, physiological study)	Both groups significantly improved in head position & neck mobility.	II
		M/F	3/3	2/4	Details	Learning to relax tense sternocleidomastoid
		Age (y)	48 (26–68)	57 (48–60)	Frequency/Duration	1–2 session/w, 27 sessions, 3m
Cleeland. et al., 1983⁵⁸ USA	Pre-post	N	10		Treatment	Biofeedback training	NA	Overall Symptoms (subjective)	Improvement in 9/10 patients	IV
		M/F	4/6		Details	EMG biofeedback (auditory & electrical shock)
		Age (y)	15–64		Frequency/Duration	6–23 sessions
Martin. et al., 1981⁵⁹ UK	Case series	N	6		Treatment	Biofeedback training + Home training	NA	EMG, ROM (physiological study, function)	All patients improved to some extent	IV
		M/F	0/6		Details	Conventional 4 sessions + Specifically designed 4 sessions
		Age (y)	40–63		Frequency/Duration	Biofeedback: 20 session/d, 3d + Home: daily, 1w
Brudny. et al., 1976⁶⁰ USA	Pre-post	N	69		Treatment	Biofeedback training	NA	Overall Symptoms (subjective)	Improvement in 37/69 patients	III
		M/F	NA		Details	EMG biofeedback
		Age (y)	NA		Frequency/Duration	3–5 sessions/w, 8–12w
Laryngeal Dystonia
Keatley. et al., 1994⁶² UK	Case report	N	1		Treatment	Speech therapy	NA	Speech evaluation (subjective, performance)	Specifically designed showed greater improvement in subjective symptoms & speech performance	IV
		M/F	M		Details	Speech therapy specifically designed to reduce lip tension
		Age (y)	62		Frequency/Duration	Conventional: 4 sessions + Specifically designed: 4 sessions
Focal Limb Dystonia
Ackermann. et al., 2021⁷⁴ Australia	Pre-post	Type	Musician’s dystonia		Treatment	Anatomy based retraining program	NA	Tubiana and Chamagne Scale (performance)	Improvement in music performance	IV
		N	4		Details	Progressive muscle activation, movement exercise program
		M/F	2/2		Frequency/Duration	Every day, 12 m
		Age (y)	27.8		Frequency/Duration	Every day, 12 m
Butler. et al., 2018⁶⁷ UK	Pre-post	Type	Musician’s dystonia	Writer’s cramp	Treatment	Sensorimotor rehab	NA	Arm dystonia disability (severity)	Slight improvement in dystonia severity	III
		N	7	5	Details	mirror therapy, slow down exercise, ultrasound, re-education, exercise, stretch
		M/F	4/8		Frequency/Duration	Supervised: 30–60 min/session, 6 sessions + Home: daily, 6m
		Age (y)	51		Frequency/Duration	Supervised: 30–60 min/session, 6 sessions + Home: daily, 6m
Yoshie. et al., 2015⁷³ Japan	Case report	Type	Musician’s dystonia		Treatment	Slow down exercise training	NA	Key stroke (performance)	Regularity of keystrokes improved	IV
		N	1		Details	Simple five-finger motor task
		M/F	F		Frequency/Duration	30 min/d, every day, 1y
		Age (y)	25		Frequency/Duration	30 min/d, every day, 1y
Hashimoto. et al., 2014⁸⁰ Japan	Case report	Type	Writer’s cramp		Treatment	Brain-computer interface rehabilitation	NA	Handwriting test (performance)	Improvement in writing performance	IV
		N	1		Details	Visual EEG feedback from sensorimotor cortex
		M/F	F		Details	Visual EEG feedback from sensorimotor cortex
		Age (y)	67		Frequency/Duration	60 min/session, 10 sessions, 5m
Cheng. et al., 2013⁷⁹ Germany	Case-control	Type	Musician’s dystonia	Healthy control	Treatment	Altered auditory feedback	No or delayed feedback	Key stroke (performance)	No significant improvement in both groups	III
		N	12	25	Details	Input at tempo of 4 notes/min, 80 beats/min
		M/F	8/4	13/12	Frequency/Duration	1 min
		Age (y)	44 (9)	25 (3)	Frequency/Duration	1 min
de Lisle. et al., 2012⁷² New Zealand	Case report	Type	Musician’s dystonia		Treatment	Instrumental retraining	NA	Music performance scales (performance)	Improvement in music performance	IV
		N	1		Details	Upper limb reversing position
		M/F	F		Frequency/Duration	18 sessions, 5w
		Age (y)	42		Frequency/Duration	18 sessions, 5w
Baur. et al., 2009⁷⁸ Germany	Pre-post	Type	Writer’s cramp		Treatment	Biofeedback training	NA	Writing frequency, fluency, pressure (performance)	Significant improvement in writing performance	III
		N	7		Details	Auditory grip force feedback training, writing strategies
		M/F	3/4		Frequency/Duration	60 min/session, 7 sessions, 2–7w
		Age (y)	52 (44–65)		Frequency/Duration	60 min/session, 7 sessions, 2–7w
Byl. et al., 2009⁶⁴ USA	Pre-post	Type	Writer’s cramp		Treatment	Home-based sensorimotor training	NA	Task specific performance (performance)	Significant improvement in writing performance	III
		N	13		Details	Imagery of normal movement, learning to interface hand with target instrument, sensorimotor training
		M/F	10/3		Frequency/Duration	3 h/d, 5 d/w for 2w in Phase I; 5 h/d for 1w in Phase II; 8w
		Age (y)	47 (27–66)		Frequency/Duration
McKenzie. et al., 2009⁶⁶ USA	Pre-post	Type	Musician’s dystonia	Writer’s cramp	Treatment	Learning based sensorimotor training	NA	Physical, sensory, & motor performance	Both groups significantly improved task specific performance	III
		N	14	13	Details	Education on healthy habits, home program
		M/F	7/7	4/9	Frequency/Duration	2 h/d home training, 8w
		Age (y)	42 ± 11	44 ± 10	Frequency/Duration	2 h/d home training, 8w
Berger. et al., 2007⁷⁵ Netherlands	Pre-post	Type	Writer’s cramp		Treatment	Biofeedback training	NA	writing test	Significant improvement in handwriting	III
		N	5		Details	Muscle feedback recorded with EMG during writing
		M/F	5/0		Frequency/Duration	5–10 sessions, 5–14 m
		Age (y)	28–54		Frequency/Duration	5–10 sessions, 5–14 m
de Lisle. et al., 2006⁷¹ New Zealand	Case series	Type	Musician’s dystonia		Treatment	Instrumental retraining	NA	Music performance scales (performance)	Improvement in music performance	IV
		N	3		Details	Motor practice with proper body biomechanics
		M/F	NA		Frequency/Duration	10 sessions, 2 w
		Age (y)	NA		Frequency/Duration	10 sessions, 2 w
Sakai. et al., 2006⁷⁰ Japan	Case series	Type	Musician’s dystonia		Treatment	Slow-down exercise	NA	Music performance scales (performance)	Improvement in music performance	IV
		N	20		Details	Practice playing piano at slowed speed
		M/F	10/10		Frequency/Duration	30min/day, daily, 1–6 y
		Age (y)	30		Frequency/Duration	30min/day, daily, 1–6 y
Schenk. et al., 2004⁶⁹ UK	Pre-post	Type	Writer’s cramp		Treatment	Writing retraining	NA	Handwriting kinematics (performance)	Significant improvements	III
		N	50		Details	Supervised motor exercises
		M/F	21/29		Frequency/Duration	50–60 min/session, 1 session/1–4w, 2–20 sessions, 4 m
		Age (y)	44 ± 11		Frequency/Duration	50–60 min/session, 1 session/1–4w, 2–20 sessions, 4 m
Byl. et al., 2003⁶³ USA	Pre-post	Type	Musician’s dystonia		Treatment	Sensory discrimination training	NA	Task specific performance (performance)	Significant improvement	III
		N	3		Details	Sensorimotor training, stress-free use for hand, aerobics, postural exercises
		M/F	1/2		Frequency/Duration	Supervised: 19–23 sessions + Home: daily, 12 w
		Age (y)	23,35,24		Frequency/Duration	Supervised: 19–23 sessions + Home: daily, 12 w
Zeuner. et al., 2002⁶⁸ USA	Pre-post	Type	Writer’s cramp		Treatment	Sensory training	NA	Fahn dystonia scale (severity)	Significant improvement in dystonia severity	III
		N	10		Details	Braille reading at grade 1 level
		M/F	1/9		Frequency/Duration	30–60 min/d, daily, 8 w
		Age (y)	50 ± 7		Frequency/Duration	30–60 min/d, daily, 8 w
Byl. et al., 2000⁶⁵ USA	Case series	Type	Musician’s dystonia		Treatment	Sensory discriminative training + Home program	NA	Sensory Integration and Praxis Test; strength; ROM, VAS (severity, function, pain)	Significant improvements in all outcomes	IV
		N	12		Details	Posture, relaxation, mobilization, fitness, motor imagery
		M/F	NA		Frequency/Duration	6–18 w
		Age (y)	NA		Frequency/Duration	6–18 w
Deepak. et al., 1999⁷⁷ India	Pre-post	Type	Writer’s cramp		Treatment	Biofeedback training	NA	VAS, EMG (performance, pain, physiological study)	Writing performance and pain improved in 9/10 patients	IV
		N	10		Details	Audio-feedback EMG from abnormally activity muscles during writing practice
		M/F	10/0		Frequency/Duration	4 sessions minimum, 8 w
		Age (y)	19–62		Frequency/Duration	4 sessions minimum, 8 w
O’Neill. et al., 1997⁷⁶ (USA)	Case report	Type	Writer’s cramp		Treatment	Biofeedback training	NA	Self-report, EMG (subjective, physiological study)	Subjective improvement & decrease in EMG amplitude	IV
		N	1		Details	EMG biofeedback (visual+auditory) during handwriting practice
		M/F	M		Frequency/Duration	Supervised: 2 sessions + Home: daily, 2w
		Age (y)	52		Frequency/Duration	Supervised: 2 sessions + Home: daily, 2w
Functional Dystonia
Gros. et al., 2024⁸¹ Canada	Pre-post	N	4		Treatment	PT	NA	Subjective symptoms (subjective)	All patients reported subjective improvement	IV
		M/F	1/3		Details	Symptom-based individualized rehabilitation
		Age (y)	22–32		Frequency/Duration	3m - 1y
Stephen. et al., 2017⁸² USA	Case report	N	1		Treatment	PT	NA	Subjective symptoms (subjective)	No significant improvement	IV
		M/F	F		Details	NA
		Age (y)	41		Frequency/Duration	NA

Values are shown as mean (standard deviation or SD), if SD was not available in the article min - max were shown if possible. AAN class, American Academy of Neurology classification framework; number of patients, n; male, M; female, F; year, y; month, week, w; hour, h; minute, min; second, s; not applicable, NA; Randomized controlled trial, RCT; 36-Item Short-Form Health Survey, SF-36; Visual Analogue Scale, VAS; Toronto Western spasmodic torticollis rating scale, TWSTRS; Physical therapy, PT; Beck Depression Inventory, BDI; Cervical Dystonia Questionnaire, CDQ; writer’s cramp rating scale, WCRS; single-photon emission computed tomography, SPECT; The Burke–Fahn–Marsden Dystonia Rating Scale, BFMDRS; Electromyography. EMG; Range of Motion, ROM; electroencephalogram, EEG.