Table 1.

Theoretical background of the standardized PT program

Muscle stretching /relaxation and mobilisations (de Morree[43], Fung[44])
Principle	Explanation	Application in standardized PT program
1. Passive mobilisation of the neck	Passive mobilization techniques of the neck create stress relaxation in the collagen fibers of the cervical facet joints. This helps to increase ROM	Passive mobilisation techniques are applied by PT’s
2. Muscle stretching for relaxation	Stretching elongates the dystonic muscle and helps to relax it due to the Golgi tendon reflex.	Passive stretching of dystonic muscles
Motor learning principles (Kleim &Jones[20])
Principle	Explanation	Application in standardized PT program
1. Use it or lose it	Failure to drive specific brain functions can lead to functional degradation.	Activation of antagonists
2. Use it and improve it	Training that drives a specific brain function can lead to an enhancement of that function.	Training of antagonists in order to improve voluntary movement of the head
3. Specificity	The nature of the training experience dictates the nature of the plasticity.	Functional training of activities of daily living tailored to the patients needs
4. Repetition matters	Induction of plasticity requires sufficient repetition.	Exercise of newly gained tasks 5–10 times a day for 10–15 minutes
5. Intensity matters	Induction of plasticity requires sufficient training intensity.	Training intensity is tailored for the individual and monitored over time
6. Time matters	Different forms of plasticity occur at different times during training.	1 year of therapy is divided in 3 stages according the 3 stages model of Fitts & Postner [45]
7. Salience matters	The training experience must be sufficiently salient to induce plasticity.	Functional training of activities of daily living tailored to the individual needs of the patient
8. Age matters	Training-induced plasticity occurs more readily in younger brains.
9. Transference	Plasticity in response to one training experience can enhance the acquisition of similar behaviors.	Functional training of activities of daily living tailored to the patients needs and variation and random practice
10. Interference	Plasticity in response to one experience can interfere with the acquisition of other behaviors.
Transference and generalization (Shea &Morgan[45], Schmidt &Lee[46])
Principle	Explanation	Application in standardized PT program
1. Random practice	Enhances the transference and generalization of a task	Tasks or exercises are given in a random order
2. Variation of practice	Enhances the transference and generalization of a task	Specific tasks or exercises are performed in different contexts
Feedback (Shea et al.[47], Schmidt &Lee[46])
Principle	Explanation	Application in standardized PT program
1. Summary Knowledge of Results	Feedback is essential for learning to take place. Summary KR is that KR is given after an entire set of trials during an exercise instead of after each individual trial. It is the most effective form for the retention and transference of a task.	Feedback is given after each set of trials of a task. Each task is performed at least 5 times after feedback is provided
Self management (Fitts &Posner three-stage model[48])
Principle	Explanation	Application in standardized PT program
1. Cognitive phase	The learner is concerned with understanding a task and developing strategies to perform a task and how the task can be evaluated. These efforts require a high degree of cognitive activity	During the first month patients receive 2 PT sessions a week to (re)learn and understand movement strategies. Movement strategies will be practiced at home 5–10 times a day for 10–15 minutes
2. Associative phase	The learner has selected the best strategy for a task and starts to refine it. This stage requires less cognitive activity	During this stage patients receive 1 PT session. Movement strategies from the first stage will be increased in difficulty. Movement strategies will be practiced at home 5–10 times day for 10–15 minutes
3. Autonomous phase	The learner is able to perform a skill automatically. A low degree of attention is required.	During the last (autonomous) stage, patients are encouraged to perform the learned tasks independently and to improve and maintain their (re)gained abilities themselves. Therapists will have a coaching role. Patients receive one PT session a month for additional advice and motivation.