Table 4.

Physical therapy approaches in functional dystonia.

PT intervention	Examples	Rationale
Distraction strategies	- Counting steps out loud while walking - Counting backwards by 3's - Naming fruits that begin with sequential letters of the alphabet	Distraction reduces the focus of the central nervous system on the altered posture/movement
Change posture/position	- LE - Supine, Prone knee extended, Prone knee flexed -Cervical - Supine, Prone, Semi-recumbent	Changing the body or limb posture relative to gravity alters sensory input and can minimize abnormal posturing allowing for active movement
Weight bearing through extremity	- Sitting with foot on an incline in some plantar flexion - Sitting with foot on a ball - Standing with UE or trunk support	Changing the sensory input of the extremity can alter the motor output
Graded task performance	- Begin with whatever movement the individual can perform actively, opposite the preferred posture	Begin slowly with goals for performance set in conjunction with the patient to promote intrinsic motivation. Gradually incorporate segmental limb movements then full body using functional tasks
Elicit automatic movements	- Generate postural control reactions in sitting and standing that engage head and neck for cervical dystonia and the LE for LE dystonia - Walking quickly, walking backwards or running may reduce altered posturing	Reflexive and automatic movements are often retained and can be used to demonstrate to the individual that typical movement is available. Increasing speed of movement might reduce posturing
Sensory - motor retraining	- Direct visualization of normalized movement - Use of mirrors for visualization of improved body posture	Actual vs. perceived body/limb/joint posture might be disparate. Visualization helps reduce the disparity
Interventions to avoid	- Passive stretching	Attempting to alter the posturing passively may result in increased muscle contraction of already overactive muscles
	- Orthotic devices/adaptive equipment	The goal is to reduce attention to the altered posture or movement
Additional considerations	- Promote a schedule of daily activity. Start at a level the individual can achieve and increase slowly every few days	Altered postures and difficulty moving can result in reduced activity levels

UE, upper extremity; LE, lower extremity.