• This can be done with the patient seated but assessment should also be done

  • With eyes closed and open

  • Following repetitive voluntary movements to look for overflow, writing, typing, drinking

  • Walking and laying down

• From behind – best position for shoulder assessment and tilt

• If possible from top – good for assessing rotation 

• The patient may adopt a compensatory posture in opposition to the dystonic spasm, which can be misleading

• Palpation for muscle soreness or hypertrophy

• In the presence of tremor look for “null position”

• Localise pain - although may also be occurring in muscles opposing spasm

• Examine the shoulder muscles, looking for elevation of one shoulder, comparing the position of the scapulae.

• Examine for trunk rotation.

• Patients often have a mixed pattern of cervical dystonia.

• The degree of tilt helps in the assessment of laterocaput versus collis

• Lateral flexion of head is at Occ-C1- maximum movement at this joint is 10 degrees

Movement between C2-C6 is up to 37 degrees so likely to be laterocollis and involve long spine to spine muscles

Maximum Extension C2-7 is up to 66 degrees so likely to be retrocollis

Movement between Occiput and C1 up to 13 degrees so most likely retrocaput

• Shoulder elevation on the side of rotation therefore suggesting dystonic levator scapulae

• Shoulder elevation on the opposite side of rotation suggests dystonic trapezius

Identical muscle fibre orientation explains the synergy of action in the rotation of the head between sternocleidomastoid and trapezius and between splenius and levator scapulae

• Overinjected - not always involved in rotation or flexion

Sternal

Clavicular Head

• Sternal head rotates

• Clavicular head tilts

Line from Thyroid cartilage to sternum 

Head to left and neck to the right - lateral shift

• Touching specific parts of the face, cheek, chin, occipital region, temple, forehead, nose, mastoid, occipital region, back of neck

• Raising the arm and holding the finger near the target region without touching the face or prior to touching the face

• Resting the back of the head or neck, bending the trunk forward, resting the back or shoulder, yawning, wearing a collar/a scarf, leaning the elbows on the armrest