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Visual and auditory feedback for head tilt and torsion in a spasmodic torticollis patient
Eehac. Res. Thu. Vol. 23, No. 1, pp. 87-88, 1985 Printed in Great Bntain. All rights reserved
OOOS-7967/85s3.00 + 0.00 Copyright r!’ 1985 Pergamon Press Ltd
Visual and auditory feedback for bead tilt and torsion in a spasmodic torticollis patient DAVID W.
HARRISON, JAMIS C. GARRETT,
DENISE HENDERSON
and
HENRY E. ADAMS
Departmen! of Psychology, The University of Georgia, Athens, GA 30602, U.S.A. (Received 8 Muy 1984) the present study a single-case design is used to investigate the importance of body-position feedback for postural control in a case of spasmodic torticollis. A simple inexpensive device for quantifying and providing auditory or visual (LED) feedback for motor disorders was used to provide feedback directly contingent upon postural deviations of the head. Within each session forward head tilt declined to 0’ with the onset of feedback. Between-session improvements in the absence of feedback were cumulative and approached 0” tilt by the fourth session. Following the attainment of postural control for forward head tilt in the absence of feedback, similar procedures were used to correct lateral head tilt. Both measures remained stable at 0” during a three-session reversal period during which no feedback was given. Summary-In
lNTRODIJCTlON
Spasmodic torticollis is a disturbance in the neuromotor control of the muscle groups of the upper back, neck and head. Several studies have reported some success in treating torticollis using behavioral therapies and especially electromyogram (EMG) biofeedback (e.g. Cleeland, 1973; Brundy, Grynbaum and Korein, 1974). In the present study the importance of body-position feedback to postural control is investigated with the provision of auditory and visual feedback directly contingent upon postural deviations of the head. This case study differs from previous investigations in several ways. First, the patient was evaluated on perceptual, motor and postural tasks in both light and dark (with blackened goggles) conditions. Secondly, data from extended baseline and training sessions are reported, including within- and between-session measurements. Progress was assessed using more precise measures including a switch-coupled light-emitting diode (LED) indicating head-tilt deviations from a preestablished criterion and a videotape procedure using horizontal and vertical grids over a TV monitor (see Bemhardt, Hersen and Barlow, 1972). Finally, a lightweight inexpensive apparatus, which may be discreetly mounted on the patient for auditory or visual feedback or for recording cumulative deviations from postural criterion in clinic or home settings, is described. METHOD
Subject
The patient was a 38-yr-old, white, female beautician referred to the psychology clinic by her neurologist. The physician’s report indicated that, in addition to spasmodic torticollis, the patient suffered from cervical arthritis. The patient’s torticollis was characterized by forward and lateral (left) head tilt. The head tilt was accompanied by shoulder tilt (with the left shoulder lower) and tilt in the facial features. She reported an abrupt onset of the torticollis approx 2 yr prior with gradual deterioration. At the time of treatment, the head tilt was constant. The patient was seen for two I-hr sessions per week. An assessment showed a greater proprioceptive deficit for the left side of the body and misinterpretation by the S of the direction and extent of head tilt. The head tilt was aggravated when blackened goggles were placed on the patient in order to remove visual cues, suggesting that she relied upon visual rather than kinesthetic cues to maintain body position. When the patient was asked to turn her head to the left and point 90” to the right the position of her hand was off by an estimated 15’; no difficulty was noted when she turned her head to the right and pointed to the left. The patient was asked to go through a range of body movements (e.g. to lift her arms above her head and behind her back and to pivot the upper part of her body) in order to test body flexibility. It was noted that head rotation to the left was approx. IO; less than rotation to the right. No other problems in flexibility were noted. When the patient’s head was placed in an upright position by the therapist. the patient reported that her head was leaning to the right and reported an increased sensation of muscle tension. When the patient lightly touched her face with her hand, she was able to maintain her head in an upright position, an effect commonly referred to as ‘gest antagoniste’. It was also observed, during the testing, that there appeared to be a general clumsiness of the left side of the patient’s body (e.g. when doing a finger-tapping test, the patient lifted the entire left arm in order to tap with the fingers of the left hand, whereas, specific and appropriate movement occurred in order to tap with the fingers of her right hand). Finally, greater muscle activity was observed along the left side of the patient’s neck. Apparatus and procedure
A simple inexpensive device for quantifying and providing auditory or visual (LED) feedback for motor disorders was used. Two types of mercury sensor switches were used. One (type: TS 3-1094) remained in the normally closed position when upright, operating from 85’ to 90’ (vertical) and releasing at 75. away from vertical. Overall dimensions of this switch were 0.225 x 0.225 x 0.026cm. allowing discrete mounting on the patient’s head. A unilateral mercury switch (RS No, 275-027) allowed assessment and feedback for forward and lateral head tilt independently when attached to the side or back of the patient’s head with a hairpin. Operation and release of the sensor switches were coupled in optional configurations as follows. For recording, a small pocket calculator with a constant function was used with switch pins connected to the ’ = ’ key allowing a cumulative frequency recording. A timer was similarly configured for duration measures. For feedback, the sensor switch was optionally coupled to a volume controlled Piezo buzer mounted directly behind the patient’s ear. 87
88
CASE HISTORIES AND
SHORTER CO.UMUNiCATIONS
FORWARO FEEDBIICK
Fig.
I. Effects of feedback
REVERSAL
LATERAL FEEDBACK
on lateral
(N)
and forward
(0) head tilt.
Videotape recordings of the patient (seated in a front or profile position) were made during each session using’s recorder. TV camera and TV monitor. A clear plastic sheet with superimposed horizontal and vertical lines was subsequently placed over the monitor and a protractor was used to quantify the degree of head tilt. Video recording allowed for the computation of observer reliability following the session. Experimental
design
A multiple-baseline
design was used. Forward and Iateral deviation from vertical provided the two measures of head tilt. During the assessment phase, the S was instructed to place her head in a vertical position and to mamtam normal posture for a 10 min period. No further prompts were gzven. During this period the S’s ability to maintain proper posture followmg the initial prompt was assessed using duration measures of normal and ‘tortocollis’ postures. During baseline the S was instructed to sit comfortably and to maintain normal posture for IO mm. Head tilt was quantified using the grid and mercury switches as described above. Following this initial baseline, auditory feedback (tone) was given first for forward head tilt and later. independently. for lateral head tilt. RESULTS AND DISCUSSION A minimum of two sesstons per experimental phase were rated by a second observer in a retrospective playback of the videotape. Observer agreement exceeded 0.90. The S’s ability to maintain normal position of the head following instructions to hold her head in an upright position. and in the absence of additional prompting, was limited to brief periods (IO set) followed by a gradual return of torticollis behavior. Subsequently, and without prompt, the patient would return her head to an upright position. The duration of normal posture periods remained constant, but brief, whereas abnormal posturing increased in duration with increasing distance from the original prompt. Feedback procedures were developed to maintain the potency of the initial prompt over time. as well as to compensate for the perceptual and proprioceptive deficits in this S. Feedback consisted of an auditory signal delivered by the apparatus described above when the patient’s head deviated from an upright position‘ Head tilt was stable across the live-session baseline phase, with a mean of I 1.5’ for both lateral and forward tilt. Auditory feedback was then provided for forward head tilt for three sessions. During this phase data were recorded each session. first in the absence of feedback, then with feedback present. Within each session forward head tilt declined to 0 with the onset of feedback. Between-session improvements in the absence of feedback were cumulative and approached 0 tilt by the fourth session. Generalization was also observed in measures of lateral tilt although significant lateral tilt remained observable throughout this phase. Following the attainment of postural control for forward head tilt in the absence of feedback, similar procedures were used to correct lateral head tilt (see Fig. I). Both measures remained stable at 0 during a three-session reversal period during which no feedback was given. Two viewpoints prevail in the proposed etiologies of torticollis. The first proposes that torticollis may result from lesions or dysfunction within the central or peripheral nervous system. The second viewpoint is that some cases are the result of lesions while other cases have a psychological etiology. The deficits noted in this patient as well as her response to the feedback indicates that, in at least some cases. torticollis may be the result of proprioceptive~kinesthetic difficulties. Finally. thts case suggests that some torticollis patients may benefit from feedback aimed at providing additional postural (proprioceptive) cues and that the resulting improvement in posture may continue in the absence of the feedback. Correspuntience-Requests
for reprints
should
be addressed
to D. W. Harrison.
REFERENCES
Bernhardt A. J.. Hersen M. and Barlow D. H. (1972) Measurement and modification of spasmodic torticollis: an experimental analysis. Behao. Ther. 3, 294-297. Brundy J., Grynbdum B. B. and Korein J. (1974) Spasmodic torticollis: treatment by feedback display of the EMG. Arc/is phys.
Cleeland
Med.
Rehcrbii.
55, 403-408.
C. S. (1973) Behavioral
techniques
in the modification
of spasmodic
torticollis.
Neuru 23, 1241-1247.
OOOS-7967/85s3.00 + 0.00 Copyright r!’ 1985 Pergamon Press Ltd
Visual and auditory feedback for bead tilt and torsion in a spasmodic torticollis patient DAVID W.
HARRISON, JAMIS C. GARRETT,
DENISE HENDERSON
and
HENRY E. ADAMS
Departmen! of Psychology, The University of Georgia, Athens, GA 30602, U.S.A. (Received 8 Muy 1984) the present study a single-case design is used to investigate the importance of body-position feedback for postural control in a case of spasmodic torticollis. A simple inexpensive device for quantifying and providing auditory or visual (LED) feedback for motor disorders was used to provide feedback directly contingent upon postural deviations of the head. Within each session forward head tilt declined to 0’ with the onset of feedback. Between-session improvements in the absence of feedback were cumulative and approached 0” tilt by the fourth session. Following the attainment of postural control for forward head tilt in the absence of feedback, similar procedures were used to correct lateral head tilt. Both measures remained stable at 0” during a three-session reversal period during which no feedback was given. Summary-In
lNTRODIJCTlON
Spasmodic torticollis is a disturbance in the neuromotor control of the muscle groups of the upper back, neck and head. Several studies have reported some success in treating torticollis using behavioral therapies and especially electromyogram (EMG) biofeedback (e.g. Cleeland, 1973; Brundy, Grynbaum and Korein, 1974). In the present study the importance of body-position feedback to postural control is investigated with the provision of auditory and visual feedback directly contingent upon postural deviations of the head. This case study differs from previous investigations in several ways. First, the patient was evaluated on perceptual, motor and postural tasks in both light and dark (with blackened goggles) conditions. Secondly, data from extended baseline and training sessions are reported, including within- and between-session measurements. Progress was assessed using more precise measures including a switch-coupled light-emitting diode (LED) indicating head-tilt deviations from a preestablished criterion and a videotape procedure using horizontal and vertical grids over a TV monitor (see Bemhardt, Hersen and Barlow, 1972). Finally, a lightweight inexpensive apparatus, which may be discreetly mounted on the patient for auditory or visual feedback or for recording cumulative deviations from postural criterion in clinic or home settings, is described. METHOD
Subject
The patient was a 38-yr-old, white, female beautician referred to the psychology clinic by her neurologist. The physician’s report indicated that, in addition to spasmodic torticollis, the patient suffered from cervical arthritis. The patient’s torticollis was characterized by forward and lateral (left) head tilt. The head tilt was accompanied by shoulder tilt (with the left shoulder lower) and tilt in the facial features. She reported an abrupt onset of the torticollis approx 2 yr prior with gradual deterioration. At the time of treatment, the head tilt was constant. The patient was seen for two I-hr sessions per week. An assessment showed a greater proprioceptive deficit for the left side of the body and misinterpretation by the S of the direction and extent of head tilt. The head tilt was aggravated when blackened goggles were placed on the patient in order to remove visual cues, suggesting that she relied upon visual rather than kinesthetic cues to maintain body position. When the patient was asked to turn her head to the left and point 90” to the right the position of her hand was off by an estimated 15’; no difficulty was noted when she turned her head to the right and pointed to the left. The patient was asked to go through a range of body movements (e.g. to lift her arms above her head and behind her back and to pivot the upper part of her body) in order to test body flexibility. It was noted that head rotation to the left was approx. IO; less than rotation to the right. No other problems in flexibility were noted. When the patient’s head was placed in an upright position by the therapist. the patient reported that her head was leaning to the right and reported an increased sensation of muscle tension. When the patient lightly touched her face with her hand, she was able to maintain her head in an upright position, an effect commonly referred to as ‘gest antagoniste’. It was also observed, during the testing, that there appeared to be a general clumsiness of the left side of the patient’s body (e.g. when doing a finger-tapping test, the patient lifted the entire left arm in order to tap with the fingers of the left hand, whereas, specific and appropriate movement occurred in order to tap with the fingers of her right hand). Finally, greater muscle activity was observed along the left side of the patient’s neck. Apparatus and procedure
A simple inexpensive device for quantifying and providing auditory or visual (LED) feedback for motor disorders was used. Two types of mercury sensor switches were used. One (type: TS 3-1094) remained in the normally closed position when upright, operating from 85’ to 90’ (vertical) and releasing at 75. away from vertical. Overall dimensions of this switch were 0.225 x 0.225 x 0.026cm. allowing discrete mounting on the patient’s head. A unilateral mercury switch (RS No, 275-027) allowed assessment and feedback for forward and lateral head tilt independently when attached to the side or back of the patient’s head with a hairpin. Operation and release of the sensor switches were coupled in optional configurations as follows. For recording, a small pocket calculator with a constant function was used with switch pins connected to the ’ = ’ key allowing a cumulative frequency recording. A timer was similarly configured for duration measures. For feedback, the sensor switch was optionally coupled to a volume controlled Piezo buzer mounted directly behind the patient’s ear. 87
88
CASE HISTORIES AND
SHORTER CO.UMUNiCATIONS
FORWARO FEEDBIICK
Fig.
I. Effects of feedback
REVERSAL
LATERAL FEEDBACK
on lateral
(N)
and forward
(0) head tilt.
Videotape recordings of the patient (seated in a front or profile position) were made during each session using’s recorder. TV camera and TV monitor. A clear plastic sheet with superimposed horizontal and vertical lines was subsequently placed over the monitor and a protractor was used to quantify the degree of head tilt. Video recording allowed for the computation of observer reliability following the session. Experimental
design
A multiple-baseline
design was used. Forward and Iateral deviation from vertical provided the two measures of head tilt. During the assessment phase, the S was instructed to place her head in a vertical position and to mamtam normal posture for a 10 min period. No further prompts were gzven. During this period the S’s ability to maintain proper posture followmg the initial prompt was assessed using duration measures of normal and ‘tortocollis’ postures. During baseline the S was instructed to sit comfortably and to maintain normal posture for IO mm. Head tilt was quantified using the grid and mercury switches as described above. Following this initial baseline, auditory feedback (tone) was given first for forward head tilt and later. independently. for lateral head tilt. RESULTS AND DISCUSSION A minimum of two sesstons per experimental phase were rated by a second observer in a retrospective playback of the videotape. Observer agreement exceeded 0.90. The S’s ability to maintain normal position of the head following instructions to hold her head in an upright position. and in the absence of additional prompting, was limited to brief periods (IO set) followed by a gradual return of torticollis behavior. Subsequently, and without prompt, the patient would return her head to an upright position. The duration of normal posture periods remained constant, but brief, whereas abnormal posturing increased in duration with increasing distance from the original prompt. Feedback procedures were developed to maintain the potency of the initial prompt over time. as well as to compensate for the perceptual and proprioceptive deficits in this S. Feedback consisted of an auditory signal delivered by the apparatus described above when the patient’s head deviated from an upright position‘ Head tilt was stable across the live-session baseline phase, with a mean of I 1.5’ for both lateral and forward tilt. Auditory feedback was then provided for forward head tilt for three sessions. During this phase data were recorded each session. first in the absence of feedback, then with feedback present. Within each session forward head tilt declined to 0 with the onset of feedback. Between-session improvements in the absence of feedback were cumulative and approached 0 tilt by the fourth session. Generalization was also observed in measures of lateral tilt although significant lateral tilt remained observable throughout this phase. Following the attainment of postural control for forward head tilt in the absence of feedback, similar procedures were used to correct lateral head tilt (see Fig. I). Both measures remained stable at 0 during a three-session reversal period during which no feedback was given. Two viewpoints prevail in the proposed etiologies of torticollis. The first proposes that torticollis may result from lesions or dysfunction within the central or peripheral nervous system. The second viewpoint is that some cases are the result of lesions while other cases have a psychological etiology. The deficits noted in this patient as well as her response to the feedback indicates that, in at least some cases. torticollis may be the result of proprioceptive~kinesthetic difficulties. Finally. thts case suggests that some torticollis patients may benefit from feedback aimed at providing additional postural (proprioceptive) cues and that the resulting improvement in posture may continue in the absence of the feedback. Correspuntience-Requests
for reprints
should
be addressed
to D. W. Harrison.
REFERENCES
Bernhardt A. J.. Hersen M. and Barlow D. H. (1972) Measurement and modification of spasmodic torticollis: an experimental analysis. Behao. Ther. 3, 294-297. Brundy J., Grynbdum B. B. and Korein J. (1974) Spasmodic torticollis: treatment by feedback display of the EMG. Arc/is phys.
Cleeland
Med.
Rehcrbii.
55, 403-408.
C. S. (1973) Behavioral
techniques
in the modification
of spasmodic
torticollis.
Neuru 23, 1241-1247.