|CLINICAL SIGNS IN MOVEMENT DISORDERS
|Year : 2019 | Volume
| Issue : 3 | Page : 98-101
Sonali Bhattad, Sanjay Pandey
Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India
|Date of Submission||21-Aug-2019|
|Date of Decision||02-Oct-2019|
|Date of Acceptance||24-Oct-2019|
|Date of Web Publication||04-Dec-2019|
Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, Academic Block, Room No. 503, New Delhi 110002.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhattad S, Pandey S. Sensory tricks. Ann Mov Disord 2019;2:98-101
The “sensory trick,” also known as “geste antagoniste” or “alleviating maneuver,” is a classical feature of focal dystonia. It can also be seen in generalized dystonia. The trick is used by patients with dystonia to transiently suppress their dystonic movement or dystonic posture. In this paper, we would like to give a brief account of sensory tricks as it has diagnostic and therapeutic implications.
| Historical Background|| |
It was first described by Brissaud in 1894; however, the term “geste antagoniste” was used by Henry Meige and Eugene Feindel in 1902. The phenomenon of sensory trick was misinterpreted by Brissaud and Meige by attributing it to the psychogenic origin. The reinforcement of its organicity was proposed later by Herz in 1944 and Marsden in 1970–1980s. The term “alleviating maneuver” was given by Patel et al. Prevalence of sensory trick is about 17%–89% in the reported literature, with the majority stating it to be 70%–80%.
| Types of Sensory Tricks|| |
The types of sensory tricks include motor tricks, forcible tricks, imaginary tricks, and reverse sensory tricks [Table 1].,,,,,
Motor tricks involve voluntary movements as their evident clinical features. Forcible tricks are atypical tricks that require the use of force and are always antagonistic to the direction of the dystonia. The two key features that differentiate them from sensory tricks are the use of force and the direction applied. Forcible tricks have found to be more effective in providing longer relief than classical sensory tricks for severe dystonia.
Imaginary tricks are a type of sensory tricks in which the relief of dystonia occurs with a mental imagination of performing the sensory trick, for example, cervical dystonia patients imagining of attaining a normal head posture. This shows that sensory input is always not necessary in relieving the dystonia.
Reverse sensory tricks emphasize the unique individual nature of sensory tricks that lead to the worsening of dystonia when applied indicating that sensorimotor integration is disadvantageous.
Sensory tricks are often multisensory and heterogeneous in nature. The various stimuli can be tactile, proprioceptive, auditory, visual, and thermal that can lead to change in dystonic muscle contractions. The heterogeneity can be explained by the fact that different maneuvers can be used by different patients to ameliorate the dystonic element.
| Sensory Tricks in Secondary Dystonias|| |
The typical feature of primary dystonia is “geste antagoniste,” although rarely they have been described in secondary, heredodegenerative, and functional (psychogenic) dystonias as well.
The “mantis sign,” which is a unique sensory trick, was observed in patients of pantothenate kinase-associated neurodegeneration (PKAN) with prominent oromandibular involvement with severe jaw-opening dystonia. It involves touching the chin with both hands characteristically clenched into a fist with flexion at the elbows. The term “mantis” was coined because of its resemblance with the praying-like posture of Mantis religiosa.
Patients with chorea–acanthocytosis have characteristic symptoms of trunk flexion and axial extension, which can be ameliorated by using sensory tricks such as folding the arms over the chest or putting hands behind the head.
| Mechanisms Proposed for Sensory Tricks|| |
The exact mechanism remains elusive as various theories on its phenomenology have been proposed.
Sensory trick has central as well as peripheral mechanisms as proposed by Schramm et al. in their study, using surface electromyography. They showed that modification of the sensory motor integration at the cortical level results in amelioration of dystonia. When the sensory trick is applied, the information regarding the head position that reaches the parietal cortex gets modified and it was most effective when it was applied with the head in a neutral or slightly overcorrected position.
The pathogenesis of dystonia involves decreased inhibition at multiple levels of the nervous system. The mechanism revolves around balancing the ratios of inhibition to facilitation. In patients with dystonia, there is increased facilitation to inhibition ratio. Ramos and colleagues proposed the hypothesis that sensory tricks decrease this ratio, and thus ameliorate dystonia.
A hypothesis that sensory tricks decrease abnormal cortical facilitation was proposed by imaging study by Naumann et al., which showed increased activation in the parietal and bilateral occipital lobes and decreased activation in the supplementary motor area and the primary sensorimotor cortex when sensory trick was performed. Another hypothesis was postulated by Gomez-Wong et al. stating that sensory tricks normalize the reflex pathologic circuits that lead to an abnormal “gating mechanism” in dystonia. The abnormal gating in dystonia was evident by somatosensory-evoked potential studies that showed abnormalities for the P22 and N30 in patients with writer’s cramp. Dystonia is secondary to a sensory input motor output mismatch and sensory trick acts by adjusting this link was proposed by Kaji et al. and Abbruzzese and Berardelli.
Proprioceptive and tactile stimuli are the most important sensory tricks for cervical dystonia and blepharospasm, respectively. A review performed by Muller et al. on cervical dystonia patients showed that sensory tricks were effective, if the body position eliciting the sensory tricks was maintained. The neutral or overcorrected position appears that sensory tricks work when the dystonic posture is present, and not in the normal or overcorrected phase; this further implicates that sensory tricks work best in the prevention mode, rather than correction mode.
The visual stimuli also act as sensory tricks in cervical dystonia, which was shown by positron emission tomography studies, in which visual information act by providing a compensatory mechanism for faulty proprioception by enhancing pathways between the occipital and parietal lobes.
It has also been found that in patients with dystonia there has been impaired spatial and temporal sensory discrimination. It can be proven by the fact that impaired sensory input and impaired sensory discrimination will lead to less-effective sensory trick.
Restoration of sensory trick effectiveness after botulinum toxin administration indicates that there is a close association between the sensory trick and botulinum toxin treatment. Because of the various pathophysiological processes proposed in the development of sensory tricks, that is, the sensorimotor mismatch, reduced activation of supplementary motor, and primary sensorimotor cortex after sensory trick use and abnormal inhibition at multiple levels of the central nervous system, these notions also further provide a viable foundation for the intriguing difference in the subjective effectiveness of botulinum toxin treatment.
Significant changes in functional sensorimotor maps on neuroimaging have been shown following botulinum toxin administration. Therefore, sensory trick acts by correcting abnormal activation patterns in these very areas. Botulinum toxin could be affecting an environment leading to normalization of the pathology.,
The duration of disease and severity of dystonia has no corelation to the presence of sensory trick as proposed by Pandey et al. in their study of sensory trick in idiopathic cervical dystonia and blepharospasm patients. Studies show that the effectiveness of sensory trick can decrease with increasing severity of dystonia, which could be either because of deterioration of sensory trick or progression of dystonia.,
The presence of sensory trick can help in the differentiation of dystonic tremor from essential tremor.
Sensory trick can be considered as a predictor of response to treatment especially with botulinum toxin as it ameliorates dystonia, as proposed by Filip et al., who stated that patients with effective sensory trick responded better to treatment.
| Conclusion|| |
Sensory tricks or “alleviating maneuvers” are voluntary maneuvers that decrease the severity of abnormal movements or postures in patients with dystonia. The term “alleviating maneuver” is appropriate than sensory trick as the latter term denotes sensory origin and the term “trick” implicates that it is fake, and hence falsely proposing psychogenic origin. The exact pathophysiology of sensory trick is unknown, but it involves central and peripheral components. Hence, dystonia can be hypothesized as a complex network disorder. It is seen in a variety of dystonias ranging from focal to generalized. Sensory tricks are risk free, low-cost aids having potential therapeutic and diagnostic implications to the patients with dystonia. However, they have a major drawback that their benefit is transient. Further studies are needed to know more about the exact physiology that can bring forth newer advances in the field of dystonia.
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Conflicts of interest
There are no conflicts of interest.
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