Background: Overuse or task-specific dystonia has been described in a number of professions characterized by repetitive actions, typically affecting the upper extremities. Cervical dystonia (CD), however, has rarely been associated with overuse.

Case Report: We present a case report of typical CD that developed in the context of chronic repetitive movements associated with the patient’s professional occupation as an office manager who spent many hours per day holding a phone to his ear.

Discussion: Overuse CD should be suspected when typical symptoms and signs of CD develop in the context of chronic repetitive use or overuse of cervical muscles, especially where exacerbating tasks involve asymmetric postures

Hogg, Elliot

Tagliati, Michele

English

Pro gradu –tutkielmani tarkastelee journalistisen pienmedian perustaneiden henkilöiden tapoja jäsentää työtään. Tutkimuksen tavoitteena on tuoda esiin journalismin murroksen aikaansaama muutos journalistiseen työhön ja siihen, mitä se tekijöille merkitsee.
 
Tutkielma on luonteeltaan laadullinen haastattelututkimus. Sen metodologinen näkökulma koostuu narratiivisen analyysin, koodaamisen, teemoittelun, sekä grounded theoryn antamista työkaluista. Narratiivinen analyysi tuo esiin haastateltujen esittämiä motivaatioita pienmedian perustamiselle. Teemoittelun ja koodaamisen avulla päästään tarkastelemaan työlle annettuja merkityksiä. Grounded theory toimi suuntaa antavana metodologiana ydinteeman löytymiselle.
 
Tutkimuksen aineistona koostuu neljän eri pienmedian, Long Playn, 11-kollektiivin, Huilin ja Huuman perustajajäsenten haastatteluista. Pienmediat on kaikki perustettu vuosien 2011–2013 välillä. Ne ovat luonteeltaan hyvin erilaisia; taideprojektista startupiin, mutta kaikkia yhdistää halu luoda kunnianhimoista journalismia mediakentälle, jota hallitsevat pääosin mediakonsernien tuottama sisältö.
 
Tutkimuksen kautta ilmeni, että pienmedian perustajia ajaa huoli journalismin tilasta, ja toisaalta vahva kaipuu merkitykselliseen työhön. Journalismin murroksen koettiin johtaneen siihen, että journalismin yhteiskunnallinen merkitys on joutunut jäämään taka-alalle taloudellisen voiton tuottamisen alta. Tämä on johtanut siihen, että mediataloja ei enää arvosteta kuten aiemmin, vaan tilalle on tullut uudenlainen henkilökohtaisen tekijyyden etsiminen. Tämä liittyy työn subjektoitumiseen, yrittäjä-identiteetin vahvistumiseen ja laajempaan kansainväliseen alan trendiin. Luovan alan yrittäjän voi nähdä olevan eräänlainen työn subjektoitumisen maksiimi. Journalistisilla pienmedioiden tekijöillä on vahva yrittäjä-identiteetti ja tarve erottua mediakonsernien tekemästä työstä. Tässä heitä ajaa kunnianhimo, huoli journalismista, työstä itsestään saatu nautinto ja toisaalta muilta saatu arvostus. Arvostuksen kaipuun ja yrittäjä-identiteetin taakse kytkeytyvät myös työn subjektoitumisen kipeät puolet.
 
Tutkimuksen ydinteemaksi muotoutui merkityksellisyyden kaipuu, niin journalismin kuin oman tekemisen kannalta. Median murros on korostanut taloudellisten arvojen hallitsevuutta ja moni journalisti kokee sen vaarantavan journalismin tehtävän. Voittoa tavoittelematon pienmediajournalismi on eräänlainen vastareaktio tälle

Pursiainen, Vilja

TamPub Julkaisuarkisto - TamPub Institutional Repository

Uutisraivaajat : haastattelututkimus pienmediajournalistien tavoista jäsentää työtään

Columbia University Academic Commons

Case ReportsOveruse Cervical Dystonia: A Case Report and Literature ReviewElliot Hogg1& Michele Tagliati1*1Department of Neurology, Cedars Sinai Medical Center, Los Angeles, CA, USAAbstractBackground: Overuse or task-specific dystonia has been described in a number of professions characterized by repetitive actions, typically affecting the upperextremities. Cervical dystonia (CD), however, has rarely been associated with overuse.Case Report: We present a case report of typical CD that developed in the context of chronic repetitive movements associated with the patient’s professionaloccupation as an office manager who spent many hours per day holding a phone to his ear.Discussion: Overuse CD should be suspected when typical symptoms and signs of CD develop in the context of chronic repetitive use or overuse of cervicalmuscles, especially where exacerbating tasks involve asymmetric postures.Keywords: Cervical dystonia, overuse, task specific, occupational, repetitive useCitation: Hogg E, Tagliati M. Overuse cervical dystonia: a case report and literature review. Tremor Other Hyperkinet Mov. 2016; 6. doi: 10.7916/D8959HR1* To whom correspondence should be addressed. E-mail: michele.tagliati@cshs.orgEditor: Elan D. Louis, Yale University, USAReceived: June 28, 2016 Accepted: August 22, 2016 Published: September 13, 2016Copyright: ’ 2016 Hogg et al. This is an open-access article distributed under the terms of the Creative Commons Attribution–Noncommercial–No Derivatives License, which permitsthe user to copy, distribute, and transmit the work provided that the original authors and source are credited; that no commercial use is made of the work; and that the work is not alteredor transformed.Funding: None.Financial Disclosures: None.Conflict of Interest: The authors report no conflict of interest.Ethics Statement: This study was reviewed by the authors’ institutional ethics committee and was considered exempted from further review.IntroductionOveruse or task-specific dystonia has been described in a numberof professions characterized by repetitive actions, typically affectingthe upper extremities. Any occupation based on repetitive movementsor overlearned tasks such as machinery or computer operation, writ-ing, sports, or playing an instrument may lead to abnormal musclecontractions in predisposed individuals.1 Prevalence estimates of task-specific dystonia range between seven and 69 cases per million in thegeneral population and may be as high as 0.5% in musicians.2Cervical dystonia (CD) has rarely been associated with chronicoveruse, and we found only three prior reported cases. We present acase report of typical CD that developed in the context of chronicrepetitive movements associated with the patient’s professionaloccupation.Case reportA 37-year-old non-Ashkenazi Jewish male, with no family history ofneurologic disease, gradually experienced bilateral painful hand pares-thesias. He was employed as an insurance company manager and hisdaily activities included typing (responding to as many as 150 emailsper day), data entry, and five or more hours on the phone daily. Thisasymmetric posture included cradling the phone typically against hisright ear by tilting his head to the right while elevating his rightshoulder and continuing to type. This became associated with neckmuscle spasms and pain while holding that posture. A few monthslater, he developed involuntary head turn to the right at rest. Hedescribed a sensory trick relieving the abnormal head pulling bytouching his left cheek. Neurological examination showed a 75˚headrotation to the right and right shoulder elevation, as well as hyper-trophy of the right levator scapulae and trapezius muscles. There wereno other areas of dystonic involvement seen. He reported chronic, dullpain in the right posterior neck and shoulders. The Toronto WesternSpasmodic Torticollis Rating Scale score was 56, with a severitysubscore of 22, disability subscore of 20, and pain subscore of 14. Onthe basis of these symptoms and signs, he was diagnosed with CD.Brain magnetic resonance imaging was unremarkable and electro-myography/Nerve Conduction Velocity (NCV) showed bilateral mildcompression of the median nerve at the carpal tunnel. Diagnosticultrasound further demonstrated bilateral ulnar neuritis with hyper-mobility of the ulnar nerves at the elbow and fusiform enlargement ofFreely available onlineTremor and Other Hyperkinetic Movementshttp://www.tremorjournal.orgThe Center for Digital Research and ScholarshipColumbia University Libraries/Information Services1both median nerves at the wrists, consistent with cubital and carpaltunnel entrapment. Multiple rounds of botulinum toxin injections inthe affected muscles failed to relieve involuntary head rotation, albeitimproving shoulder elevation. Initial injections targeted the right(60 unit) and left (30 unit) splenius capitis, semispinalis capitis (60 unit)and trapezius (60 unit), in addition to the left SCM (30 unit). Morerecent injections added the right obliquus capitis inferior and rightrectus capitis posterior for a total of 400 unit. Pharmacologic interven-tions with maximum doses (if available) included clonazepam, lorazepam(1 mg), baclofen (10 mg three times a day as needed), alprazolam(1.5 mg as needed), Flexeril (cyclobenzaprine) (20 mg daily as needed),Soma (carisoprodol), Flector (diclofenac patch), and Lidoderm (lidocaine)patches. Overall, these medications helped with associated pain andanxiety, but not the involuntary spasms.DiscussionHistorically, musicians, Morse code operators, writers, tailors,shoemakers, and hairdressers have been described to develop painfuldystonias related to their activity.2 Sports-related overuse conditionsinclude ‘‘golfer’s yips,’’ ‘‘pistol shooter’s cramps,’’ and petanqueplayer’s arm dystonia.2 Modern jobs require heavy schedules of rapidalternating movements (e.g. computer programmers, data entryworkers) or repetitive, sustained, coordinated movements.3 A numberof risk factors, including improper keyboard techniques, asymmetricalpostures with poor gravitational alignment, and forceful, rapid, repeti-tive movements can lead to overuse syndromes.3 This patienthad evidence of compressive neuropathies based on history andelectrodiagnostic testing, which supports his engagement in overusebehaviors. There is possibly no direct relationship between theseinjuries and the development of dystonia, but they are illustrative ofthe repetitive nature of his work.Despite being the most frequent type of focal dystonia,4 CD hasrarely been associated with specific tasks or repetitive use. Our casepresents the hallmark feature of prolonged asymmetrical postures(i.e. cradling the phone with right head and shoulder) described as riskfactors for overuse dystonia. Although initially dystonic spasmsoccurred only while performing the specific action or task, over timethey became present at rest as well, following a progression previouslyreported as typical of dystonia.5The pathophysiology of CD remains poorly understood6,7 andoveruse possibly represents an under-reported etiology.8 We foundonly three cases of CD associated with overuse in the literature (seeTable 1). All three were reported in male subjects. The first caseportrays a male forced to write and draw for many years using only hismouth (as a consequence of bilateral traumatic arm amputations at theage of 15), who in later life developed CD characterized by phasicinvoluntary head turning to the right side and severe neck pain.Botulinum toxin injections into the affected muscles led to mildimprovement.6Two more CD cases related to chronic overuse were embeddedin a series of 13 cases of dystonia affecting primarily the shoulders.9Both were male patients in their thirties. One used a sledgehammerprofessionally and the other engaged in heavy lifting. In both cases thetrapezius muscle was affected. Botulinum toxin injection improvedpain and shoulder elevation in one patient. Interestingly, we foundindications that occupational CD may be more widely diagnosed inJapan, where it seems to be common in production line and visualdisplay terminal workers developing symptoms of neck or shoulderstiffness.8 Many healthcare providers may not know how to recognizethis condition, suggesting it is under-reported.In conclusion, overuse CD should be suspected when typicalsymptoms and signs develop in the context of repetitive use oroveruse of cervical muscles, especially where exacerbating taskswere asymmetric. As this is a rare condition, there are no specificmanagement guidelines available beyond those relative to otheroveruse dystonias.Table 1. Cases Reporting Overuse Cervical DystoniaReference Age at Onsetand GenderTask/ProvokingFactorAffected Muscles Response to Botulinum ToxinWright and Ahlskog9 39 male Chronic overuseof sledgehammerTrapezius Substantial benefit to pain andshoulder elevationWright and Ahlskog9 35 male Chronic heavy lifting Trapezius Not administeredSchramm, et al.6 35 male Bilateral traumatic armamputation at the ageof 15. Writing anddrawing, using toolsheld in his mouth.Left sternocleidomastoidRight splenius capitis Leftsplenius capitis(antagonistic)Injections of botulinum toxin intoseveral cervical muscles up to adose of 300 units botulinum toxinled to only a mild improvement.Current case 37 male Repetitive typing,data entry, and cradlinga phone to the right earRight levator scapulaeRight trapeziusRight splenius capitisMultiple rounds of botulinum toxininjections failed to relieve neckspasmsHogg E, Tagliati M Overuse Cervical DystoniaTremor and Other Hyperkinetic Movementshttp://www.tremorjournal.orgThe Center for Digital Research and ScholarshipColumbia University Libraries/Information Services2References1. Hunter D. The diseases of occupations. London: Hodder & Stroughton;1978.2. Torres-Russotto D, Perlmutter JS. Task-specific dystonias: a review.Ann NY Acad Sci 2008;1142:179–199. doi: 10.1196/annals.1444.012.3. Byl N, Wilson F, Merzenich M, et al. Sensory dysfunction associated withrepetitive strain injuries of tendinitis and focal hand dystonia: a comparative study.J Orthop Sports Phys Ther 1996;23:234–244. doi: 10.2519/jospt.1996.23.4.234.4. Epidemiological Study of Dystonia in Europe Collaborative Group.A prevalence study of primary dystonia in eight European countries. J Neurol2000;247:787–92. doi: 10.1007/s004150070094.5. Marsden CD, Quinn NP. The dystonias. BMJ 1990;300:139–144.doi: 10.1136/bmj.300.6718.139.6. Schramm A, Naumann M, Reiners K, Classen J. Task-specific cranio-cervical dystonia. Mov Disord 2008;23:1041–1043. doi: 10.1002/mds.22006.7. Dauer WT, Burke RE, Greene P, Fahn S. Current concepts on the clinicalfeatures, aetiology and management of idiopathic cervical dystonia. Brain 1998;121(Pt 4):547–560. doi: 10.1093/brain/121.4.547.8. Tamagawa A, Uozumi T, Tsuji S. [Occupational dystonia associated withproduction line work and PC work]. Brain Nerve 2007;59:553–559.9. Wright RA, Ahlskog JE. Focal shoulder-elevation dystonia. Mov Disord2000;15:709–713. doi: 10.1002/1531-8257(200007)15:4,709::AID-MDS1017.3.0.CO;2-4.Overuse Cervical Dystonia Hogg E, Tagliati MTremor and Other Hyperkinetic Movementshttp://www.tremorjournal.orgThe Center for Digital Research and ScholarshipColumbia University Libraries/Information Services3

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