Anyone who has spent any time perusing the re+active dystonia content library knows how much we talk about the importance of “variability” in recovery. And for good reason - this is based not only on our experience working with patients over many years, but also on some of the best studies in dystonia rehabilitation - including by Dr. Nancy Byl at UCSF. We know from research in the field of neuroscience and human learning that a flexible, variable approach is the most effective way to learn any new skill - whether it’s a language, an instrument, or as in your case - helping the brain unlearn an established, maladaptive motor pattern, and strengthen your normal movement pattern. Understanding this concept and putting it into practice are two different things. Patients I work with have questions - of two main varieties: 

1. How do I know how much variability I need? What type of variability is needed? 
2. How do I actually incorporate this into my routine?

We’re going to cover these ideas in today’s post - because beyond it’s powerful efficacy - variability might just be the missing ingredient to make your dystonia training more fun and enjoyable, or at least less boring. If you or someone you know has dystonia - read on to learn how to spice up your dystonia recovery. 

How Much Variability Do I Need? 

As you continue on your dystonia recovery journey, you will - hopefully - be finding more and more specific exercises, categories of exercise, and sensory tools/strategies as part of your program. This means you have more options to choose from on any given training session, and you won’t be able to do all of them each session. You will have to create variability through choosing what to do. The reality of having a relatively rare and under-researched diagnosis is that there is often a lack of hard, empirical evidence to answer questions like these, so I want to be clear that we are operating in the zone of expert opinion - rather than hard data. Having said that, we can give sound recommendations based on experience - and you can know you’re on the right track if you regularly check in with yourself by asking two questions: 

• Have I been focusing only on one or a few of the same things? 
• Am I feeling stuck, or, are the old cues and sensory tools that used to improve my movement losing some of their effectiveness? 

If you can answer these questions - you will likely know whether or not you need more variability in your routine. Dystonia is “smart” - which means that using the same sensory cues over and over can cause the brain to “learn” these cues and adapt the dystonic pattern around them. Varying them day to day, or week to week, reduces the chance of that significantly. If you find yourself in this situation - don’t panic, just shake it up - and if you return to those previous cues and tools down the road - you will likely find they start to help you again. 

How Do I Put Variability Into Practice? 

The first step to effective variability in your dystonia training is to have the right group of exercises and sensory strategies to vary among. The dish is only as effective as the ingredients in them. Finding the tools that help your movement specifically is the first step. The goal of variability in your training is to liberate you - rather than overwhelm. If you have a long list of exercises, but they are all effective, it reduces the cognitive load and stress of choosing a variable routine - because you know whatever you choose, you can’t go wrong! Finally - don’t neglect fun. There needs to be components of your routine that are genuinely enjoyable. Whether it’s a goofy dance routine, fun competition with friends, or pickleball with family, making some time for fun and laughter can keep you from getting off track. There are two components to implementing variability: type, and method. 

Types of Variability: 

Whether you are a naturally organized person or not - and let’s be honest, there is a desire for organization that is prevalent among those with dystonia - listing and categorizing your dystonia exercises, tools, and variables is one of the most powerful things you can do to make recovery easier. It also ensures you are providing your brain and body with the best mix of ingredients to stimulate positive connections. Here are some types to consider: 

Sensory Variability: 

• Touch: for runner’s dystonia I often think about the surfaces you walk or run on - sand, grass, cobblestone pathways, concrete, carpet, etc, for a musician - it might mean changing the surface of the strings, keys, or mouthpiece to change input 
• Proprioception: such as weighting or vibration 
• Vestibular 
• Visual
• Smell 

Autonomic Nervous System Variability: 

• Breath 
• Heart Rate or Exercise Intensity 

Motor Variability: 

• Posture 
• External Cues 
• Pace 
• Starting and Stopping 

Other Variables: 

• Who you are with 
• What you wear 
• What time of day
• External pressures, environment 
• For a runner: are you running for a specific pace or goal? Can you change or remove the time or speed pressure? 

And Exercise Type Variability: 

• High, Moderate, or Low intensity - based on how it affects your symptoms or overall fatigue levels 
• Balance 
• Strength 
• Mobility 
• Motor Control: using external focus of attention, mirrored movement, video observation or VR, or just different movement types, playing a sport 

Method of Variability: 

There are many ways of doing this - and as always, find what works for you. Some patients like to schedule their variables - for example, an individual with runner’s dystonia might schedule weekday walks on grass in the park, with weekend walks on the track or harder surface. They might similarly schedule balance and strength exercises one day, sensory focused exercises on another. For someone with cervical dystonia - it might look similar in terms of using certain sensory tools on one day like a vibration massager, on other days using a weighted headband,  or a visual cue. My personal favorites are the Variability Jar or Random Generator App (Google Play Link , Apple Store Link) - because when your schedule is already busy - the last thing you need is more decisions - dystonia already causes fatigue, so let the Jar or the Phone pick for you. 

The variability jar consists of writing out your exercises - categorized by either type or intensity, or both - on to color-coded strips of paper and placing them into a jar. Then on a given day, you might have scheduled 3 high intensity exercises and 2 low intensity exercises for a 30 min routine - and you randomly select those from the jar and bada bing! - there you go. Similarly you might decide to pick 2 balance exercises and one sensory tool at random. The permutations are endless. For the less arts-and-crafts-inclined, you might opt for the app - which involves essentially the same structure, except you simply type the exercises out into the app rather than writing them. 

Regardless of which method you choose, creating variability in this way has been one of the most powerful drivers of the success of patients I have worked with. The brain thrives on challenge and novelty in all endeavors - but honestly, so do humans in general. Recovery is challenging, and can feel like a slog - but your training doesn’t have to be all bland. Variability, as they say, is the spice of life - so put your chef’s hat on and bring on the heat. 

Did you like this post? Do you want more content to help you get the most out of your dystonia recovery, and start making progress? Join our Dystonia Class! A weekly class for all types of dystonia with practical tips and strategies to understand your symptoms and take control of your recovery - linked below!!! 

• Become a Dystonia Class Member Here! 
• Also: sign up for our dystonia freebie: a free guide for people with dystonia
• Or if you’re ready to commit to treatment: apply for a program on our website
• and share this article with anyone you know with dystonia! 

Dr. Lincoln Beal, PT, DPT, NCS 

Physical Therapist 

Dystonia Program Director 

re+active Therapy and Wellness 

[email protected] 

References: 

1. Rosenkranz K, Butler K, Williamon A, Rothwell JC. Regaining Motor Control in Musician’s Dystonia by Restoring Sensorimotor Organization. Journal of Neuroscience. 2009;29(46):14627-14636. doi:https://doi.org/10.1523/jneurosci.2094-09.2009
2. Byl NN, Archer ES, McKenzie A. Focal hand dystonia: effectiveness of a home program of fitness and learning-based sensorimotor and memory training. J Hand Ther. 2009;22(2):183-198. doi:10.1016/j.jht.2008.12.003