Optimal physiotherapy management strategies for cervical dystonia: an international Delphi study

BACKGROUND: Isolated cervical dystonia is a rare, lifelong, focal, idiopathic dystonia causing uncontrollable spasms in the neck. In conjunction with medical management, physiotherapy can improve pain and quality of life, however there are no evidence-based guidelines indicating optimal physiotherapy goal setting, assessments and treatments. PURPOSE: To determine international consensus among physiotherapists who regularly treat people with cervical dystonia on optimal physiotherapy management. METHODS: A Delphi study was conducted between June 2024 and September 2025. Physiotherapists with more than 12 months experience working with people with cervical dystonia were invited to participate. The first survey asked participants to rate how essential common physiotherapy assessment and treatment techniques were for the management of people with cervical dystonia on a 5-point Likert scale (strongly agree to strongly disagree). Responses were analysed descriptively with a 70% threshold indicating agreement between participants. The second survey clarified if the agreed physiotherapy techniques were "essential" or "optional". RESULTS: Ten physiotherapists completed the first survey, and nine completed the second. Participants were mostly female (n = 6) and from Europe (n = 7). Essential assessments included head and neck position at rest, posture, tremor, movement, pain and impact on quality of life. Essential treatments included education, postural correction, active neck exercises, relaxation techniques, sensory retraining and other treatments relating to specific individual goals. CONCLUSION: This Delphi study achieved consensus on recommendations for physiotherapy assessment, goal setting and treatment of cervical dystonia which reflect expert opinion and can be used in the future in controlled trials to enable the development of clinical guidelines.