Strength Training Rewires the Brain in Cervical Dystonia

Clients with cervical dystonia often turn to bodywork for relief from tight, overworked neck and shoulder muscles. A new trial from the University of Florida adds an important piece to the picture. It suggests that structured strength training does more than build muscle: it appears to change how the brain plans and prepares movement.

What is cervical dystonia?

Cervical dystonia is the most common form of dystonia that starts in adulthood. Neck muscles contract involuntarily, pulling the head into abnormal positions, sometimes with jerky or tremor-like movements. It can cause pain, disability and social stigma.

It’s increasingly understood as a brain network disorder, not a muscle problem. The smooth coordination between sensory input, movement planning and movement execution breaks down, so the wrong neck muscles fire at the wrong times.

The standard treatment is botulinum toxin (Botox) injections every three to four months. It helps many people, but the benefit can be partial or fade over time, and up to a third of patients eventually stop treatment.

What we already knew

Earlier research, including two large randomised trials from the UK and the Netherlands, showed that physical therapy can reduce symptoms and disability. Effective programs have combined stretching, relaxation, massage, postural training and strengthening of the muscles that counteract the dystonic pull. What nobody had shown was what these therapies actually do in the brain.

The study

• Who: 42 adults aged 30 to 85 with moderate cervical dystonia who weren’t getting enough benefit from Botox despite maximum tolerated doses. Most were women, with an average age in the mid-60s. After dropouts and exclusions, 37 people were analysed.
• Design: participants were randomly assigned to one of two groups. One group added a supervised resistance training program to their usual Botox care. The other continued usual care alone. Medication and injection schedules stayed the same in both groups.
• The program: six months of progressive strength training for the neck, shoulders and upper arms, twice a week, supervised by trained physical therapists at clinics near participants’ homes. The aim was to strengthen muscles that could counterbalance the overactive dystonic muscles.
• Measurements: brain scans (functional MRI) during a simple hand-grip task, plus symptom ratings scored from video by two neurologists who didn’t know which group each person was in.

What they found

Adherence was good

Everyone in the training group completed more than 80% of sessions. Six people reported mild to moderate neck pain during the first 12 weeks, but all of them tolerated the program as it progressed.

Symptoms improved modestly

On the main cervical dystonia severity scale, the training group improved by about 2 points on average, while the control group stayed roughly the same. This difference was statistically significant with a moderate effect size. A second, broader dystonia scale showed no clear difference between groups.

The improvement is smaller than the 10 to 12 point change considered clinically meaningful on the scale’s total score. However, the study measured the severity subscale, which has no established threshold. The training was also added on top of Botox, and the trial was designed to detect brain changes rather than clinical benefit.

The brain changed

• The cerebellum calmed down. Activity fell in parts of the cerebellum and brainstem. The cerebellum is known to be overactive in cervical dystonia, so this may reflect a dampening of that abnormal output.
• Networks reconnected. Communication increased between deep movement centres (the basal ganglia and cerebellum) and cortical areas involved in planning, preparing and sequencing movement.
• Some over-active pathways quietened. Connections between the thalamus and parts of the parietal and cingulate cortex decreased, which the authors suggest may reduce excessive sensory-motor drive.
• The cerebellum was the key hub. Changes in cerebellar connections were larger than basal ganglia changes, and they were more closely linked to symptom improvement. In particular, stronger links between the cerebellum and the prefrontal cortex and precuneus (a region involved in body awareness and spatial processing) tracked with greater clinical gains.

Notably, these brain changes appeared during a hand task, even though the training targeted the neck and shoulders. That suggests the training affected general movement-planning networks, not just the trained muscles.

Important limitations

• Small study. Only 37 people were analysed, mostly women and almost all white.
• No comparison exercise. The control group didn’t do any alternative activity, so the effects of attention, expectation and regular therapist contact can’t be separated from the training itself.
• No healthy comparison group. It’s unclear whether the brain changes represent a return towards normal or a new compensatory pattern.
• Associations, not proof. Only 3 of 132 brain–symptom correlations held up after correcting for multiple comparisons. The authors are clear that they can’t yet say the brain changes caused the improvement.
• Unanswered questions. The study didn’t test whether benefits last after training stops, whether exercise extends the effect of Botox, or how neck strength itself changed.

What this means for bodywork therapists

Your clients may benefit from strengthening, not just release work. This trial adds to evidence that active strengthening of the muscles opposing the dystonic pull is valuable. Bodywork aimed at easing overactive muscles can complement that, but it isn’t a substitute.

Think team, not solo. Cervical dystonia needs diagnosis and management by a neurologist or movement disorders specialist. The trial program was delivered by trained physical therapists. Encourage clients to ask their care team about a structured strengthening program, and work alongside it.

Coordinate around injections. Clients receiving Botox should check with their injecting clinician about when massage near injection sites is appropriate.

Expect a slow start. Some people in the trial had extra neck pain in the first three months of training. Supportive bodywork during this phase may help clients stay on track, and it’s worth reassuring them that early discomfort was tolerated by participants.

Use careful language. It’s fair to say exercise-based therapy was associated with changes in brain networks involved in planning movement. It’s not yet accurate to say it “cures” or “retrains” dystonia.

Remember the brain is involved. Because cervical dystonia is a network disorder, how a client senses, plans and prepares movement matters. Many people with the condition use a “sensory trick”, such as a light touch to the face or neck, that temporarily eases symptoms. Tactile and sensory input is part of the picture, which is one reason hands-on work may have a role in multidisciplinary care.

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Source study: Adury RZ, Arpin DJ, Remz M, Rawls A, Vaillancourt DE, Wagle Shukla AA (2026). Exercise training reshapes motor planning and preparation networks in cervical dystonia. Brain, accepted manuscript. doi:10.1093/brain/awag327. Trial registration NCT05663840.