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About 15 percent of patients with torticollis also have oral, mandibular, or hand dystonia, 10 percent have blepharospasm, and a similarly small number have a family history of dystonia or tremor (Chan et al) No neuropathologic changes were found in the single case studies reported by Tarlov and by Zweig and colleagues Spasmodic torticollis is resistant to treatment with L-dopa and other antiparkinsonian agents, although occasionally they give slight relief In a few of our patients (four or ve of several dozens), the condition disappeared without therapy, an occurrence observed in 10 to 20 percent in the series of Dauer et al In their experience, remissions usually occurred during the rst few years after onset in patients whose disease began relatively early in life; however, nearly all these patients relapsed within 5 years.

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Treatment The periodic (every 3 to 4 months) injection of small amounts of botulinum toxin directly into several sites in the affected muscles is by far the most effective form of treatment The injections are best guided by palpation of muscles in spasm and by EMG analysis to determine which tonically contracted muscles are most responsible for the aberrant postures All but 10 percent of patients with torticollis have had some degree of relief from symptoms with this treatment Adverse effects (excessive weakness of injected muscles, local pain and dysphagia the latter from a systemic effect of the toxin) are usually mild and transitory Five to 10 percent of patients eventually become resistant to repeated injections because of the development of neutralizing antibodies to the toxin (see Brin; also Dauer et al).

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spastic diplegia and athetosis The following list includes the bestknown entities: 1 Hereditary spastic paraplegia with spinocerebellar and ocular symptoms (Ferguson-Critchley syndrome) This syndrome is characterized by a disorder of gaze, optic atrophy, cerebellar ataxia, and spastic paraparesis Most impressive are the manifestations of spinocerebellar ataxia beginning during the fourth and fth decades of life, accompanied by weakness of the legs, alterations of mood, pathologic crying and laughing, dysarthria and diplopia, dysesthesias of limbs, and poor bladder control The tendon re exes are lively, with bilateral Babinski signs Sensation is diminished distally in the limbs The whole picture resembles multiple sclerosis In other cases, running through several generations of a family, the extrapyramidal features were more striking; such cases overlap with the following syndromes Hereditary spastic paraplegia with extrapyramidal signs.

Variety in Teaching Variety in teaching is considerable. There are different age groups, different subjects, and different types of students. All three distinctions are in uential in shaping the nature of teaching. Table 2.1 lists the most common categories of teachers, the types of schools in which they teach, and the kinds of teaching licenses that they must hold. Clear differentiations in teaching are made among kindergarten, elementary school, middle and junior high school, high school, and specialarea teachers (teachers who work in elds other than the core subjects). Usually, though, state departments of education promulgate program and

In the most severe cases and those refractory to treatment with botulinum toxin, a combined sectioning of the spinal accessory nerve (of the more affected sternomastoid) and of the rst three cervical motor roots bilaterally has been successful in reducing spasm of the muscles without totally paralyzing them Considerable relief has been achieved for as long as 6 years in one-third to one-half of cases treated in this way (Krauss et al, Ford et al) Bilateral thalamotomy has also been tried, but since it is less effective and carries a considerable risk, particularly to speech and swallowing, it should be reserved for the most severely affected patients with more widespread dystonia These surgical procedures are rarely necessary now that botulinum toxin treatment has been re ned..

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