The mechanisms underlying dystonia after injury are unclear. Pain has been implicated as an important factor. We report four patients who exhibited segmental dystonia following removal of a cast, only two of whom experienced pain during casting. Recent work implicates the cerebral cortex as an important site of neural plasticity underlying the development of dystonia. Cortical changes may be induced by peripheral stimuli that are repetitive, spatially and temporally proximate, stereotyped, and attended. Immobilization by casting may meet these requirements if there is sufficiently persistent sensation of the immobilized limb to assure that it is regularly attended. The fact that all of our patients were immobilized but only two experienced pain during casting suggests that pain is not necessary and immobilization alone may be sufficient for the development of segmental dystonia after peripheral injury, consistent with the implications of animal studies.
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