Effectiveness of acupuncture in cervical dystonia
Ravindran Deepak, Hans Mathew and Mathew KoshyAcupunct Med 2010 28: 94-96doi: 10.1136/aim.2009.002048
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Effectiveness of acupuncture in cervical
is to administer four weekly sessions of Western medical acupuncture followed
by top-ups (consisting of single ses-sions) if the initial course proves to be beneﬁ cial.
Ravindran Deepak,1 Hans Mathew,2 Mathew Koshy2
her were a combination of classical Chinese points along with segmental
thalassaemia minor and hypertension. points. The acupuncture points we used
This case describes the successful addition of
Her drug treatment included aspirin, were GV14, GB20, GB21, SI9, SI10, SI11,
acupuncture to treat a patient with cervi-
clopidogrel, atenolol, baclofen, losartan, SI12 and LI4 (ﬁ gure 3). Needle depth was
cal dystonia previously managed with Botox
bendroﬂ umethiazide, simvastatin, esome-
varied and periosteal ‘pecking’and man-
(botulinum toxin) injections. This resulted in
reduced pain and muscle spasm relief and to
ble. De qi was not sought after insertion
the authors’ knowledge is the fi rst case to be
reported using this treatment combination. The
On examination she sat with her head 15–20 min.
patient was diagnosed with the idiopathic var-
turned to the left and her neck in forward
iant of cervical dystonia and had been treated
and lateral ﬂ exion. All movements of her Outcome
with regular Botox injections for almost a year
neck were restricted. Turning her head to She obtained more than 50% pain relief
and half. She was then referred for a course
the right, lateral rotation to the right and from the initial course of acupuncture
of acupuncture to manage pain and reduce
lateral ﬂ exion were almost impossible. The
excessive muscle tone. She had excellent ben-
superior and middle ﬁ bres of her left tra-
efi t from the acupuncture and she continued to
pezius were very ﬁ rm, tight and tender on
ing with Botox injections. She requested
get top-ups of acupuncture every 8–10 weeks.
palpation. She also had diffuse tenderness a repeat course of acupuncture (four ses-
Requirement for Botox injections had decreased
on the left side of her neck and over the left
sions) in February 2007 with similar pain
thus reducing its long-term side effects.
supra scapular and infra scapular area (ﬁ g-
movements. She continues to receive top-ups every 8–10 weeks and has received
CASE REPORT Treatment
This case report details the successful use
of acupuncture in conjunction with Botox
ture clinic, dictated by time constraints, ously. She continues to have improved
injections for the management of cervical dystonia.
clinic with an 8-year history of torticol-lis, mainly affecting her left side, forcing her to adopt an awkward posture. This reduced neck mobility was sufﬁ cient to stop her driving. Figure 1 shows the patient’s usual posture before acupunc-ture treatment. She complained of pain in her left lower cervical area. Movements were reduced and painful particularly when she attempted right lateral ﬂ ex-ion and rotation. This had been steadily worsening over the past few years and by 2005 she was not able to lift her head most of the time. There was no signiﬁ cant aetiology to explain the onset of symp-toms and after conﬁ rming diagnosis of an idiopathic variant of cervical dystonia, she was referred to the neuro-rehabilita-tion doctor in 2005 for a course of Botox (500 units type A toxin —Dysport) injec-tions into her left trapezius, sternocleido-mastoid and splenius capitis muscles. This initially gave her excellent beneﬁ t. After two further repeat injections she was referred in February 2006 for a course of acupuncture to manage pain and reduce excessive muscle tone.
mic heart disease, reﬂ ux oesophagitis,
Figure 1 Before acupuncture treatment —simulated views. Acupunct Med June 2010 Vol 28 No 2
form of torticollis, starts insidiously and worsens over time and is associated with signiﬁ cant physical and psychological dis-ability. Head tremors and neck spasms are characteristic clinical signs in patients with torticollis.2 This excessive muscle tone and ensuing neck contractions result in signif-icant pain, and treatment is aimed at pro-viding pain relief and muscle relaxation.
ticollis is poorly understood and is thought to be due to an abnormal central motor processing; possibly in the thalamus. The condition is twice as common in women as in men. It can occur at any time in life
Figure 3 Acupuncture points used. Figure 2 Painful areas shaded red.
but most patients report symptoms in middle age or later. A familial history of dystonia is found in 12% of cases.3 Most patients develop a sensory trick or ‘geste antagoniste’ to control or eliminate their symptoms and this has been reported as a unique feature of dystonia.4
drugs, complementary therapies (acupunc-ture, biofeedback, massage), injections and patient education, all with varying success. Drug treatment, usually skeletal muscle relaxants and analgesics, has been the mainstay in relieving symptoms but their efﬁ cacy is limited with a low rate of success reported in clinical trials.5
been considered as one of the treatment options. Injecting overactive muscles with minute quantities of botulinum toxin type-A (Botox) results in decreased muscle activity by blocking the presynap-tic release of acetylcholine from the neu-ron. This will render the muscle unable to contract for a period of up to 3–4 months, thus providing improved mobility and symptomatic pain relief. However, injec-tions have to be repeated and they may not always be successful in achieving the desired effect.
60–90% improvement following injec-tion but beneﬁ ts last only for about 10–12 weeks, requiring further repeat injec-tions.6 Furthermore, repeat injections are associated with the risk of developing neutralising antibodies7 and the toxin is associated with adverse side effects such as dysphagia, dysphonia and xerostomia
Figure 4 After acupuncture treatment.
that may last from weeks to months.8 Reported adverse events from cosmetic
torticollis. Spasmodic torticollis or cervical
use includes headaches, focal facial paral-
dystonia is the most common of all focal ysis, muscle weakness, dysphagia, ﬂ u-like
dystonias affecting the neck muscles, mak-
patient, however, did not develop any of
As far as we are aware, this is the ﬁ rst case
tures. According to the National Spasmodic
report showing a signiﬁ cant beneﬁ t using
Torticollis Association,1 torticollis affects this may be partly owing to the reduced
acupuncture in conjunction with Botox 90 000 people in the USA. Idiopathic frequency of Botox injections after start-
injections for the management of cervical
spasmodic torticollis, the most common ing acupuncture. Acupunct Med June 2010 Vol 28 No 2
patients with chronic neck pain. A recent
better side-effect proﬁ le and is better tol-
pilot study14 has been published outlining
1. National Spasmodic Torticollis Association. http://
erated. An audit highlighted the efﬁ cacy
the number of patients needed to perform
www.torticollis.org (Accessed 15 December 2009).
of acupuncture in providing pain relief a large-scale randomised trial looking into
2. Jankovic J, Leder S, Warner D, et al. Cervical dystonia:
clinical fi ndings and associated movement disorders.
lasting for more than a year in 40% of acupuncture and its effectiveness in treat-
patients with chronic neck pain.10 Our ing chronic neck pain. It is to be noted that
3. Chan J, Brin MF, Fahn S. Idiopathic cervical dystonia:
patient responded well to acupuncture all the above studies have studied cervi-
clinical characteristics. Mov Disord 1991;6:119–26.
and obtained pain relief and functional cogenic neck pain and primary musculo-
4. Müller J, Wissel J, Masuhr F, et al. Clinical
neck mobility, which has been sustained skeletal problems mainly due to trauma.
characteristics of the geste antagoniste in cervical dystonia. J Neurol 2001;248:478–82.
for the past 18 months. Both the severity There is, however, very limited evidence 5. Adler CH, Kumar R. Pharmacological and surgical of her episodes and the general pain level
in English publications about the use of
options for the treatment of cervical dystonia.
decreased markedly since her acupuncture
acupuncture alone or in combination with
Neurology 2000;55(12 Suppl 5):S9–14.
treatment began. The patient claimed that
routine medical care in the management 6. Balash Y, Giladi N. Effi cacy of pharmacological treatment
of dystonia: evidence-based review including
acupuncture had signiﬁ cantly contributed
meta-analysis of the effect of botulinum toxin and other
cure options. Eur J Neurol 2004;11:361–70.
spasms. This has also reduced her need SUMMARY
7. Comella CL, Jankovic J, Brin MF. Use of botulinum
for more frequent Botox injections, thus In these times of multidisciplinary approach
toxin type A in the treatment of cervical dystonia.
reducing the adverse effects due to the to chronic pain management, we propose
Neurology 2000;55(12 Suppl 5):S15–21.
8. Lew MF. Drug Management in Cervical Dystonia. US
that acupuncture should be offered in con-
Neurological Disease: Touch Briefi ngs, 2007; 27–9.
Another major study from Germany junction with routine medical care at a 9. Coté TR, Mohan AK, Polder JA, et al. Botulinum toxin
looked into the effectiveness of acupunc-
type A injections: adverse events reported to the US
ture alongside routine medical care in the
cervical dystonia to improve outcome and,
Food and Drug Administration in therapeutic and cosmetic cases. J Am Acad Dermatol 2005;53:407–15.
potentially, provide longlasting beneﬁ t.
10. Blossfeldt P. Acupuncture for chronic neck pain – a
validated scale was used to assess neck 1 John Radcliffe Hospital, Oxford, UK
cohort study in an NHS pain clinic. Acupunct Med
pain and disability. They reported a sig-
2 Buckinghamshire Hospitals NHS Trust, Buckinghamshire, UK
11. Witt CM, Jena S, Brinkhaus B, et al. Acupuncture for
Correspondence to Dr Hans Mathew, Department
patients with chronic neck pain. Pain 2006;125:98–106.
of Anaesthesia, Wycombe General Hospital, High
12. Wheeler AH, Goolkasian P, Baird AC, et al.
and this beneﬁ t was sustained for up to Wycombe, Buckinghamshire HP11 2TT, UK; Hans.
Development of the Neck Pain and Disability Scale.
Item analysis, face, and criterion-related validity. Spine
has also been proved to be cost effective Competing interests None.
when combined with routine treatments Patient consent Obtained.
13. Willich SN, Reinhold T, Selim D, et al.
for neck pain.13 Willich et al13 argue that
Cost-effectiveness of acupuncture treatment in patients
Provenance and peer review Not commissioned;
with chronic neck pain. Pain 2006;125:107–13.
in comparison with international cost-ef-
14. Salter GC, Roman M, Bland MJ, et al. Acupuncture for
fectiveness threshold values, acupuncture Acupunct Med 2010;28:94–96.
chronic neck pain: a pilot for a randomised controlled
is a cost-effective treatment strategy in doi:10.1136/aim.2009.002048
trial. BMC Musculoskelet Disord 2006;7:99. Acupunct Med June 2010 Vol 28 No 2
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