Acupuncture for cervical dystonia associated with anxiety and depression: A case report

Abstract

BACKGROUND

Cervical dystonia (CD) is a type of muscle tone disorder that usually occurs in the neck muscles. Due to the intermittent or continuous involuntary contraction of the neck muscles, the head and neck are twisted and skewed and some postural abnormalities occur. Long-term abnormal posture or pain can cause negative emotions in patients, which can affect their quality of life.

CASE SUMMARY

This case report included a 37-year-old woman who was diagnosed with CD associated with anxiety and depression; the accompanying symptoms were head and neck tilt of approximately 90° to the right and mental abnormality. After two courses of acupuncture treatment, the patient’s head and neck can be maintained in a normal position, and the negative emotions can be relieved.

CONCLUSION

This case indicates that acupuncture can effectively improve CD and the emotional state and quality of life of patients, making it an effective alternative treatment for the condition.

Key Words: Cervical dystonia, Anxiety and depression, Neurological disease, Acupuncture, Case report

Core Tip: Cervical dystonia (CD) is commonly accompanied by anxiety disorders, contributing substantially to the quality-of-life impairment of the patients. Currently, there is a lack of effective treatments without side effects. Thus, we propose the application of acupuncture as treatment, which could relieve muscle spasms and regulate balance and sedate the mind. Thus, acupuncture may be an effective and beneficial treatment option for CD with anxiety and depression.

INTRODUCTION

Cervical dystonia (CD) is a dystonic neurological disorder, mainly due to the abnormal head and neck posture caused by the involuntary contraction of the cervical musculature, particularly the sternocleidomastoid muscles[1]. The incidence of CD is low, with a prevalence of only 5.7/100000 in Europe, with women having a higher prevalence than men[2]. However, anxiety particularly affects the CD population and is observed in 30%–40% of all CD patients[3].

The mechanism of CD is uncertain, which can be polyfactorial and related to hereditary and central dysfunction[4,5]. Currently, international guidelines recommend botulin as the first line treatment choice for CD, but long-term maintenance treatment may be required, leading to drug resistance or a series of side effects[6]. However, acupuncture is also effective in the treatment of CD[7]. In the treatment of CD, acupuncture should be used as needed to help improve the clinical outcomes[8].

The present case report describes a CD patient with severe anxiety and depression whose symptoms were improved by acupuncture treatment. Her head and neck tilt angle decreased from 90° to 0° after two courses of treatment, with her mental symptoms having been further ameliorated.

CASE PRESENTATION

Chief complaints

A 37-year-old woman with an involuntary rightward deviation of the head and neck with tremor for 2 mo.

History of present illness

Two months ago, the patient exhibited an involuntary rightward movement of her neck, experiencing difficulty in returning it to a neutral position. Additionally, she displayed noticeable head tremors and presented evident signs of anxiety and depression, along with self-reported contemplation of suicide. She was administered with 2 mg of benzhexol hydrochloride once daily.

History of past illness

The patient denied any other medical history.

Personal and family history

The patient denied any family history of CD.

Physical examination

The patient’s head and neck turned to the right side, and the head could not reach its normal position even after correcting it with self-exertion and also had involuntary shaking (Figure 1A). The tone of the left sternocleidomastoid muscle was strengthened (Figure 2A). Limb muscle strength, tension, and coordination movement were normal. No apparent anomalies in depth or superficial sensation were observed. Furthermore, the patient showed a Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) score of 54, Hamilton Anxiety Rating Scale (HAMA) score of 29, and Hamilton Depression Rating Scale (HAMD) score of 41.

Figure 1 The condition of the patient's head and neck. A: The patient’s head and neck were involuntarily skewed to the right before acupuncture treatment; B: Head and neck are tilted to the right by an angle of approximately 30° after the first course of treatment; C: Head and neck maintained in the middle position after acupuncture treatment.

Figure 2 Electromyography activity. A: Electromyography activity of the sternocleidomastoid; B: Electromyography activity of the sternocleidomastoid muscle. Blue indicates the root mean square (RMS) for the left side, while red indicates the RMS for the right side.

Laboratory examinations

The patient’s laboratory tests were unremarkable.

Imaging examinations

A magnetic resonance imaging scan of the cervical region was conducted at a local hospital in July 2022 and revealed a C3/C4 and C4/C5 disk protrusion.

FINAL DIAGNOSIS

Based on the standard diagnostic criteria, the patient was diagnosed with CD, anxiety, and depression.

TREATMENT

The acupuncture points used in this case were as follows: GV14 (Dazhui), GV15 (Yamen), GV20 (Baihui), GV18 (Qiangjian), BL10 (Tianzhu), GB20 (Fengchi), GV8 (Jinsuo), and MS14 (lower-lateral line of the occiput) (Figure 3A). Cervical acupoints were added after one course of treatment, with acupuncture administered at the onset, endpoint, and midpoint of the bilateral sternocleidomastoid muscles (Figure 3B). The acupuncturist inserted sterile and disposable needles (0.35 mm × 40 mm) at the above-mentioned points. In a sitting position, GV14, GV15, and GB20 were straight needled at a depth of 25–30 mm; BL10, GV20, and GV18 were obliquely needled at a depth of 15–20 mm; MS14 was obliquely needled with an angle of approximately 30°, wherein the body of the needle lay flat after needling the galea aponeurotica, and the recommended needle frequency was 200 times/min; GV8 was needled at a depth of 10–15 mm with the needle tip toward the BL18 (Ganshu); and in the acupoints of the sternocleidomastoid muscle, heavy stimulation intensity was applied on the affected side and light stimulation intensity on the healthy side, and the acupoints were straight needled at a depth of 25–30 mm. Each treatment had a duration of 30 min and was performed thrice a week, ten times, as a period of treatment.

Figure 3 Acupoints selected for acupuncture treatment. A: Nomenclature and location of meridian points; B: Selection of points of the sternocleidomastoid muscle.

OUTCOME AND FOLLOW-UP

Following the initial acupuncture, the patient's shaking frequency decreased and she was able to sustain head alignment within 10 degrees for longer periods of time. Following the initial course of acupuncture therapy, the patient’s head and neck were inclined roughly 30° to the right (Figure 1B), the tremor disappeared, and her emotions became better. After the second course of acupuncture therapy, her head and neck can be kept in the regular posture (Figure 1C), with the exception of an occasional restriction in mobility and a stiff neck, and the tone of the left sternocleidomastoid muscle was improved (Figure 2B). Furthermore, the patient had a TWSTRS score of 0, HAMA score of 9, and HAMD score of 11. After 6 mo of follow-up, no recurrence of the symptoms was observed.

DISCUSSION

The etiology and pathogenesis of CD have not been determined, and its main manifestation is dystonia, which may be associated with the dysfunction of the basal ganglia and cerebellum[9]. Persistent head and neck abnormalities induce negative emotions, exacerbate the disease, and seriously affect patients’ quality of life. At presentation, the patient’s head and neck were deflected 90° to the right, and negative emotions were also noted. The TWSTRS, HAMA, and HAMD scores were abnormally increased, which confirmed the diagnosis of CD, anxiety, and depression.

At present, the clinical treatment of this disease is aimed at relieving symptoms and improving the patient's quality of life and involves the use of botulinum neurotoxin therapy, physiotherapy, drugs acting on the central nervous system, and surgical intervention therapy[1]. The intramuscular injection of botulinum neurotoxin exhibits significant curative effects, but its efficacy is only short-term; it also requires repeated injections to generate drug resistance[10]. Several studies have suggested that physiotherapy has an important role in the treatment of patients with dystonia[11]. However, oral drugs (anticholinergic agents, gamma-aminobutyric acid, dopamine, etc.) have an unstable curative effect and exhibit several adverse reactions[12]. Surgery carries a higher risk, which many find difficult to accept. The long-term physical deformity caused a serious psychological burden on the patient, which involves anxiety disorders, and seriously affected the patient’s living quality[3]. In the present study, the patient was already in a severe state of anxiety and depression. She showed a poor response to oral medications and was advised to receive botulinum toxin injection or surgical treatment but declined due to expense and worries about the risks of the surgery. Therefore, the patient was suggested to accept acupuncture.

Acupuncture is a widely used treatment method in China. On the basis of the theoretical underpinnings of acupuncture and the local anatomical features of the neck's muscles and nerves, we aimed to investigate the most effective acupuncture treatment approach for CD. The treatment approach used in this study unclogged the meridian, relieved the muscle spasms, adjusted balance, and sedated the mind. Considering that the patient had never been treated with acupuncture, fewer acupoints were selected during the first course of treatment. Therefore, the main purpose of the first course of acupuncture was to regulate the emotional state of the patient, which was supplemented to regulate muscle spasms. Additional acupoints were added after a satisfactory curative effect was obtained. The midpoint of the sternocleidomastoid muscle with abundant nerve distribution and the onset and endpoint of the sternocleidomastoid muscle were used as acupoints, which can relieve localised muscle spasms and promote nerve nutrition. Acupuncture was performed with heavy stimulation intensity on the injured side and light stimulation intensity on the wellness side. The strong stimulating intensity induced inhibitive and calming effects, thereby decreasing muscle tone and reducing muscle traction, while the light stimulating intensity tended to excite and stimulate muscle tone. Following the second course of acupuncture therapy, the CD was not only cured, but her mood improved dramatically.

The findings of the present case suggest that the efficacy and lack of adverse effects of acupuncture in the treatment of CD, with potential promise as a treatment of choice. Further clinical investigations should be undertaken in accordance with evidence-based medicine requirements to enhance the sample size and carry out prospective studies incorporating suitable control groups, aiming to validate the precise effects of acupuncture in managing this disease. Concurrently, it is imperative to conduct further research on the mechanisms and positive effects of acupuncture on CD.

CONCLUSION

In summary, clinically relevant anxiety and anxiety disorders are commonly associated with CD, substantially contributing to the quality-of-life impairment of the patients. In the present case, acupuncture was able to treat CD and relieve the patient’s emotional disorders, such as anxiety and depression. Thus, acupuncture may represent an alternative to botulinum neurotoxin therapy or surgical treatment for CD that patients should consider.

ACKNOWLEDGEMENTS

We are grateful for the patient's contribution to this case report. We would also like to acknowledge the Acupuncture and Rehabilitation Department’s Clinic of the First Affiliated Hospital of Anhui University of Chinese Medicine for their great support during the treatment process.