What is the treatment of Spasmodic Torticollis ?

Spasmodic Torticollis, also known as Cervical Dystonia is an extremely painful neurological disorder that is characterized by the involuntary contraction of neck muscles resulting in abnormal movements and awkward posture for the head and neck. The neck muscles contract involuntarily twist and tilt in various directions. The movements are either sustained (tonic) or jerky (clonic). The involuntary movements cause considerable pain and discomfort to the patients. The spasms become worse when the patient stands or walks. This makes even simple tasks difficult. The causes of spasmodic torticollis are mostly idiopathic, however, there is some contribution from genetic factors. It may also occur by itself as a result of physical trauma. It generally affects people between the ages of 25 to 55, with women being more susceptible to the condition than men. A family history of cervical dystonia or any other form of dystonia also increases susceptibility to the condition.

Diagnosis of spasmodic torticollis is generally done based on patient information, physical and neurological examinations. There are no tests to confirm the diagnosis of the condition as most tests are normal. As a result, the misdiagnosis rate is large. The condition is often misdiagnosed as arthritis, stiff neck or wryneck. Spasmodic Torticollis has no specified, permanent cure. However, there are varieties of treatments that have been tried alone, or in combination with other drugs and procedures that have shown some promising results and as a possible permanent solution to spasmodic torticollis. Though in most cases, these treatments are just used to manage the symptoms in order to provide some alleviation of discomfort to the patients. It is also important to note that in most cases of dystonia the symptoms go away with time. 

How is the treatment done?

In patients suffering from spasmodic torticollis, the brain sends faulty signals to the neck muscles causing the random contractions that are characteristic of that disease. The treatment procedure is as follows: 

1. At the start of the treatment procedure, the affected muscles are identified by asking the patients to identify the area of the neck that is the source of pain or discomfort that is generally a hyperactive muscle. The patients are then asked to relax the neck muscle and not employ any ‘geste antagoniste’. In the relaxed state, the head position, neck posture and tremors are noted, the neck muscles are then palpated for the detection of any tenderness in the muscles or hyperactivity. 

2. The muscles that are to be injected are based on the location of the hyperactive muscles and the type of jerky movements visible as a result of torticollis. For example, the muscles to be injected in case of rotary movements (the head involuntarily rotates itself about the neck) are different from the muscles to be injected in case of lateral (side-to-side) movements of the neck. 

3. Botox is usually injected with a 1-inch, 25 ml needle. The potency of the injection is decided based on the severity of the spasms, level of adipose tissue deposits on the injection site, age and body mass of the patients. The injection of the botulinum toxin into the neck muscles paralyzes the dystonic muscles by preventing the release of acetylcholine from the presynaptic axon of the motor end plate. 

4. The use of botulinum toxin is often combined with oral medications that act as dopamine blockers, or anticholinergic agents. Extensive physical therapy is often required to decrease the frequency of spasms and alleviate pain and discomfort. 

5. Ticks like touching the opposite side of the patient face or the back of the head, may help in reducing the spasms or even can stop it temporarily. Thus, different sensory tricks can be used and can work for different people, but this way of treatment often loses effectiveness as the disease progresses.

Who is eligible for the treatment? (When is the treatment done?)

At the first onset of symptoms, all patients are eligible for the botulinum toxin treatment, unless they have any allergies that may disqualify them from treatment. In most cases, Botulinum Toxin Type A is used for treatment, however, in some cases, patients develop immunological resistance to type A botulinum toxin after prolonged usage of said drug and are forced to switch to type B botulinum toxin. On an average, 4% to 17% of all patients using the type A toxin develop antibodies against it, thus preventing its use.

Who is not eligible for the treatment?

Botulinum toxin must not be used in case of pregnant or lactating women. Patients who have shown to have allergic reactions against botulinum toxin or against other secondary ingredients used in the drug should not be treated using botulinum toxin.

Are there any side-effects?

Some of the side effects of the treatment are as follows: 

1. The Botox injections, when administered at the affected site, may result in some redness, swelling, pain or allergic reactions at the injection site. 

2. Other possible side effects of botulinum toxin include difficulty swallowing, upper respiratory infection, neck pain, headache, increased cough, flu-like symptoms, back pain, inflammation of the nasal passages, dizziness, increased muscle tone or stiffness, soreness at injection site, general weakness/fatigue or lack of energy, oral dryness, speech disorder, fever, nausea, and drowsiness. 

3. It is of vital importance to note that some side effects of botox are fatal in nature. If the patient suffers from any of the following side effects, then medical help must be immediately called. 

4. Problems swallowing, speaking, or breathing, due to the weakening of associated muscles, can be severe and result in loss of life. The effect of botulinum toxin may affect areas away from the injection site and cause serious symptoms including: loss of strength and all-over muscle weakness, double vision, blurred vision and drooping eyelids, hoarseness or change or loss of voice (dysphonia), trouble saying words clearly (dysarthria), loss of bladder control, trouble breathing, trouble swallowing. The problem, however, with the injection of botulinum toxin is that in spite of the fact that it is the most commonly used treatment for cervical dystonia, it is not always successful among patients suffering from the disease. In spite of the large amount of research that has gone into this procedure, the reasons behind its failure as a treatment option are largely idiopathic. Added to that, the fact a significant amount of the patients undergoing the treatment slowly develops immune-resistance to the drug, hindering its ability to work. 

Apart from the above, in case any patient reports any other complexity after undergoing the treatment the patient is advised to consult the doctor immediately. 

What are the post-treatment guidelines?

Treatment by botulinum toxin must be combined with oral medications such as anticholinergic agents to decrease neurotransmitter imbalance and lengthen the relief period afforded by the Botox injections. Extensive physical therapy is also required to decrease the frequency of spasms and reduce pain and discomfort of the spasms. Physical therapy includes muscle stretching and relaxation, balance and coordination training, and exercises for muscle strengthening and endurance.

How long does it take to recover?

The treatment recovery time varies from the patient condition to condition and differs from the mode of the treatment opted for the patient. Exact recovery time is unknown as it depends on a variety of neurological, physiological, pharmacological and idiopathic factors. Acute dystonia often goes away within about 36 to 48 hours while complete recovery takes about a week. Effects of Botox are generally visible for about 12 to 16 weeks after which symptoms may reappear. However, sometimes relapse occurs in about half that time while at other times the patients may be in remission for up to 6 months.

Are the results of the treatment permanent?

The results of the treatment are not permanent. Patients may require re-administration of the drug every 3 to 4 months. However, cervical dystonia is not a condition that presents itself throughout a patient’s lifetime. Although it is not common, the symptoms sometimes go away after a few years. 

What are the alternatives to the treatment?

Some of the alternatives to the treatment are as follows: 

1. In case of patients who develop immunoresistance to the botulinum toxin, surgical intervention becomes necessary. Deep Brain Stimulation to the basal ganglia and thalamus has been successfully used to reduce spasms. Patients are subjected to stimulation of the globus pallidus internus, or the subthalamic nucleus which results in the inhibition of hyperactive cortical activity. 

2. Selective denervation surgery is another option for patients of spasmodic torticollis where nerves carrying the faulty signal to the affected muscles are surgically severed. 

3. Heat packs and massage can help relaxation of the neck and shoulder muscles and thus can be used as an alternative. An exercise which helps in improving the neck strength and flexibility may also be helpful.