Prolotherapy and Botox – botulinum toxin – for Cervical dystonia and Spastic Torticollis

Cervical dystonia

Ross Hauser, MD

Cervical dystonia also called Spastic Torticollis is a painful spasm of the neck muscles that forces the head to rotate and tilt forward, backward or sideways. Cervical dystonia occurs in 1 out of every 10,000 people and is about one and a half times more common among women than among men. Although the condition can occur at any age, it develops most frequently between the ages of 30 and 60.

If you have questions about Cervical dystonia | Spastic Torticollis, you can get help and information from our Caring Medical Staff.

The cause of Cervical dystonia is, for the most part, unknown. However, in some cases, it is caused by conditions such as hyperthyroidism, nervous system infections, tardive dyskinesia (involuntary movements, see below)) or neck tumors. In our line of thinking cervical dystonia is part of the myriad of complex and confusing maladies that affect patients with undiagnosed or untreated cervical instability.

A better look at cervical instability symptoms

Tardive dyskinesia

  • The National Institutes of Health describe Tardive dyskinesia as primarily characterized by repetitive involuntary movements of the jaw, lips and tongue such as grimacing; sticking out the tongue; and smacking, puckering and pursing the lips.

Cervical dystonia/Spastic torticollis

  • Causes involuntary muscle spasms in the neck
  • Sharp, painful neck muscles spasm may start suddenly and occur intermittently or continuously. Usually only one side of the neck is affected. The direction in which the head tilts and rotates depends on which neck muscle is affected. Eventually, because the muscles continue to tighten, it becomes impossible to turn the head to the side.
  • One third of the individuals who suffer from this disorder also suffer from other spasms throughout their body including the eyelids, face, jaw or hand. The spasms occur without any warning and rarely while that afflicted individual is sleeping.
  • Like all chronic painful conditions, Cervical dystonia/Spastic torticollis has a cause, which in the target age group (30 – 60 years old) is typically ligament laxity.
  • Another rare cause is a form of arthritis called cervical spondylosis, which affects the neck.

Cervical dystonia and posture control

A new study from the University of Antwerp published in the journal Experimental brain research looked at the Cervical dystonia patient’s inability to have posture control. People with Cervical dystonia sway when they are standing and they sway when they are sitting. The sway is caused by impaired cervical sensorimotor control (sense of position and place). The researchers note that treatment for this sway should be focused on the cervical area and that further research towards the potential value of postural control exercises is recommended.(1)

The same research team, concurrently published data in the journal Brain and Behavior that cervical sensorimotor control can be trained through exercise and this might be a potential treatment option for therapy, adjuvant to botulinum toxin injections. (see below on Botox®). (2) Botulism toxin injected into the tight muscles, paralyzes and relaxes them and allows the head to straighten for a period of time. Although this may provide temporary pain relief, it does not get at the root of the problem – weak and damaged cervical ligaments, which are due either to an injury or another cause.

So what is happening in these studies and similar studies? Cervical instability, Cervical positioning, and posture.

  • The patients sway because they have cervical instability causing disorientation.
  • If the patient can fix his/her cervical instability, as determined by the research above in the form of exercise to strengthen the neck, they won’t sway.
  • In the second study the problem of joint error repositioning was discussed. The swaying and disorientation come from the patient’s inability to center (reposition after movement) his/her head properly on the neck.

Let’s go to the muscle spasms which are prevalent in Cervical dystonia. The body is trying to fix these problems on its own by spasms and using muscles, instead of ligaments, to provide temporary stability.

Comparing Botox® Injections to Prolotherapy Injections

Botox® Injections: Injection of the botulism toxin to prevent painful muscle spasms.

  • Injection of the botulism toxin is a temporary treatment, however it can provide pain relief for up to three months. Patients may be or are required to frequently return for more Botox injections.
  • Prolotherapy: Injection of simple dextrose into the soft tissue of the neck to help rebuild the cervical ligaments. Restored ligament strength help prevent pain muscle spasms.

Botox injections are not disease altering – they do not fix what is causing the muscle spasms

It is clear that the main attribute of Botox injections is the reduction of pain through the management of painful muscle spasm. This is symptom suppression. It should be noted that Botox injections are not disease altering, meaning they do not fix what is causing the muscle spasms.

In December 2017, researchers in Portugal published in the

Despite good results, these researchers wrote of the following concerns: 

  • “We have moderate certainty in the evidence that a single botulinum toxin type A treatment session is associated with a significant and clinically relevant reduction of cervical dystonia-specific impairment, including severity, disability, and pain, and that it is well tolerated, when compared with placebo.
  • There is also moderate certainty in the evidence that people treated with botulinum toxin type A are at an increased risk of developing adverse events, most notably dysphagia (swallowing difficulties) and diffuse weakness (widespread muscle weakness).
  • There are no data from randomized control trials evaluating the effectiveness and safety of repeated botulinum toxin type A injection cycles.
  • There is no evidence from randomized control trials to allow us to draw definitive conclusions on the optimal treatment intervals and doses, usefulness of guidance techniques for injection, the impact on quality of life, or the duration of treatment effect.”(3)

Botox effective for 12 weeks then benefits evaporate

University researchers in Belgium have released their finding in the September 8, 2018 edition of the Journal of Neurology, here is what they found as to the long-term effectiveness of Botox injections in the treatment of cervical dystonia.

  • 24 adult patients with idiopathic (it is not clear how the problem started) cervical dystonia were assessed three times over a treatment period of 12 weeks following a single treatment with botulinum toxin.
  • Disease symptoms significantly improved following botulinum toxin injections and deteriorated again at 12 weeks.
  • This improvement was not accompanied by
    • improved postural control,
    • cervical sensorimotor control and perception of visual verticality. (The involuntary movement continued).(4)

Why do cervical dystonia patients discontinue botulinum toxin therapy? The most common reason for discontinuing therapy is lack of benefit. Here is another study.

Publishing their findings in the medical journal Toxicon : official journal of the International Society on Toxinology, they wrote:

  • Numerous studies have established botulinum toxin to be safe and effective for the treatment of cervical dystonia. Despite its well-documented efficacy, there has been growing awareness that a significant proportion of cervical dystonia patients discontinue therapy. The reasons for discontinuation are only partly understood.

The research describes studies that provide strong evidence that botulinum toxin is both safe and effective in the treatment of cervical dystonia for many years.

  • But, overall, approximately one third of cervical dystonia patients discontinue botulinum toxin therapy.
  • The most common reason for discontinuing therapy is lack of benefit, often described as primary or secondary non-response.
  • The apparent lack of response is only rarely related to true immune-mediated resistance to botulinum toxin. Other reasons for discontinuing include side effects, inconvenience, cost, or other reasons.(5)

Here you have the evidence presented in this study that botulinum toxin does not repair the problems causing the symptoms.  Now we present the case for Prolotherapy.

The difference between Botox injections and Prolotherapy is that Prolotherapy addresses why the neck muscle spasms in the first place.

The difference between Botox injections and Prolotherapy is that Prolotherapy addresses why the neck muscle spasms in the first place. For most people, the reason for chronic neck muscle spasms is because the underlying ligaments are damaged/stretched/weakened, thus, they can no longer stabilize the neck. The brain then recruits the neck muscles to do it.

Conversely Botox injections simply treat the spasm and mask the real problem. It is expensive and temporary. If Botox is something you have been considering, think again and consider Prolotherapy for a permanent fix. Most patients require 3-6 visits spaced about one month apart.

In September 2017, doctors from the Dystonia Coalition Investigators, Emory University, Rush University Medical Center, Washington University School of Medicine, and from the National Institute of Neurological Disorders and Stroke, National Institutes of Health Bethesda, Maryland tried to answer the confounding question.

A patient with Cervical dystonia/Spastic torticollis

Here is a story of a typical patient. The patient struggled with spastic torticollis for several years prior to coming to our office. Because torticollis is a condition in which the head will twitch or turn uncontrollably and tilt to one side. Our patient needed to turn her body to the side in order to see straight ahead.

In addition to the social stigma, the patient experienced debilitating neck pain. Her attempts to relieve her pain with physical therapy, muscle relaxants, and Valium® proved unsuccessful. Spastic torticollis is not due to a Valium® deficiency.

Upon examination, the patient exhibited a positive “jump sign” when the cervical vertebral ligaments were palpated.

Prolotherapy and cervical realignment therapy

For this patient, a better approach is to strengthen the loose ligaments in the neck with Prolotherapy and, if a significant shortening of the neck muscles has already occurred, to supplement the Prolotherapy treatments with botulism toxin injections. Once a ligament is loose, as occurs in a neck injury, the overlying muscles must tighten to support the structure, and if the ligaments on only one side of the neck are loose, muscles on that side will spasm, resulting in spastic torticollis. When strengthened with Prolotherapy, the weakened ligaments of the neck will cause the muscle spasms to cease and allow the neck to regain its full range of motion.

In our patient story, the patient’s twitching neck made the treatment difficult, but with persistence it was successfully completed. After the second treatment, The patient reported that she could sleep facing to the left. After five treatments, the patient became pain-free, with the ability to turn their head in both directions.

Caring Cervical Realignment Therapy (CCRT) was developed by Ross Hauser, M.D. after decades of treating patients with neck disorders, including cervical instability and degenerative disc disease, to provide long-term solutions to symptoms such as headaches, neck pain, dizziness, vertigo, lightheadedness, imbalance and a host of other symptoms attributed to neck injuries. CCRT combines individualized protocols to objectively document spinal instability, strengthen weakened ligament tissue that connect vertebrae, and re-establish normal biomechanics and encourage restoration of lordosis. CCRT is the ideal program for patients who want lasting pain relief and symptom resolution in order to discontinue pain medication and other treatments that only focus on short-term relief, as well as those looking to avoid spinal surgery or who have already failed surgery. For more information on Caring Cervical Realignment Therapy (CCRT)

If you have questions about Cervical dystonia | Spastic Torticollis, you can get help and information from our Caring Medical Staff.

Prolotherapy Specialists Cervical dystonia

1 De Pauw J, Mercelis R, Hallemans A, Van Gils G, Truijen S, Cras P, De Hertogh W. Postural control and the relation with cervical sensorimotor control in patients with idiopathic adult-onset cervical dystonia. Experimental Brain Research. 2018 Jan 16:1-9. [Google Scholar]

2 De Pauw J, Mercelis R, Hallemans A, Michiels S, Truijen S, Cras P, De Hertogh W. Cervical sensorimotor control in idiopathic cervical dystonia: A cross‐sectional study. Brain and behavior. 2017 Sep 1;7(9). [Google Scholar]

3. Castelão M, Marques RE, Duarte GS, Rodrigues FB, Ferreira J, Sampaio C, Moore AP, Costa J. Botulinum toxin type A therapy for cervical dystonia. The Cochrane Library. 2017. [Google Scholar]

4 De Pauw J, Cras P, Truijen S, Mercelis R, Michiels S, Saeys W, Vereeck L, Hallemans A, De Hertogh W. The effect of a single botulinum toxin treatment on somatosensory processing in idiopathic isolated cervical dystonia: an observational study. Journal of Neurology. 2018:1-2.

5 Jinnah HA, Comella CL, Perlmutter J, Lungu C, Hallett M, Dystonia Coalition Investigators. Longitudinal studies of botulinum toxin in cervical dystonia: Why do patients discontinue therapy?. Toxicon. 2017 Sep 6.  [Google Scholar]

 

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