How Do You Treat Dystonic Movements in the Upper Extremity in Your Practice?

Hermann Oppenheim, md, (1858–1919 ad) first coined the term dystonia in 1911 to describe a neurologic disorder that manifests as sustained muscle contractions that cause twisting and repetitive movements or abnormal postures.¹ In adults, dystonia usually remains confined to a specific part of the body (focal form), such as the neck, hands, face, or eyelids. If dystonia starts in childhood, the disease usually spreads to other parts of the body (generalized form).² As many as 250,000 people in the United States have dystonia, and it is the third most-common movement disorder after essential tremor and Parkinson's disease.³

In the majority of cases, the cause is not known and is called primary or idiopathic dystonia. Some cases involve inheriting the condition through one or more affected genes. In other cases, dystonia can be secondary to illnesses or injuries, such as stroke, brain injury, encephalitis, or Parkinson's disease. Dystonia can also be drug-related or due to heavy metal poisoning. The usual presentations include:

• • Cervical dystonia (torticollis), wherein the neck is pulled in one particular direction

• • Blepharospasm

• • DOPA [3,4-dihydroxyphenylalanine]–responsive dystonia, which often starts in childhood and presents as an abnormal, stiff way of walking with a bent or turned foot; this kind of dystonia can also affect the arms and torso

• • Oromandibular dystonia

• • Writer's cramp

• • Laryngeal dystonia

• • Generalized dystonia, which often starts at puberty, involving one limb, and spreads to various other parts of the body.

The pathophysiology is incompletely understood. Dystonia is probably a secondary disorder in which a genetically predisposed brain is acted upon by environmental factors.⁴ The condition is generally believed to be a disorder related to the basal ganglia, but there is emerging evidence that the cerebellum has a role as well.⁵

Diagnosis is based on history; clinical examination; blood and urine tests to detect toxins and other conditions; magnetic resonance imaging/computed tomography to identify abnormalities in the brain; and electromyography (EMG).

Modern biomedical treatment involves injecting botulinum toxin into the involved muscles to eliminate contractions. This would to be repeated every 3–4 months. Other options include a carbidopa–levodopa combination, triphexyphenidyl, benztrophine, tetrabenazine, diazepam, clonazepam, and baclofen.

Dystonia in Chinese Medicine

Diagnosis

In Chinese Medicine, spasticity and tremor are considered together as Zhi Zhong. Zhi refers to contraction or bending of the limbs; Zhong refers to relaxation or stretching. The pathology is Liver Wind. If any movement that is normally under voluntary control occurs involuntarily, that is a Wind condition, and the source of Internal Wind is Liver. Liver Wind may be due to Liver Yang rising or Liver Fire, which are Excess conditions; or Liver Wind could be due to Liver Yin or Liver Blood Deficiency, which are Deficiency patterns. In Excess patterns, the symptoms are more pronounced and there can be added vertigo. In Deficiency patterns, the symptoms are usually milder. The Wind may combine with Phlegm; and, in that case, there will usually be numbness and heaviness of the limbs. The details of Liver disharmonies are given in Table 1.

Table 1.

Liver Wind Patterns

Patterns	Clinical picture	Points	Herbs
1. Liver Yang rising from Liver Yin Deficiency	Tremor, dizziness, tinnitus, headache, hypertension, blurred vision, dry eyes, tongue without coating, wiry pulse	LR 3↓, LB 20↓, TE 5↓, GV 20↓, LR 8↑, KI 3↑, SP 6↑	Three Carapaces Restoring The Pulse Decoction
2. Liver Yang rising from Kidney Yin Deficiency	Same as above, plus backache, scanty urination, poor memory, deficient hearing	Same as above plus CV 4↑, KI 6↑	Pacifying the Liver and Subduing Wind Decoction
3. Liver Yang rising from Liver Blood Deficiency	Same as above (1) with pale tongue	Same as in (1) plus BL 17↑ (Back Shu point for Blood), LI 4↑	Gelatinum corii asini–Egg Yolk Decoction
4. Liver Fire generating Wind	Tremor, outbursts of anger, tinnitus, headache, red face, thirst, bitter taste, dream-disturbed sleep, dry stools, dark yellow urine, epistaxis, red tongue with redder sides, yellow tongue coating, rapid wiry pulse	LR 3, LR 2, GB 20, LI 11, GB 1, SP 6, LR 1, GV 8—all ↓	Cornu antelopis–Uncaria Decoction plus radix Gentianae scabrae
5. Phlegm Heat causing Wind	Obesity, disinclination to exercise, oppression in chest, tremor, yellow phlegm, red tongue with sticky yellow coating, wiry rapid pulse	ST 40, SP 6, SP 9, LR 3↓↑, CV 12↑, BL 20↑	Conducting Phlegm Decoction plus Gastrodia–Uncaria Decoction

↓ Reduced; ↑ Reinforced; ↓↑ Even Method.

Treatment

In general, for symptomatic relief in upper-extremity dystonias, I would reduce LI 11 (Homeostatic point), TE 5, LI 4 (local points), GB 34 (Influential point of the muscles), HT 7, and GV 20 (Tranquilizing points). Scalp acupuncture, using the Chorea line and Apraxia area can be effective. I would treat the underlying Liver syndromes as described in Table 1. Any other seemingly unrelated Disharmony in the patient has to be looked for and treated, as its continued presence can interfere with recovery.

Auricular points

The auricular points to use are the Muscle relaxation point, Thalamus point, Point Zero, Ear Shen Men, and corresponding body area points.

Illustrative Case

A 63-year-old female presented with a history of progressive pain and clumsiness of her right hand, and, to a much lesser degree, of her left hand, for more than 4 years. Of late, writing had become increasingly difficult for her, due to spasms and pain. Writing for more than 45–60 sixty minutes induced disabling symptoms. In addition, she had recently been dropping utensils. Finding a suitable position of the arm in bed had become increasingly difficult for her. She also suffered from classical migraine after the birth of her first child; this became less severe after she reached menopause. A diagnosis of writer's cramp was made based on this patient's clinical picture. EMG was not performed.

Acupuncture treatment involved the use of BL 62 (right), SI 3 (left), in that order, by the reduction method to open the Yang Heel vessel, which helped to reduce cramps. (In men, the sides would be reversed.) LI 4, LI 10, Baxie, PC 8, GB 34, and the Apraxia area on the scalp were all reduced bilaterally. Her migraine was attributed to Liver Yang rising due to Liver Yin Deficiency (a tongue without a coating and dry eyes), and was treated by reinforcing KI 3, LR 8, and SP 6 to nourish her Liver. To prevent occasional headaches due to Liver Yang rising, GB 20, LI 4, and TE 5 were reduced bilaterally. Acupuncture was applied twice per week for 2 months and once per month thereafter for 1 year for maintenance.

Nutritional support for her muscle and nervous tissues was given, including Magnesium Phosphate twice daily, and Calcium Phosphate and Natrum Phosphate once per day in homeopathic dilutions of 30c. Milk Thistle (Silybum marianum) Extract (1 tablet; equivalent to 7 g of the whole fruit) was given to her twice per day to nourish her Liver.

This patient has progressed to a level at which she can now write for 1 hour continuously without symptoms, she does not drop utensils from her hand, and cramps do not bother her during sleep. Prolonged use of her hand still triggers symptoms but to a lesser degree than before. She continues to take the supplements and receives acupuncture once every 3 months.

Comment

The current author is not aware of any study on acupuncture used to treat upper-limb dystonia; however a case report showed similar results to the illustrated case.⁶