Volume 1, Number 4 | Winter 2006

Clinical Report 1 (Japan)
Acupuncture for Cervical Dystonia

Makiko Tani1), Aya Takada1), Hironori Inoue1),
Toshiaki Suzuki1), Ikuro Wakayama1), Sohei Yoshida1)
and Toshihiko Kinoshita2)
1)Research Center of Neurological Diseases
Kansai University of Health Sciences2)Department of Neuropsychiatry
Kansai Medical University

promising methods in patients with cervicaldystonia.
Key words: cervical dystonia, acupuncture,electromyography, primary and secondary
disorder, needle retention method, multiple
epidermis-penetrating needle stimulation
I. IntroductionDystonia is a diverse set of movement

Abstract
We introduce our new concept for acupuncture
therapy in patients with cervical dystonia. To
achieve satisfactory therapeutic effects, we
divided the affected muscles into two groups
using clinical evaluations and EMG findings on
motion analysis, i.e., muscles affected by aprimary disorder and those by a secondary
disorder. Abnormal hypertonus or hypotonus of
the muscles and unsustained head movement aredesignated as the primary disorder. Muscle andskin shortening were designated as the secondary
disorder. We used the needle retaining method forprimary
disorders
andmultiple
epidermis-penetrating needle stimulation on
tender spots for secondary disorders. Thus, weapplied these different and specific acupuncture
treatments to each group once a week. After 10
sessions of acupuncture treatment, clinicalexamination showed improvement in 72.9% of thepatients, EMG evaluations showed improvement
in all patients, and with no side effects in anypatients. The characteristics of patients who did
not respond to our acupuncture treatment wereas follows: 1) longer duration of disease, 2) neckposture demonstrating retrocollis, 3) severe
unsustained head movement, 4) longer intervalsof treatment of more than a week, and 5) treatedby several different methods of acupuncture
previous to our treatment.
These findings suggest that acupuncture
treatment using the needle retention method
combined with multiple epidermis-penetratingneedle stimulation is one of the most effective anddisorders characterized by involuntary muscle
contractions, which may cause twisting andrepetitive

musclemovements,

orabnormal

postures. Different classifications of dystonia
have been proposed based upon the following
criteria: distribution of affected body parts, age at
onset, cause, and genetic criteria. Cervicaldystonia is one of the most common subtypes ofdystonia.
Dystonia is the least understood movement
disorderassociateddysfunction;

with

basal

gangliaa

newly

proposed

however,hypothesis to explain this disorder involves
multiple levels of the nervous system: spinal cord,basal ganglia, thalamus, somato-sensory system,
sensorimotor integration, and motor cortical
function1).
Treatment options for dystonia include drug
treatment

andsurgicalprocedures.

Drugtreatment can be subdivided into the applicationof systemically active orally administered drugs
and local botulinum toxin injections, while
surgicaltreatment

may

peripheral

denervation

surgery.

treatedWeor

involveselectivefunctional

patients

with

brain
cervical

dystonia using acupuncture, and followed theirprogress by clinical and electromyography (EMG)
evaluations2). In this report, we introduce our new
acupuncture method and provide clinical and
EMG evaluations of the outcome.
II. Materials and Methods
Todetermine

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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11Volume 1, Number 4 | Winter 2006

acupuncture method for each patient withcervical dystonia, clinical and EMG evaluations
were performed before acupuncture treatment.
Based on these clinical and EMG evaluations,acupuncture
regimens
weredeveloped
respectively for primary or secondary disorders ofcervical dystonia. Primary disorders indicate local
muscular hypertonus, hypotonus, or unsustained
head movement due to basal ganglia dysfunction
or other causes derived from the central nervoussystem. Secondary disorders indicate muscle
and/or skin shortening due to primary disorders.
Written informed consent for our acupuncture
method was obtained from each patient.
1. Clinical evaluations
Clinical evaluation included the Tsui scale
modified by Mezaki et al.3), range of motion(ROM) of the neck and visual analogue scale.
① Modified Tsui scale (Table 1)

This scale has a maximal score of 34 and assesses
the abnormality of neck posture based on theamplitude of sustained movements of the neck,duration of sustained movements of the neck,axial
distortion,
andunsustained
headmovement.
② ROM of the neckActive and passive ROM of the neck were tested
to clarify abnormal mobility, muscle tonus,
muscle and skin shortening, and muscle
weakness.

12③ Visual analogue scale
The visual analogue scale awarded values on ascale of 0 (normal) to 10 (worst).
2. EMG evaluation
EMG evaluation using Viking Ⅳ (NICOLET)
testedtheEMG
activityofthesternocleidomastoid muscle (SCM), the trapezius
muscle and the splenius muscle (SPL) at rest andduring actions involving 5 different movements:
neck flexion, extension, right rotation, left
rotation, and shoulder elevation in the sitting
position. To determine whether shoulder andtrunk muscles were affected, EMG activities ofthese muscles, such as the abdominal muscle anderector spinae muscle, were also tested. Inaddition, neck movement was tested using
displacement transducers, built-in reel type(KYOWA) and dynamic strain amplifiers,
DPM-601A (KYOWA), simultaneously with EMG
records
The affected muscles with clinical evaluations
showing abnormal EMG findings indicatedprimary disorders, i.e., hypertonus muscles,
hypotonus muscles, or unsustained headmovement. Affected muscles with normal EMG
findings indicated secondary disorders, i.e.,
muscle shortening. Skin shortening is also an
important secondary disorder.
3. Acupuncture methods
The needle retention method on the meridian
points for primary disorders and multiple
epidermis-penetrating needle stimulation on
tender spots for secondary disorders were applied
once a week.
For
theneedle
retention
method,pre-sterilized disposable acupuncture needles (0.2mm in diameter, 50 mm in length) were inserted
ipsilaterally into Hegu (LI4) when the SCM
muscle was affected. Also, we selected ipsilateral
Waiguan (TE5) when the trapezius was affected

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 1, Number 4 | Winter 2006

and ipsilateral Houxi (SI3) when the SPL muscle
was affected. The selection of these acupoints wasbased on the meridian concept of typical distal
acupoints on the meridians running through theaffected muscles. If the affected muscles included
the trunk flexor or extensor muscles,
pre-sterilized disposable acupuncture needles
were inserted into the ipsilateral Chongyang(ST42)and
ipsilateral
Kunlun(BL60),respectively. Acupuncture needles were inserted 5mm in depth and left in place for 5 minutes todecrease and 10 minutes to increase muscle tonus.
A retained needle on Baihui (GV20) at the top of
the head was used for treating unsustained head
movement, with needles being 5 mm in depth andleft for 10 minutes. For muscle and skinshortening, ten points in the tender area wereselected and multiple epidermis-penetratingneedle stimulation was applied to decrease thetension in the tender area.
III. Results
1. Effect of acupuncture
Among 48 patients (26 males and 22 females,mean age of 40.8 years, mean disease duration of
44.8 months; range: 3- 252 months), clinicalexamination, especially by the modified Tsui scale,showed improvement in 35 patients (72.9 %), andno change or deterioration in 13 patients (27.1%)
after 10 sessions of acupuncture treatment. EMG
evaluation showed improvement in all patients
after the acupuncture treatment. There were noside effects in any of the patients.
The characteristics of patients who did not
respond to our acupuncture treatment were asfollows: 1) longer duration of disease, 2) neckposture demonstrating retrocollis, 3) severe
unsustained head movement, 4) more than 1
week intervals between acupuncture sessions,and 5) treated by several different methods ofacupuncture previous to our treatment.

2. Case studies
Patient 1 was a 24-year-old male. He had
previously received medication and MAB (muscleafferent block) in other hospitals, but the neckposture remained unchanged and demonstrated
left rotation and left lateral flexion. The modified
Tsui score was 14. Clinical and EMG evaluations
revealed that the main problems were increased
muscle tonus in the left SPL and decreased
muscle tonus in the left SCM. EMG activity in theleft SCM during right neck rotation was weak(Figure 1, left). Acupuncture treatment wasinitially performed once a week using theretaining needle method at the left Houxi (SI3) todecrease the tonus of the left SPL and left Hegu
(LI4) to increase the tonus of the left SCM.
Multiple
epidermis-penetratingneedlestimulation was employed in the left nuchal
region before the retention needle method wasapplied. After 25 sessions using these techniques,
the abnormal neck posture with left rotation andleft lateral flexion, and EMG findings during
right neck rotation were markedly improved andthe modified Tsui score recovered to 8 (Figure 1,right).

Figure 1

Patient 2 was a 21- year-old female. She had
previously received medication and MAB in otherhospitals, but left rotation of the neck and left
elevation of the shoulder girdle were still
prominent. The modified Tsui score was 25 andthe visual analogue scale was 10. Clinical and
EMG evaluations revealed that the main
problems were increased muscle tonus in theThe Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 1, Number 4 | Winter 2006

right SCM and the left SPL, and shortened skinat the left front region of the neck. EMG activities
in the right SCM and the left SPL increased
during right neck rotation (Figure 2, left).

30

Tsui modified scale

Visual analogue scale

25
20
15
1050
Before acupuncture

Figure 2

Acupuncture

treatment

wasinitiallyperformed once a week using the needle
retention method at the right Hegu (LI4) andleft Houxi (SI3) to decrease the tonus of therightSCMandleft

SPL.

Multiple

epidermis-penetrating needle stimulation wasemployed at the front neck to stretch the skinbefore the needle retention method was applied.
After 10 sessions using these techniques, theabnormal neck posture was slightly improved to

After 10 sessions ofacupuncture treatment

After 40 sessions ofacupuncture treatment

Figure 3
Patient 3 was a 47-year-old male withretrocollis and extension of the trunk. Clinicaland EMG evaluations showed that the main
problems were increased tonus in the bilateraltrunk extensor muscles and the bilateral SCM,and decreased tonus in bilateral trunk flexor
muscles during walking (Figure 4). Acupuncture
treatment was initially performed once a week
using the needle retention method at the bilateral
Kunlun (BL60) to decrease the tonus of thebilateral trunk extensor muscles and bilateral
Chongyang (ST42) to increase the tonus of thebilateral trunk flexor muscles. Neck and trunk
posture during walking were improved withalmost normal EMG data after 24 sessions ofacupuncture treatment (Figure 4).

22 in the modified Tsui score, and 7 on the visual
analogue scale. However, elevation and flexion of
the left shoulder girdle still remained, indicating
the involvement of the levator scapulae muscle
and pectoralis major. Therefore, the needle
retention method at the left Kunlun (BL60) todecrease the tonus of the left levator scapulae
muscle and at the left Chongyang (ST42) todecrease the tonus of the left pectoralis major

Figure 4muscle was added to the regular acupuncture
regimen. The EMG data, modified Tsui score, andIV. Discussion

visual analogue scale showed further improvement

Treatment of cervical dystonia includes several
methods such as medication, injection ofbotulinum toxin, surgery, and so on, but presently,
there are no specifically effective methods.
Although acupuncture is not widely accepted as acommon method to treat this intractable

after 40 sessions of acupuncture treatment (Figure2, left and Figure 3).

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Volume 1, Number 4 | Winter 2006

neurological disease, we applied acupuncture inpatients with cervical dystonia, and developed aunique method of acupuncture treatment. Our
method employs knowledge of both modern
medical technology and ancient Chinese/Japanesetraditional medicine, particularly that ofmeridians.
The following is a summary of our uniqueacupuncture method:
1) Using clinical evaluations and EMG findings on
motion analysis, we divided affected muscles into
two groups, muscles affected by primary disorderand those by secondary disorder. Thereafter, weapplied different and specific acupuncture
methods to each group.
2) For muscles with primary disorder, we used theneedle retention method on distal acupoints along
the meridian running through the affected muscle.
For muscles with secondary disorder, multiple
epidermis-penetrating needle stimulation on
tender spots was applied. In our previous study2),
EMG findings during and after acupuncture using
our method were much improved compared toother acupuncture methods, indicating thesuperiority of our method.
3) In addition, we applied the same acupuncture
method to trunk muscles, and found that it wasvery important to improve trunk function for the
successful treatment of cervical dystonia. When we
assessed patients who had both cervical and trunk
postural abnormalities, we realized that correctionof the trunk muscles positively influenced thepostural abnormality of the neck.
4) We decided the depth of retained needles to be 5mm since the potential in the primary sensory
area during acupuncture treatment with 5 mm
depth showed a significant change in thesomatosensory evoked potential (SEP).
5) We decided the standard duration of retainedneedle treatment to be 5 minutes to decrease
muscle tonus and 10 minutes to increase it,although we changed the duration to some extentaccording to the condition of the affected muscles,
determined by manual palpation in individual
cases. Importantly, techniques such as botulinum
toxin injection can only decrease muscle tonus,
whereas we found that acupuncture can produce
bidirectional effects, both increasing anddecreasing muscle tonus.
6) For multiple epidermis-penetrating stimulationon tender spots, we learned from our experiencethat we should continue stimulation until thetenderness disappears in each treatment.
7) In patients with dystonia exhibiting both primaryand secondary disorders, we found that we have totreat muscles with secondary disorders first.
Although the effectiveness by clinical evaluations
after 10 sessions was 72.9 %, there were somepatients who did not show any improvements
using our method. Therefore, we need to develop
other new techniques of acupuncture treatment for
those patients, particularly with retrocollis andunsustained head movement.
V. Conclusions
We have developed a unique method of
acupuncture treatment using knowledge ofmodern medical techniques as well as ancient
Chinese/Japanese traditional medicine. We believethat our method will become one of the mosteffective treatments for patients with cervicaldystonia.
Reference
1) Maja T: Dystonia update. Curr Opin Neurol
16:495-500, 2003
2) Suzuki

T,etal:Evaluations

cliniqueetelectromyographique de l’effet de l’acupuncture surles patients souffrants de torticolis spasmodique.
MERIDIENS 115:17-26. 2000 (French)
3) Mezaki T, et al: The clinical usefulness of Botulinum
Toxin type A for spasmodic torticollis and facial spasm.
Brain and nerve 47: 749-754, 1995 (In Japanese andabstract in English)

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Volume 1, Number 4 | Winter 2006

Introduction of Kansai University of HealthSciences (KUHS)
Ikuro Wakayama
Department of Acupuncture and Moxibustion
Kansai University of Health Sciences1) General information of Kansai University
of Health Sciences
Kansai University of Health Sciences(KUHS), former Kansai College of OrientalMedicine (KCOM), is located in southern
Osaka Prefecture near Kansai International
Airport. Access from the airport as well asfrom the railway station is very convenient.
KUHS is composed of three departments,
Department of Acupuncture and Moxibustion,
Department of Physical Therapy andGraduate School of Health Sciences. The
Department of Acupuncture and Moxibustion
includes two divisions, a program in oriental
medicine and a program in acupuncture andathletic training.
KCOM was founded in 1985 as athree-year college for training acupuncturists,then reorganized as a four-year college in
2003. On April, 2007, a four-year program forphysical therapists was added, and the nameof the institution became Kansai UniversityofHealthSciences.
Inaddition,
apostgraduate
two-yearmasterdegreeprogram was started at the same time.
2) Educational stuffs of KUHS
The motto of KUHS is bringing up young
talent to serve the community as anacupuncturist or physical therapist. To send
fully trained professionals to the community,
KUHS provides capable teachers in the fields
of general education, basic and clinical oriental
medicine, basic and clinical western medicine,
acupuncture and moxibustion, and physicaltherapy all supported by a detailed curriculum.
3) Research works conducting in KUHS
16

Researchers actively perform investigationsin the field of basic and clinical medicine related
to acupuncture and moxibustion, and physicaltherapy. The themes of each research team arelisted below.
(1) Anatomical and biological investigation of
the mechanisms of action of acupuncture andmoxibustion(2) Investigation of the influence ofacupuncture and moxibustion on the immunesystem(3) Neurobiology of acupuncture stimulation(4) Novel acupuncture treatment in patientswith cervical dystonia and related disorders(5) Study of the effect of acupuncture inpatients with hemodialysis(6) Effect of acupuncture treatment onpatients with osteoarthritis of the knee - a
randomized controlled trial(7) Changes in the autonomic systemfollowing acupuncture stimulation(8) Psychological changes in patients receiving
acupuncture and moxibustion(9) Study of the effect of ear acupuncture4) Outpatient Clinic attached to KUHS
The mission of our outpatient clinic is torender good service to the community andpatients, and to lead our students to learnclinical skills of acupuncture and moxibustion,
physical therapy, as well as skills for personalcommunication. Our outpatient clinic has 16
medical doctors working in the Divisions ofInternal Medicine, Neurology, Psychiatry,
Orthopedics,
Surgery,
Rehabilitation,
Dermatology, Gynecology and Kampo Medicine(Japanese traditional herbal medicine). The
clinic is equipped with MRI and other modern
technological instruments to establish a precise
diagnosis as well as to prepare crude drugs fromplants and animal products to provide
traditional and natural remedies.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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In addition, the clinic has an institute foracupunctureandmoxibustion
treatment.
Presently, 21 acupuncturists work in the institutetreating patients using traditional, modern or
combined techniques. Techniques or principles
used are traditional Japanese / Chinese medicine,
Ryodoraku method, Akabane method, trigger
point techniques and so on.
In conclusion, KUHS provides good
opportunities for the students aiming to becomea knouledgeable, skillful and well trained
acupuncturist and physical therapist as well as
for patients who are eager to receive oriental
medical therapies and integrated (modern andtraditional combined) medical therapies.

Photo1: University Campus,

Photo 2: Outpatient Clinic

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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