Acquired torticollis
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
without pain or functional impairment
observation
Asymptomatic patients require no treatment.
physiotherapy
Treatment recommended for ALL patients in selected patient group
Physiotherapy and stretching should be considered to maintain range of motion.
with functional impairment or pain or diminished quality of life
oral medication
Multiple oral medications from various classes have been reported to ameliorate dystonia.
The medicines listed below are those most commonly used in clinical practice and span a range of different pharmacological mechanisms of action (anticholinergic, GABAergic and centrally acting).[19]Albanese A, Barnes MP, Bhatia KP, et al. A systematic review on the diagnosis and treatment of primary (idiopathic) dystonia and dystonia plus syndromes: report of an EFNS/MDS-ES Task Force. Eur J Neurol. 2006 May;13(5):433-44. https://www.doi.org/10.1111/j.1468-1331.2006.01537.x http://www.ncbi.nlm.nih.gov/pubmed/16722965?tool=bestpractice.com
Some principles are applicable to all agents: efficacy is limited at tolerable dosing, central side effects (i.e., fatigue or confusion) are usually dose limiting, and all agents should be started at low doses and increased to efficacy or until tolerability limits dose.
Primary options
trihexyphenidyl: 1 mg orally once daily at bedtime initially, increase according to response, maximum 12 mg/day given in 3-4 divided doses
OR
clonazepam: 0.25 mg orally twice daily initially, increase according to response, maximum 6 mg/day given in 2-3 divided doses
OR
baclofen: 5 mg orally three times daily initially, increase according to response, maximum 160 mg/day given in 3-4 divided doses
OR
tizanidine: 2 mg orally once daily at bedtime initially, increase according to response, maximum 24 mg/day given in 3-4 divided doses
physiotherapy
Treatment recommended for ALL patients in selected patient group
While a robust evidence base for physiotherapy in cervical dystonia is lacking, physiotherapy can be helpful for some patients and does not carry significant risk of harm.[20]De Pauw J, Van der Velden K, Meirte J, et al. The effectiveness of physiotherapy for cervical dystonia: a systematic literature review. J Neurol. 2014 Oct;261(10):1857-65. https://www.doi.org/10.1007/s00415-013-7220-8 http://www.ncbi.nlm.nih.gov/pubmed/24413637?tool=bestpractice.com [21]Delnooz CC, Horstink MW, Tijssen MA, van de Warrenburg BP. Paramedical treatment in primary dystonia: a systematic review. Mov Disord. 2009 Nov 15;24(15):2187-98. http://www.ncbi.nlm.nih.gov/pubmed/19839012?tool=bestpractice.com It is thus reasonable to consider physiotherapy as part of any treatment plan.
intramuscular botulinum toxin
The intramuscular administration of botulinum toxin provides the best proven efficacy in acquired torticollis.
[ ]
What are the benefits and harms of botulinum toxin type B in people with cervical dystonia?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1331/fullShow me the answer Sustained efficacy in reduction of dystonia severity has been demonstrated after 7 years of repeated injections with onabotulinumtoxinA.[25]Camargo CH, Teive HA, Becker N, et al. Botulinum toxin type A and cervical dystonia: a seven-year follow-up. Arq Neuropsiquiatr. 2011 Oct;69(5):745-50.
http://www.scielo.br/pdf/anp/v69n5/a03v69n5.pdf
http://www.ncbi.nlm.nih.gov/pubmed/22042174?tool=bestpractice.com
Botulinum toxin injections are considered as first-line therapy for acquired torticollis by the European Federation of Neurological Societies and are recommended by the American Academy of Neurology.[18]Albanese A, Asmus F, Bhatia KP, et al. EFNS guidelines on diagnosis and treatment of primary dystonias. Eur J Neurol. 2011 Jan;18(1):5-18.
http://onlinelibrary.wiley.com/doi/10.1111/j.1468-1331.2010.03042.x/pdf
http://www.ncbi.nlm.nih.gov/pubmed/20482602?tool=bestpractice.com
[26]Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache - report of the guideline development subcommittee of the American Academy of Neurology. Neurology. 2016 May 10;86(19):1818-26.
http://www.neurology.org/content/86/19/1818.full
http://www.ncbi.nlm.nih.gov/pubmed/27164716?tool=bestpractice.com
Botulinum toxin types A and B have been shown to provide significant benefit in placebo-controlled trials.[33]Rodrigues FB, Duarte GS, Marques RE, et al. Botulinum toxin type A therapy for cervical dystonia. Cochrane Database Syst Rev. 2020 Nov 12;11:CD003633.
https://www.doi.org/10.1002/14651858.CD003633.pub4
http://www.ncbi.nlm.nih.gov/pubmed/33180963?tool=bestpractice.com
[54]Lew MF, Brashear A, Factor S. The safety and efficacy of botulinum toxin type B in the treatment of patients with cervical dystonia: summary of three controlled clinical trials. Neurology. 2000;55(12 suppl 5):S29-35.
http://www.ncbi.nlm.nih.gov/pubmed/11188982?tool=bestpractice.com
[ ]
How does botulinum toxin A (BtA) compare with placebo for people with cervical dystonia?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.3499/fullShow me the answer The unit doses are not equivalent/interchangeable. Botulinum toxin has also been found to be significantly more beneficial than oral trihexyphenidyl.[26]Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache - report of the guideline development subcommittee of the American Academy of Neurology. Neurology. 2016 May 10;86(19):1818-26.
http://www.neurology.org/content/86/19/1818.full
http://www.ncbi.nlm.nih.gov/pubmed/27164716?tool=bestpractice.com
[27]Brans JW, Lindeboom R, Snoek JW, et al. Botulinum toxin versus trihexyphenidyl in cervical dystonia: a prospective, randomized, double-blind controlled trial. Neurology. 1996 Apr;46(4):1066-72.
http://www.ncbi.nlm.nih.gov/pubmed/8780093?tool=bestpractice.com
[28]Brashear A. Botulinum toxin type A in the treatment of patients with cervical dystonia. Biologics. 2009;3:1-7.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2726049/pdf/btt-3-001.pdf
http://www.ncbi.nlm.nih.gov/pubmed/19707390?tool=bestpractice.com
[29]Truong D, Duane DD, Jankovic J, et al. Efficacy and safety of botulinum type A toxin (Dysport) in cervical dystonia: results of the first US randomized, double-blind, placebo-controlled study. Mov Disord. 2005 Jul;20(7):783-91.
http://www.ncbi.nlm.nih.gov/pubmed/15736159?tool=bestpractice.com
[30]Comella CL, Jankovic J, Truong DD, et al. Efficacy and safety of incobotulinumtoxinA (NT 201, XEOMIN(®), botulinum neurotoxin type A, without accessory proteins) in patients with cervical dystonia. J Neurol Sci. 2011 Sep 15;308(1-2):103-9.
http://www.ncbi.nlm.nih.gov/pubmed/21764407?tool=bestpractice.com
[31]Marques RE, Duarte GS, Rodrigues FB, et al. Botulinum toxin type B for cervical dystonia. Cochrane Database Syst Rev. 2016 May 13;(5):CD004315.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004315.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/27176573?tool=bestpractice.com
No significant differences in efficacy of botulinum toxin type A and botulinum toxin type b have been demonstrated.[24]Comella CL, Jankovic J, Shannon KM, et al. Comparison of botulinum toxin serotypes A and B for the treatment of cervical dystonia. Neurology. 2005 Nov 8;65(9):1423-9.
http://www.ncbi.nlm.nih.gov/pubmed/16275831?tool=bestpractice.com
[32]Pappert EJ, Germanson T; Myobloc/Neurobloc European Cervical Dystonia Study Group. Botulinum toxin type B vs. type A in toxin-naive patients with cervical dystonia: randomized, double-blind, noninferiority trial. Mov Disord. 2008 Mar 15;23(4):510-7.
http://www.ncbi.nlm.nih.gov/pubmed/18098274?tool=bestpractice.com
[33]Rodrigues FB, Duarte GS, Marques RE, et al. Botulinum toxin type A therapy for cervical dystonia. Cochrane Database Syst Rev. 2020 Nov 12;11:CD003633.
https://www.doi.org/10.1002/14651858.CD003633.pub4
http://www.ncbi.nlm.nih.gov/pubmed/33180963?tool=bestpractice.com
Dry mouth was more frequent adverse event with botulinum toxin type B.[33]Rodrigues FB, Duarte GS, Marques RE, et al. Botulinum toxin type A therapy for cervical dystonia. Cochrane Database Syst Rev. 2020 Nov 12;11:CD003633.
https://www.doi.org/10.1002/14651858.CD003633.pub4
http://www.ncbi.nlm.nih.gov/pubmed/33180963?tool=bestpractice.com
The American Academy of Neurology states that abobotulinumtoxinA and rimabotulinumtoxinB are established effective treatments for cervical dystonia and and should be offered, and onabotulinumtoxinA and incobotulinumtoxinA are probably effective and should be considered.[26]Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache - report of the guideline development subcommittee of the American Academy of Neurology. Neurology. 2016 May 10;86(19):1818-26. http://www.neurology.org/content/86/19/1818.full http://www.ncbi.nlm.nih.gov/pubmed/27164716?tool=bestpractice.com
Technical considerations for its use include: injection into dystonic muscles which serves to block acetylcholine release into the neuromuscular junction resulting in partial denervation; clinical effect typically lasts 3 to 4 months;[35]Marsh WA, Monroe DM, Brin MF, et al. Systematic review and meta-analysis of the duration of clinical effect of onabotulinumtoxinA in cervical dystonia. BMC Neurol. 2014 Apr 27;14:91. http://www.biomedcentral.com/1471-2377/14/91 http://www.ncbi.nlm.nih.gov/pubmed/24767576?tool=bestpractice.com injections are typically repeated every 3 to 4 months;[35]Marsh WA, Monroe DM, Brin MF, et al. Systematic review and meta-analysis of the duration of clinical effect of onabotulinumtoxinA in cervical dystonia. BMC Neurol. 2014 Apr 27;14:91. http://www.biomedcentral.com/1471-2377/14/91 http://www.ncbi.nlm.nih.gov/pubmed/24767576?tool=bestpractice.com some clinicians advocate the use of electromyography to localise muscles for injection; electromyography is particularly useful in injecting deep or small muscles. Limited evidence suggests that using electromyography guidance may improve outcomes.[36]Nijmeijer SW, Koelman JH, Kamphuis DJ, et al. Muscle selection for treatment of cervical dystonia with botulinum toxin-a systematic review. Parkinsonism Relat Disord. 2012 Jul;18(6):731-6. http://www.ncbi.nlm.nih.gov/pubmed/22575237?tool=bestpractice.com Ultrasound imaging is also sometimes used to guide injections.[37]Castagna A, Albanese A. Management of cervical dystonia with botulinum neurotoxins and EMG/ultrasound guidance. Neurol Clin Pract. 2019 Feb;9(1):64-73. https://www.doi.org/10.1212/CPJ.0000000000000568 http://www.ncbi.nlm.nih.gov/pubmed/30859009?tool=bestpractice.com
Side effects of therapy with intramuscular botulinum toxin are related to induced muscle weakness and can include significant dysphagia (when injected into cervical muscles) or systemic uptake of toxin resulting in mild botulism (of which difficulty swallowing is an early symptom). When compared with placebo, patients treated with rimabotulinumtoxinB were at increased risk of dry mouth and dysphagia.[31]Marques RE, Duarte GS, Rodrigues FB, et al. Botulinum toxin type B for cervical dystonia. Cochrane Database Syst Rev. 2016 May 13;(5):CD004315. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004315.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/27176573?tool=bestpractice.com Ultrasound-guided injections into the sternocleidomastoid are being investigated as a way to reduce the risk of dysphagia.[38]Hong JS, Sathe GG, Niyonkuru C, et al. Elimination of dysphagia using ultrasound guidance for botulinum toxin injections in cervical dystonia. Muscle Nerve. 2012 Oct;46(4):535-9. http://www.ncbi.nlm.nih.gov/pubmed/22987694?tool=bestpractice.com
Neutralising antibody development occurs in 2% of patients and may manifest as loss of efficacy, although some patients with demonstrated antibodies to abobotulinumtoxinA continue to have a clinical response to injection.[40]Coleman C, Hubble J, Schwab J, et al. Immunoresistance in cervical dystonia patients after treatment with abobotulinumtoxinA. Int J Neurosci. 2012 Jul;122(7):358-62. http://www.ncbi.nlm.nih.gov/pubmed/22356470?tool=bestpractice.com Risk can be reduced by using the lowest effective dose of botulinum toxin and temporally spacing injections by at least 3 months.[39]Swope D, Barbano R. Treatment recommendations and practical applications of botulinum toxin treatment of cervical dystonia. Neurol Clin. 2008 May;26(suppl 1):54-65. http://www.ncbi.nlm.nih.gov/pubmed/18603168?tool=bestpractice.com
The US Food and Drug Administration (FDA) posted an early communication in February 2008 warning of potential botulism with local infection of botulinum toxin.[42]Apkon SD, Cassidy D. Safety considerations in the use of botulinum toxins in children with cerebral palsy. PM R. 2010 Apr;2(4):282-4. http://www.ncbi.nlm.nih.gov/pubmed/20430330?tool=bestpractice.com These products now come with a boxed warning highlighting the risk of potential distant spread of toxin effects resulting in systemic symptoms with local injection. Most cases occurred in children treated for spasticity in the setting of cerebral palsy.[42]Apkon SD, Cassidy D. Safety considerations in the use of botulinum toxins in children with cerebral palsy. PM R. 2010 Apr;2(4):282-4. http://www.ncbi.nlm.nih.gov/pubmed/20430330?tool=bestpractice.com
physiotherapy
Treatment recommended for ALL patients in selected patient group
While a robust evidence base for physiotherapy in cervical dystonia is lacking, physiotherapy can be helpful for some patients and does not carry significant risk of harm.[20]De Pauw J, Van der Velden K, Meirte J, et al. The effectiveness of physiotherapy for cervical dystonia: a systematic literature review. J Neurol. 2014 Oct;261(10):1857-65. https://www.doi.org/10.1007/s00415-013-7220-8 http://www.ncbi.nlm.nih.gov/pubmed/24413637?tool=bestpractice.com [21]Delnooz CC, Horstink MW, Tijssen MA, van de Warrenburg BP. Paramedical treatment in primary dystonia: a systematic review. Mov Disord. 2009 Nov 15;24(15):2187-98. http://www.ncbi.nlm.nih.gov/pubmed/19839012?tool=bestpractice.com It is thus reasonable to consider physiotherapy as part of any treatment plan. One small randomised study (26 patients with initial sub-optimal response to botulinum toxin treatment) found physiotherapy plus botulinum toxin treatment to be superior to botulinum toxin treatment alone.[22]Hu W, Rundle-Gonzalez V, Kulkarni SJ, et al. A randomized study of botulinum toxin versus botulinum toxin plus physical therapy for treatment of cervical dystonia. Parkinsonism Relat Disord. 2019 Jun;63:195-8. https://www.doi.org/10.1016/j.parkreldis.2019.02.035 http://www.ncbi.nlm.nih.gov/pubmed/30837195?tool=bestpractice.com
refractory to therapy with botulinum toxin
deep brain stimulation
Deep brain stimulation of the globus pallidus pars interna (GPi) is a proven treatment for generalised dystonia and has been shown to provide significant benefit to patients with medically refractory acquired torticollis.[18]Albanese A, Asmus F, Bhatia KP, et al. EFNS guidelines on diagnosis and treatment of primary dystonias. Eur J Neurol. 2011 Jan;18(1):5-18. http://onlinelibrary.wiley.com/doi/10.1111/j.1468-1331.2010.03042.x/pdf http://www.ncbi.nlm.nih.gov/pubmed/20482602?tool=bestpractice.com [43]Kiss ZH, Doig-Beyaert K, Eliasziw M, et al. The Canadian multicentre study of deep brain stimulation for cervical dystonia. Brain. 2007 Nov;130(Pt 11):2879-86. http://brain.oxfordjournals.org/cgi/content/full/130/11/2879 http://www.ncbi.nlm.nih.gov/pubmed/17905796?tool=bestpractice.com However, a Cochrane Review rated current clinical evidence for deep brain stimulation in cervical dystonia as low quality.[44]Rodrigues FB, Duarte GS, Prescott D, et al. Deep brain stimulation for dystonia. CochraneDatabase of Systematic Rev. 2019 Jan 10;(1):CD012405. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012405.pub2/full In a randomised sham-controlled trial, GPi deep brain stimulation significantly reduced severity of torticollis compared with sham stimulation at 3 months.[45]Volkmann J, Mueller J, Deuschl G, et al. Pallidal neurostimulation in patients with medication-refractory cervical dystonia: a randomised, sham-controlled trial. Lancet Neurol. 2014 Sep;13(9):875-84. http://www.ncbi.nlm.nih.gov/pubmed/25127231?tool=bestpractice.com
Stimulation of bilateral GPi has been shown to have durable effect at 3 years, and a positive effect was reported for deep brain stimulation of the bilateral subthalamic nucleus in 9 patients with refractory cervical dystonia.[46]Cacciola F, Farah JO, Eldridge PR, et al. Bilateral deep brain stimulation for cervical dystonia: long-term outcome in a series of 10 patients. Neurosurgery. 2010 Oct;67(4):957-63. http://www.ncbi.nlm.nih.gov/pubmed/20881561?tool=bestpractice.com [48]Ostrem JL, Racine CA, Glass GA, et al. Subthalamic nucleus deep brain stimulation in primary cervical dystonia. Neurology. 2011 Mar 8;76(10):870-8. http://www.ncbi.nlm.nih.gov/pubmed/21383323?tool=bestpractice.com Another series showed significant improvement in dystonia severity at a median of 30 months in a blinded evaluation.[47]Skogseid IM, Ramm-Pettersen J, Volkmann J, et al. Good long-term efficacy of pallidal stimulation in cervical dystonia: a prospective, observer-blinded study. Eur J Neurol. 2012 Apr;19(4):610-5. http://www.ncbi.nlm.nih.gov/pubmed/22117556?tool=bestpractice.com
Referral for these procedures is best made by a movement disorders specialist.
physiotherapy
Treatment recommended for ALL patients in selected patient group
While a robust evidence base for physiotherapy in cervical dystonia is lacking, physiotherapy can be helpful for some patients and does not carry significant risk of harm.[20]De Pauw J, Van der Velden K, Meirte J, et al. The effectiveness of physiotherapy for cervical dystonia: a systematic literature review. J Neurol. 2014 Oct;261(10):1857-65. https://www.doi.org/10.1007/s00415-013-7220-8 http://www.ncbi.nlm.nih.gov/pubmed/24413637?tool=bestpractice.com [21]Delnooz CC, Horstink MW, Tijssen MA, van de Warrenburg BP. Paramedical treatment in primary dystonia: a systematic review. Mov Disord. 2009 Nov 15;24(15):2187-98. http://www.ncbi.nlm.nih.gov/pubmed/19839012?tool=bestpractice.com It is thus reasonable to consider physiotherapy as part of any treatment plan.
radiofrequency ablation or selective surgical sectioning of peripheral nerves
Selective denervation by radiofrequency ablation may be helpful in patients with severe or refractory acquired torticollis. Significant and durable improvement in symptoms has been reported in 70% of patients undergoing radiofrequency ablation and post-procedure physiotherapy.[49]Cohen-Gadol AA, Ahlskog JE, Matsumoto JY, et al. Selective peripheral denervation for the treatment of intractable spasmodic torticollis: experience with 168 patients at the Mayo Clinic. J Neurosurg. 2003 Jun;98(6):1247-54. http://www.ncbi.nlm.nih.gov/pubmed/12816272?tool=bestpractice.com Case series of selective surgical denervation have shown significant reduction in disease severity scores.[50]Wang J, Li J, Han L, et al. Selective peripheral denervation for the treatment of spasmodic torticollis: long-term follow-up results from 648 patients. Acta Neurochir (Wien). 2015 Mar;157(3):427-33; discussion 433. http://www.ncbi.nlm.nih.gov/pubmed/25616622?tool=bestpractice.com
A single institution series found similar results with selective peripheral denervation compared with deep brain stimulation.[51]Huh R, Han IB, Chung M, et al. Comparison of treatment results between selective peripheral denervation and deep brain stimulation in patients with cervical dystonia. Stereotact Funct Neurosurg. 2010;88(4):234-8. http://www.ncbi.nlm.nih.gov/pubmed/20460953?tool=bestpractice.com There are limited but positive published data regarding combining deep brain stimulation and selective denervation in refractory cases.[52]Chung M, Han I, Chung SS, et al. Effectiveness of selective peripheral denervation in combination with pallidal deep brain stimulation for the treatment of cervical dystonia. Acta Neurochir (Wien). 2015 Mar;157(3):435-42. http://www.ncbi.nlm.nih.gov/pubmed/25471274?tool=bestpractice.com
Referral for these procedures is best made by a movement disorders specialist.
physiotherapy
Treatment recommended for ALL patients in selected patient group
While a robust evidence base for physiotherapy in cervical dystonia is lacking, physiotherapy can be helpful for some patients and does not carry significant risk of harm.[20]De Pauw J, Van der Velden K, Meirte J, et al. The effectiveness of physiotherapy for cervical dystonia: a systematic literature review. J Neurol. 2014 Oct;261(10):1857-65. https://www.doi.org/10.1007/s00415-013-7220-8 http://www.ncbi.nlm.nih.gov/pubmed/24413637?tool=bestpractice.com [21]Delnooz CC, Horstink MW, Tijssen MA, van de Warrenburg BP. Paramedical treatment in primary dystonia: a systematic review. Mov Disord. 2009 Nov 15;24(15):2187-98. http://www.ncbi.nlm.nih.gov/pubmed/19839012?tool=bestpractice.com It is thus reasonable to consider physiotherapy as part of any treatment plan.
injected phenol
Injections of 2% phenol have been shown to be effective.[53]Takeuchi N, Chuma T, Mano Y. Phenol block for cervical dystonia: effects and side effects. Arch Phys Med Rehabil. 2004 Jul;85(7):1117-20. http://www.ncbi.nlm.nih.gov/pubmed/15241760?tool=bestpractice.com
Needle electromyography or motor stimulation is used to localise the region of the motor end plate, and phenol solution is injected.
Adverse effects can include pain, swelling, tissue necrosis, and thrombosis.
Primary options
phenol: (2%) consult specialist for guidance on dose
physiotherapy
Treatment recommended for ALL patients in selected patient group
While a robust evidence base for physiotherapy in cervical dystonia is lacking, physiotherapy can be helpful for some patients and does not carry significant risk of harm.[20]De Pauw J, Van der Velden K, Meirte J, et al. The effectiveness of physiotherapy for cervical dystonia: a systematic literature review. J Neurol. 2014 Oct;261(10):1857-65. https://www.doi.org/10.1007/s00415-013-7220-8 http://www.ncbi.nlm.nih.gov/pubmed/24413637?tool=bestpractice.com [21]Delnooz CC, Horstink MW, Tijssen MA, van de Warrenburg BP. Paramedical treatment in primary dystonia: a systematic review. Mov Disord. 2009 Nov 15;24(15):2187-98. http://www.ncbi.nlm.nih.gov/pubmed/19839012?tool=bestpractice.com It is thus reasonable to consider physiotherapy as part of any treatment plan.
baclofen injection via continuous pump infusion
Intra-thecal baclofen may be helpful in patients with severe or refractory acquired torticollis, and in particular those with concomitant spasticity.
Referral for these procedures is best made by a movement disorders specialist.
Primary options
baclofen intrathecal: consult specialist for guidance on dose
physiotherapy
Treatment recommended for ALL patients in selected patient group
While a robust evidence base for physiotherapy in cervical dystonia is lacking, physiotherapy can be helpful for some patients and does not carry significant risk of harm.[20]De Pauw J, Van der Velden K, Meirte J, et al. The effectiveness of physiotherapy for cervical dystonia: a systematic literature review. J Neurol. 2014 Oct;261(10):1857-65. https://www.doi.org/10.1007/s00415-013-7220-8 http://www.ncbi.nlm.nih.gov/pubmed/24413637?tool=bestpractice.com [21]Delnooz CC, Horstink MW, Tijssen MA, van de Warrenburg BP. Paramedical treatment in primary dystonia: a systematic review. Mov Disord. 2009 Nov 15;24(15):2187-98. http://www.ncbi.nlm.nih.gov/pubmed/19839012?tool=bestpractice.com It is thus reasonable to consider physiotherapy as part of any treatment plan.
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
Use of this content is subject to our disclaimer