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Successful Ayurvedic management of a chronic case of Cervical Dystonia - A Case report 

Dr K G Raveendran

ABSTRACT

A 39-year-old female diagnosed as Cervical dystonia/Torticollis [1] presented with involuntary jerky movement of head towards the left side without any tremor. Neck stiffness present occasionally. Clinical diagnosis was made based on the presentation. She was prescribed Clonazepam by Neurologist, the patient being reluctant to take this medicine approached Dr KG Raveendran. This condition was diagnosed as Manyasthambham2. The line of treatment given was Vatahara, Avaranahara, Brhmana and Snehana. She underwent follow up courses of In-Patient Ayurvedic treatments in 2020 and 2021, as instructed by the Physician. After the Ayurvedic treatments, she was able to place her head in a straight position without any jerky movements. The TWSTRS (Toronto Western Spasmodic Torticollis Rating Scale) pre and post treatment was used for assessing the outcomes. The Score for the 3 courses of treatments were recorded as follows:

In 2016 - Admission - 62, Discharge – 48.5 (28.3.16-28.7.16): In 2020 - Admission -15, Discharge time – 12 (24.7.20-12.8.20) and in 2021 - Admission – 03, Discharge -02- (6.5.21-19.5.21)

KEYWORDS

Ayurveda, Manyasthambha, Cervical Dystonia, Torticollis, Ayurveda, Standalone

INTRODUCTION

Cervical dystonia, also called spasmodic torticollis, is a very painful condition where the neck muscles involuntarily contract, resulting in the head twisting or turning to one side. Sometimes, this condition can also cause the head to tilt forward or backwards uncontrollably.  This is a rare disorder that can occur at any age, is more prevalent in women than men and is normally found during middle age.

Diagnostic Criteria: The manifestations of the symptoms are very gradual, and they reach a point where they become a constant clinical presentation. Diagnosis is made based on the clinical presentation. But the doctor may suggest some additional blood tests and MRI to rule out or assess any underlying disease condition. In this patient, the provisional diagnosis was made by her Neurologist based on the clinical presentations.

PATIENT INFORMATION

A 39-year-old female patient presented with involuntary jerky movement of head towards the left side without any tremor. There is occasional stiffness and a noticeable presence of mass on one side of neck that recuperates itself.

Medical History: The patient is a known case of Torticollis / Cervical Dystonia since February 2016. The patient was apparently healthy till end of December 2015. She noticed slight pain in the nape of the neck but did not consult anybody and eventually felt some instability of the neck with slightest tremor.  This would gradually end up as involuntary movement of the neck to left side. Initially, the movement of the neck was slow and uniform to left side without jerk and eventually presented with jerky movement to the left side and then presented with complete tilt of the head to left side. This was also accompanied with pain in the nape of the neck. She used to try to control the jerk with back support or by applying pressure in the back of the head. These symptoms were absent while on lying position. Now she consulted a Neurologist, who made the provisional diagnosis. She was prescribed Clonazepam which she was reluctant to consume. So, in 2016 she consulted the specific Ayurvedic physician and took Inpatient treatment for 3 months. On discharge, she found less intensity and frequency of jerking of the neck. The position of neck was tilted to the left side back then. Since then, she underwent 3 courses of Inpatient treatment over a span of 5 years (2016-2021). So, in 2016 she consulted the specific Ayurvedic physician, and took Inpatient treatment for 3 months. On discharge, she found less intensity and frequency of jerking of the neck. The position of neck was tilted to the left side back then. Since then, she underwent 3 courses of Inpatient treatment over a span of 5 years (2016-2021).

PHYSICAL EXAMINATION/CLINICAL FINDINGS

General Examination: Normal; Respiratory System; B/L Lung fields are clear. Cardiovascular System: S1, S2 Heard. Gastrointestinal System: No bloatedness, Tenderness or Organomegaly

TIMELINE

Image 1. Timeline of events Attched below

DIAGNOSTIC ASSESSMENT

Modern Diagnostic parameter: A Provisional diagnosis was made based on the clinical presentation.

Ayurvedic Assessment was done based on the clinical evaluation by the ayurvedic physician Differential Diagnosis- There was no clinical presentation indicating any other pathology.

Prognosis- Prognosis & Treatment: The safest and efficient treatment of choice is injection of Botulinum toxin into the affected neck muscles. Studies show that most patients have good efficacy and health-related quality of life also in the long term. The minority of patients with unsatisfactory treatment responses should be evaluated for pallidal deep brain stimulation. Treatment may be considered ineffective if neither the patient nor the therapist has observed a satisfactory reduction of symptoms or if significant adverse effects occur. Studies have shown that most patients stop their treatments finding it unsatisfactory. This patient did not want to take Clonazepam and so opted for Ayurveda. This was stated as a Krcchrasadhya vyadhi by the treating physician.

THERAPEUTIC INTERVENTION

See the tab 'Treatment Details' 

FOLLOW-UP AND OUTCOMES

The patient is advised to come for a follow up next year for assessment.

Clinician-based assessment; Absence of involuntary jerky movements throughout the course of treatment. No noticeable mass over the neck and pulsating sensation inside the neck.

Patient-based assessment: TWSTRS SCORE (TORONTO WESTERN SPASMODIC TRTICOLLIS RATING SCALE SCORE) done pre and post treatment were as follows:

In 2016 - Admission - 62, Discharge – 48.5 (28.3.16-28.7.16)

In 2020 - Admission -15, Discharge time – 12 (24.7.20-12.8.20)

In 2021 - Admission – 03, Discharge -02 (25.4.21-20.5.21)         

Image 2. TWSTRS documented in 2016         

Image 3. TWSTRS documented in 2020

Image 4. TWSTRS documented in 2021

Intervention adherence and tolerability – The patient adhered to the prescribed treatments and tolerated the treatments well.

Method of assessment- By monitoring the patient.

Adverse and unanticipated events; None reported

DISCUSSION:

Cervical dystonia cannot be exactly correlated to any specific clinical condition mentioned in the classical Ayurvedic textbooks. This was diagnosed as Manyasthambha by the treating physician, based on the clinical presentation. The main line of treatment adopted was vatahara to reduce the atipravritti of vata and to address the avarana.

The target of the treatment was:

a. Avaranahara

b. Vatahara

c. Snehana

d. Brimhana

PATIENT’S PERSPECTIVE

Not available.

LEARNING POINTS/TAKE-HOME MESSAGES

The patient, a chronic case of Cervical dystonia was reluctant to take clonazepam, so she opted for Ayurveda. She was diagnosed as Manyastambha, a krcchra sadhya vyadhi and vatahara line of treatment was adopted. With a course of 3 Inpatient treatments, she got relief from her symptoms and the TWSTRS showed significant reduction.

INFORMED CONSENT

Written consent obtained from patient.

ACKNOWLEDGEMENTS 

None

CONFLICT OF INTEREST

None declared

FUNDING

None

REFERENCE

1. Reichel G, Kamm C, Kang JS, Müngersdorf M, Paus S, Reuter I, Stenner A, Weise D. Zervikale Dystonien [Cervical Dystonia]. Fortschr Neurol Psychiatr. 2018 Jun;86(6):368-386. German. doi: 10.1055/s-0043-107834. Epub 2018 Jun 28. PMID: 29954019.

2. Katkar et al. Conceptual study of Mashadi Taila Nasya in Manyastambha with special reference to Sharangdhara Samhita. World Journal of Pharmaceutical Research. Vol 8, Issue 13, 2019.

 

Image 1. Timeline of events 

Image 2. TWSTRS documented in 2016         

Image 3. TWSTRS documented in 2020

Image 4. TWSTRS documented in 2021