**3. Acupuncture treatment for cervical dystonia**

In cervical dystonia, the sternocleidomastoid, splenius, and trapezius (upper fibers) muscles are considered typical affected muscles. When improving the muscle tone of each affected muscle with acupuncture, there are some points to keep in mind. One of the hypothesized mechanisms of dystonia is to normalize the "abnormality in the motor subroutine formed by sensory input and motor output" [6]. Therefore, the acupuncture needle insertion depth is made shallow, 0.5 mm or less, to make the stimulation milder and to normalize sensory input through stimulation of the cutaneous nerves.

### **3.1 Evaluation of changes in cervical muscle tone using surface electromyography**

We present the effects of acupuncture treatment on a case of cervical dystonia with left lateral flexion-right rotation deviation of the neck (Case 1) (**Table 1**). In the prone position, surface electromyography of the bilateral sternocleidomastoid muscles and bilateral upper trapezius muscle fibers was recorded. As a result, a marked increase in muscle activity was observed in the left upper trapezius muscle fibers. Acupuncture was performed using stainless steel disposable needles (0.2 mm in diameter) placed at a depth of 5 mm into the left Bailao (Ex-HN15), an acupuncture point located on the left upper trapezius muscle fiber. After the


#### **Table 1.**

*Background of the patients.*

acupuncture treatment, muscle activity of the left upper trapezius muscle fibers decreased. Treatment was continued at weekly intervals, and after approximately 5 months, no abnormal activity was observed on the surface electromyogram in the supine position (**Figure 1**). However, in the sitting and standing positions, cervical deviation remained, and re-evaluation of the surface EMG in the sitting position revealed increased muscle activity in both the bilateral sternocleidomastoid and bilateral upper trapezius fibers (**Figure 2**). The same treatment was continued, and the patient no longer showed abnormalities in the surface EMG waveforms in the sitting position. This confirmed the importance of considering the treatment posture during acupuncture treatment.

#### **3.2 Effects of treatment on remote acupuncture points**

As mentioned above, it was confirmed that treatment to acupuncture points located above the affected muscle was effective. Next, we examined the effect of acupuncture treatment on meridians located at sites other than on the affected muscles. In Oriental medicine and acupuncture and moxibustion treatment, the meridians that pass through the site of the patient's symptoms are identified, and the acupuncture points belonging to these meridians are considered to be the treatment sites. The acupuncture point to be treated may be set at a remote location, not at the site of the symptoms. In the acupuncture treatment for cervical dystonia, the meridian running over the affected muscle was identified, and the acupuncture points on that meridian but distant from the affected muscle were used as the treatment site.

In a patient with cervical left lateral flexion-right rotation deviation (Case 2), a surface electromyogram was recorded, confirming increased muscle tone in the left upper trapezius muscle fibers. We then selected the left Waiguan (TE5) from the Triple Energizer meridian, which is a meridian that passes over the upper trapezius muscle fibers, and placed acupuncture needles on the left Waiguan (TE5). As a result, the peak-to-peak amplitude and mean rectified voltage of the surface electromyogram decreased with each passing minute, immediately after the needles were removed (POST 0), 5 minutes later (POST 5), and 10 minutes after (POST 10) the needles were removed, compared to before treatment, and improvement in neck posture was also observed (**Figure 3**). Such a phenomenon of a decrease in muscle tone over time

#### **Figure 1.**

*Long-term acupuncture treatment significantly reduced the abnormal muscle activity seen in each test muscle before acupuncture treatment. The effect of acupuncture treatment was pronounced when abnormal muscle activity was observed before acupuncture treatment. However, when no abnormal muscle activity was observed before acupuncture treatment, almost no change was observed.*

#### **Figure 2.**

*Surface EMG waveform changes with postural changes on the same examination day are shown. No abnormal EMG activity was observed in each examined muscle in the prone position, but in the sitting position, abnormal EMG activity was prominent.*

even after the needles were removed was not observed when the acupuncture points on the affected muscles were used as the treatment sites. These results indicate that acupuncture treatment at acupuncture points belonging to meridians running over the affected muscle and located remotely from the affected muscle is effective.

#### **3.3 Therapeutic acupuncture points for affected muscles of cervical dystonia**

After having treated the abnormal muscle tone of the upper trapezius muscle with the Waiguan (TE5) of the Triple Energizer meridian, we set up treatment acupoints

**Figure 3.** *Left trapezius EMG changes before and after stimulation of the left Waiguan (TE5).*

for the other affected muscles. For the sternocleidomastoid muscle, we used Hegu (LI4) of the Large Intestine meridian, and for the splenius muscle, we used Houxi (SI3) of the Small Intestine meridian or the Waiguan (TE5) of the Triple Energizer meridian. In addition, Kunlun (BL60) of the Bladder meridian is used for the levator scapulae muscle, and Chongyang (ST42) of the Stomach meridian is used for the oblique muscles. Furthermore, even in cases of cervical dystonia, the affected muscles that affect cervical bias may not be limited to the cervical muscles. For example, in cases of cervical retroversion, which is often difficult to treat, there may be decreased tone in the abdominal muscles and increased tone in the dorsal muscles in addition to cervical muscle problems. In this case, one can use the Stomach meridian, Chongyang (ST42) for the abdominal muscle group and the Bladder meridian, Kunlun (BL60) for the dorsal muscle group.

### **3.4 Setting the duration of acupuncture placement in adjusting muscle tone in affected muscles**

In general, the problem of dystonia is often thought of as hypertonia of the affected muscles. In fact, the standard treatment with botulinum therapy, alcohol blocks, and oral medications is thought to be aimed at decreasing hypertonia. However, the muscles affected by dystonia may show not only hypertonia but also hypotonia, which is described as "negative dystonia". For example, a surface electromyography study of a patient with left cervical rotation deviation may show no muscle activity in the right sternocleidomastoid muscle at rest. Furthermore, the left sternocleidomastoid muscle may not be fully engaged as the primary active muscle when the patient is asked to perform a right cervical rotation movement. In such cases, suppressing muscle tone in the right sternocleidomastoid muscle as a problem of left cervical rotation deflection does not lead to improvement of cervical posture. Therefore, treatment for decreased muscle tone should be considered.

We experienced an event in which we were able to increase muscle tone during acupuncture treatment of a patient. The patient had a left lateral flexion-right rotation bias of the neck (Case 3). We treated the affected muscle, the left sternocleidomastoid


#### **Figure 4.**

*The electromyographic waveform of the left sternocleidomastoid muscle was inhibited at 5 minutes after acupuncture stimulation and facilitated at 10 minutes after stimulation to left Hegu (LI4).*

by left Hegu (LI4), and observed changes in muscle activity using surface electromyography. Five minutes after the start of acupuncture stimulation, the muscle tone of the left sternocleidomastoid muscle was suppressed, but after following the time course, muscle activity of the left sternocleidomastoid muscle was observed again 10 minutes after the start of acupuncture stimulation (**Figure 4**). From this result, we considered that prolonging the duration of acupuncture stimulation could increase muscle tone. Thereafter, the stimulation time was shortened for the purpose of suppressing muscle tone and lengthened for the purpose of facilitating muscle tone. The standard duration of stimulation is from 5 minutes until muscle tone inhibition is confirmed and from 10 minutes until muscle tone stimulation is confirmed in the case of muscle tone stimulation. At this point, it is important to determine the exact point at which the effect is obtained since the time of effect differs depending on the affected muscle. In addition, as mentioned above, the same acupuncture points are used to treat one affected muscle for both muscle tone control to inhibit and facilitate. Therefore, it is even more important to confirm the stimulation time.

#### **3.5 Acupuncture treatment for involuntary movements**

Cervical dystonia requires treatment of the affected muscles. Along with this, treatment of involuntary movements is often necessary. In such cases, we treat the affected muscles that produce involuntary movements and simultaneously apply acupuncture to the acupuncture point on the head, Baihui (GV20). In Oriental medicine, it is believed that "wind" is responsible for involuntary movements. Baihui (GV20) is considered to be an acupuncture point to treat diseases that bring about "wind," and it is also effective in treating involuntary movements in dystonia. The needles used are 0.2 mm in diameter, and the depth of penetration is 5 mm or less, as with the acupuncture points for the affected muscles. The duration of stimulation should be determined by checking the degree of suppression of involuntary movements.

#### **3.6 Dealing with muscle shortening and skin shortening**

The primary disability brought about by dystonia is abnormal muscle tone and involuntary movements. However, if the affected muscles are in a state of persistent contraction, or if some muscles are inactive because of persistence of the same cervical bias, a secondary disorder may result in muscle shortening and skin shortening. In this case, in addition to acupuncture to the acupuncture points, the muscle shortening or skin shortening should be stretched. We use acupuncture needles that can be stimulated from the skin surface or stretched manually on the shortened skin

or muscles. The acupuncture needles used to stimulate the skin from the skin surface are called "syu-mou-shin," which are used in Japan to treat children and are used to stimulate the shortened area while stretching it.
