How Do You Treat Dystonic Movements in the Upper Extremity in Your Practice? (2024)

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.

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.

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Dystonia is an extrapyramidal-tract disease characterized by abnormal posture or involuntary movement of any part of the body. Upper-limb dystonia is a focal disease. The symptoms of upper-limb dystonia include difficulty with writing or drawing (writer's cramp), playing a musical instrument (musician's cramp), typing, and other activities.

Previously, we reported a novel acupuncture method combined with modern biomedical techniques and ancient Chinese/Japanese Traditional Medicine for treating cervical dystonia. To achieve satisfactory therapeutic effects, we categorized subjects into groups according to primary and secondary disorders, using motion analysis: (1) abnormal muscle hypertonia or hypotonia and involuntary head movements were considered primary disorders; and (2) muscle- and skin-tightening were considered secondary disorders. We used the needle-retaining method to treat primary disorders and multiple epidermis–penetrating needle stimulation of tender points to treat secondary disorders. We applied various specific acupuncture treatments for each cervical dystonia group once per week. Clinical examination of the patients indicated improvement of 72.9% after 10 acupuncture sessions.

The protocol used in our acupuncture method for treatment of upper-limb dystonia is as follows. First, we use scalp or hairline acupuncture (advocated by Seikichi Wada) at the “upper-limb area.” Second, we use acupoints along meridians through the affected muscles (Meridian concept). Third, we evaluate tightening of the skin and muscles on the hands. If we observe tightening, we use multiple epidermis-penetrating needles to allow the tissues to stretch.

Acupuncture for Treating Upper-Limb Dystonia

Our method is as follows. First, we observe each patient for abnormal writing movements and search for an associated muscle with abnormal tone. If the patient has another symptom (e.g., difficulty with playing an instrument, typewriting, etc., we observe the movement that elicits the symptom and perform a motion analysis. For all patients, we use the upper-limb area for hairline acupuncture. The upper-limb area is located as follows: separate the diagonal hairline above the sideburns into three parts; then, use an acupuncture needle to pierce 2 cm from the upper 1/3 point to the vertex.

If the patient has a strong involuntary movement, we use the GV 20 (Baihui) or GB 20 (Fengchi) acupoints. Then, we use retaining needles at acupoints selected according to the meridian concept. We usually find that the affected muscle is the anterior deltoid. If the anterior deltoid muscle is hypotonic, the patient cannot raise the upper limb. Moreover, if the serratus anterior muscle is hypotonic, the patient cannot move the upper limb freely. In addition, if the abdominal muscles are hypotonic, the torso becomes unstable and the patient cannot use the upper limbs well.

Abnormal muscle tone is elicited in the anterior deltoid when we use the LI 4 (Hegu) acupoint. Patients will sometimes show abnormal abdominal muscle tone when we use the ST 42 (Chongyang) acupoint. Abnormal muscle tone can be observed in the serratus anterior when we use the GB 40 (Qiuxu) acupoint. To stimulate an acupoint, we insert the needle ∼2–5 mm. The length of needle-retention time is important. We recommend at least 10 minutes for hypotonia and ∼5–10 minutes for hypertonia. However, it is essential to confirm that each muscle tone improves.

Results

Both writing and subjective evaluation scores were significantly improved after 3 weeks of acupuncture treatment in all 3 subjects.

Conclusions

These findings suggest that acupuncture therapy with multiple epidermis-penetrating needles and retained needles is beneficial for treating writer's cramp.

References