Optimizing treatment for cervical dystonia: botulinum toxin alone or combined with physical therapy?

Idiopathic cervical dystonia (ICD) is a chronic movement disorder characterized by involuntary neck muscles contractions, leading to pain, disability, and poor quality of life. While botulinum toxin (BTX) type A is the first-line treatment, its efficacy on non-motor symptoms is limited. Physical therapy (PT) may act synergistically and improve functional outcomes.

To evaluate whether BTX with tailored PT yields superior clinical outcomes compared to BTX alone in ICD patients, focusing on motor severity, disability, pain,mood, and quality of life.

This is a monocentric crossover trial on adults with ICD receiving stable BTX. They were randomized to two treatment sequences (BTX → BTX+PT or BTX+PT → BTX), with a 4-week washout. PT consisted of a six-week individualized program including daily home exercises and weekly supervised sessions. Outcomes were assessed using TWSTRS, BDI-II, SAS, and CDIP-58.

Among 20 enrolled patients, 18 completed the trial. Both treatments improved TWSTRS total scores (p = 0.0001), with greater improvement in the BTX+PT group (p = 0.0024). PT addition significantly reduced disability (p = 0.0024), pain (p = 0.0024), and depression (p = 0.0089). Anxiety improved, without significant between-group differences. CDIP-58 scores showed greater quality-of-life gains with BTX+PT (p < 0.0001).

BTX with PT shows greater effectiveness than BTX alone in managing ICD, improving motor and non-motor symptoms. These findings support the integration of individualized PT into standard care to optimize clinical benefits.