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

Background: 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. Objective: 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. Methods: 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. Results: 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). Conclusions: 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.