CASE REPORT
Sustainable Improvement of Anterocollis-type Cervical Dystonia with a Hanger Reflex Device: A Case Report
2024 Volume 11 Pages 263-266
Details
2024 Volume 11 Pages 263-266
The hanger reflex is an automatic head rotation movement. When individuals wear a wire clothes hanger on the head to compress the frontotemporal region, the head spontaneously rotates toward the compressed side. The device to induce the hanger reflex was first developed for treating rotation-type cervical dystonia, followed by the development of a device for anterocollis-type cervical dystonia. However, there is a lack of comprehensive clinical reports on hanger reflex treatments, especially for anterocollis-type dystonia. We present the case of anterocollis that completely resolved after hanger reflex treatment without any other invasive treatment. In the treatment, patients wear the device on their heads for 30 min once per day. Hanger reflex treatment is an easy, simple, noninvasive, and inexpensiveness approach that may be considered the first choice for cervical dystonia.
When individuals wear a wire clothes hanger on the head to compress the frontotemporal region with its longer side, the head spontaneously rotates toward the compressed side (Fig. 1).1) This is called the "hanger reflex." 1,2) It is hypothesized to be an automatic movement addressing the uncomfortable sensation of skin shearing force.3)
Illustration of the original hanger reflex; the head spontaneously rotates toward the compressed side (A). A device for anterocollis-type cervical dystonia; the forehead skin is pulled upward (red arrow), and a downward-to-upward hanger reflex is induced (B, C, D, E).
In 1991, Christensen reported two cases of rotation-type cervical dystonia treated by placing a cardboard box on the head and rotating it contralateral to the involuntary movement.4) In the 2000s, a device designed to induce the hanger reflex was first developed for rotation-type cervical dystonia.5) Subsequently, a device for anterocollis-type cervical dystonia was then developed. Its mechanism is that pulling the forehead skin upward facilitates turning the dropped head forward and upward.
Several reports have highlighted considerable improvement in symptoms with hanger reflex treatment.5-7) However, there is a lack of comprehensive clinical reports on hanger reflex treatments, especially for anterocollis-type dystonia.
In this study, we present a case of anterocollis-type cervical dystonia that was dramatically improved by a hanger reflex device for anterocollis.
A woman in her 70s diagnosed with angina pectoris and osteoporosis, receiving nicorandil and eldecalcitol, was referred to our hospital for scoliosis that had developed 5 months after a left-rib fracture. Although the scoliosis has slightly remained, it spontaneously improved within 3 months while she underwent imaging tests, and anterocollis subsequently developed. The persistent neck anteflexion, which lacked phasic movement, was characterized by stereotypy and morning benefit without task specificity. A sensory trick was also observed; wearing a soft neck collar slightly relieved the anterocollis. Touching the forehead and/or occiput did not act as a sensory trick. It was challenging for her to keep looking forward and upward, and her daily activities were severely affected. We diagnosed her with tonic anterocollis-type cervical dystonia and prescribed clonazepam for 1 month. However, the symptoms did not improve, and she discontinued medications due to the side effect of sleepiness. Other medications were not prescribed due to the patient's concerns about potential complications.
Three months after anterocollis developed, it did not improve spontaneously and remained severe. We then prescribed a hanger reflex device (TSS Co., Tokyo, Japan) (Fig. 1). Initially, she wore the device, and we confirmed the presence of the hanger reflex; she felt slight facilitation to look forward. Subsequently, she started wearing the device on the head once daily for 30 min.
The degree of anterocollis improved within 2 weeks of the device usage. Symptoms completely resolved in 8 months (Fig. 2). After 8 months of the device usage, the movement scores on the Burke-Fahn-Marsden Dystonia Rating Scale improved from 6 to 1, and the severity scores on the Toronto Western Spasmodic Torticollis Rating Scale decreased from 25 to 1 (Fig. 3). The patient has not received any other invasive treatment, while she continued using the hanger reflex device for over 1 year, with no side effects of the hanger reflex treatment.
Anterocollis symptom before treatment (A). Although anterocollis persisted, the patient found it easier to turn the head forward when wearing the hanger reflex device on the head for the first time (B). Anterocollis comparatively improved at 1 month of the device usage (C, D). Anterocollis had completely resolved in 8 months (E, F).
Changes in the movement and disability scores of the Burke-Fahn-Marsden Dystonia Rating Scale and severity, disability, and pain score of the Toronto Western Spasmodic Torticollis Rating Scale.
Verbal and written informed consent were obtained from the patient.
We presented a case of cervical dystonia in which anterocollis resolved using a hanger reflex-inducing device. There is only one case with anterocollis treated with the device,6) and this detailed case report will be valuable when considering treatment for similar cases.
Commonly employed treatments for cervical dystonia, such as botulinum toxin injection (generally first-line) and deep brain stimulation,8) are associated with high cost, invasiveness, and technical intricacies. Conversely, the hanger reflex device treatment is noninvasive, simple, and inexpensive. Therefore, we opted for this treatment before considering botulinum toxin. Since the efficacy was observed within 2 weeks with gradual relief of anterocollis, additional invasive treatment was not considered necessary.
The hanger reflex is hypothesized to be an automatic movement addressing the uncomfortable sensation of skin shearing force.3) It has been confirmed that the reflex occurs not only around the head but also around the wrists, ankles, and lumbar area,6) and the body part turns toward resolving the discomfort. Unlike sensory tricks, occasionally observed in dystonia, this reflex occurs in individuals without dystonia and is observed in >95% of normal individuals.7) The hanger reflex increases the cervical rotator muscles in normal individuals9) and relaxes abnormal muscle contractions in patients with cervical dystonia.10) Although higher body mass index and younger age were respectively suspected to be associated with less active muscle contractions,9) and mental conditions such as nervousness might also be related to not feeling the autonomic movement, the mechanism of non-response remains unclear.
Pathophysiology of dystonia is known to be associated with the sensory system, and the importance of developing new therapeutic strategies using the character is emphasized.11) According to our experience and previous reports,4-6) the repetitive hanger reflex input may induce corrective changes in the brain network and prevent the recurrence of involuntary movement even without device usage.
The suitable types of dystonia for hanger reflex treatment remain unclear. A potential indicator of efficacy could be a head rotation sensation while wearing the device, even without observable rotation movement. Since the hanger reflex acts unidirectionally, treatment may be more effective for tonic-type dystonia than for phasic-type dystonia. Treatment efficacy was observed within 2 weeks and considerable improvement within a few months.4,5) Therefore, it is appropriate to judge treatment effectiveness after several months and decide whether to continue or change the treatment strategy.
This study has a limitation; just as scoliosis improved, there was a possibility that anterocollis also spontaneously improved over time. However, as with previous reports,4-6) the symptomatic relief was observed immediately after the device usage and the treatment efficacy within 2 weeks, and significant improvement was achieved within 3 months. The therapeutic course of the present case was similar to previous reports of rotation- and anterocollis-type cervical dystonia.4-6) Therefore, it is more reasonable to attribute the symptom resolution to a therapeutic effect.
This study emphasizes the potential of the hanger reflex device as the primary choice for treating cervical dystonia owing to its noninvasiveness, simplicity, and inexpensiveness. Further investigations with a large case number are warranted to substantiate these findings.
The authors declare no conflicts of interest.
