Reperfusion of tissues subjected to prolonged ischaemia results in ischaemic/reperfusion injury. Fortunately, there are strategies that can be applied to attenuate this injury. These include ischaemic pre- and post-conditioning; both have been shown experimentally to reduce ischaemic/reperfusion injury by up to 75%. The molecular mechanisms of ischaemic conditioning involve the activation of surface G-protein-coupled receptors for adenosine, bradykinin, opioids, and cannabinoids. These in turn stimulate growth receptors which then trigger the activation of cytoprotective pathways resulting in a reduction in apoptosis via the mitogen-activated protein kinase/extracellular-signal regulated kinase 1/2 kinase route and a reduction in opening of mitochondrial permeability transition pores (mPTPs) via the phosphatidylinositol 3-kinase pathway. Opening of mPTPs can cause cell death. Recently, activated surface tumour necrosis factor-α receptors have been shown to also contribute to cytoprotection by activating the Janus kinase and the signal transducer and activating factor of transcription-3 pathway. Research into the mechanisms of ischaemic conditioning is still ongoing and hopefully, with the better understanding of this phenomenon, new therapeutic strategies, with possible translation into meaningful clinical trials, will be developed to reduce ischaemic/reperfusion injury.

This case describes the successful addition of acupuncture to treat a patient with cervical dystonia previously managed with Botox (botulinum toxin) injections. This resulted in reduced pain and muscle spasm relief and to the authors' knowledge is the fi rst case to be reported using this treatment combination. The patient was diagnosed with the idiopathic variant of cervical dystonia and had been treated with regular Botox injections for almost a year and half. She was then referred for a course of acupuncture to manage pain and reduce excessive muscle tone. She had excellent benefi t from the acupuncture and she continued to get top-ups of acupuncture every 8-10 weeks. Requirement for Botox injections had decreased thus reducing its long-term side effects. CASE REPORTThis case report details the successful use of acupuncture in conjunction with Botox injections for the management of cervical dystonia.A 65-year-old woman presented to our clinic with an 8-year history of torticollis, mainly affecting her left side, forcing her to adopt an awkward posture. This reduced neck mobility was suffi cient to stop her driving. Figure 1 shows the patient's usual posture before acupuncture treatment. She complained of pain in her left lower cervical area. Movements were reduced and painful particularly when she attempted right lateral fl exion and rotation. This had been steadily worsening over the past few years and by 2005 she was not able to lift her head most of the time. There was no signifi cant aetiology to explain the onset of symptoms and after confi rming diagnosis of an idiopathic variant of cervical dystonia, she was referred to the neuro-rehabilitation doctor in 2005 for a course of Botox (500 units type A toxin -Dysport) injections into her left trapezius, sternocleidomastoid and splenius capitis muscles. This initially gave her excellent benefi t. After two further repeat injections she was referred in February 2006 for a course of acupuncture to manage pain and reduce excessive muscle tone.Her past history included ischaemic heart disease, refl ux oesophagitis, Figure 1 Before acupuncture treatment -simulated views. thalassaemia minor and hypertension. Her drug treatment included aspirin, clopidogrel, atenolol, baclofen, losartan, bendrofl umethiazide, simvastatin, esomeprazole and amitriptyline. ExaminationOn examination she sat with her head turned to the left and her neck in forward and lateral fl exion. All movements of her neck were restricted. Turning her head to the right, lateral rotation to the right and lateral fl exion were almost impossible. The superior and middle fi bres of her left trapezius were very fi rm, tight and tender on palpation. She also had diffuse tenderness on the left side of her neck and over the left supra scapular and infra scapular area (fi gure 2). TreatmentThe normal practice in our acupuncture clinic, dictated by time constraints, is to administer four weekly sessions of Western medical acupuncture followed by top-ups (consisting of single sessions) if the initial...