Spasmodic torticollis

Definition

Torticollis (cervical dystonia or spasmodic torticollis) is a type of movement disorder, in which the muscles controlling the neck cause sustained twisting or frequent jerking.

Description

In torticollis, certain muscles controlling the neck undergo repetitive or sustained contraction, causing the neck to jerk or twist to the side. Cervical dystonia causes forward twisting, and is called antecollis. Backward twisting is known as retrocollis. The abnormal posture caused by torticollis is often debilitating, and is usually painful.

Torticollis most commonly begins between age 30- 60, with females affected twice as often as males. According to the National Spasmodic Torticollis Association, torticollis affects 83,000 people in the United States. Dystonia tends to become more severe during the first months or years after onset, and may spread to other regions, especially the jaw, arm, or leg. Torticollis should not be confused with other causes of abnormal neck posture, such as orthopedic or congenital problems.

Causes & symptoms

The nerve signals responsible for torticollis are thought to originate in the basal ganglia, a group of brain structures involved in movement control. The exact defect is unknown. Some cases of dystonia are due to the inheritance of a defective gene, whose function was unknown as of mid-1998. Other cases are correlated with neck or head trauma, such as from an automobile accident. Use of certain antipsychotic drugs, or neuroleptics, can induce dystonia.

There are three types of torticollis:

• Tonic, in which the abnormal posture is sustained
• Clonic, marked by jerky head movements.
• Mixed, a combination of tonic and clonic movements

Symptoms usually begin gradually, and may be intermittent at first, worsening in times of stress. Symptoms usually progress over two to five years , and then remain steady. Symptoms may be relieved somewhat when lying down. Many people with torticollis can temporarily correct their head position by sensory tricks, as touching the chin or cheek on the side opposite the turning. The reason for the effectiveness of this "geste antagoniste," as it is called, is unknown.

Pain in the neck, back, or shoulder affects more than two-thirds of all people with torticollis. Pain may spread to the arm or hand.

Diagnosis

Diagnosis of torticollis is aided by an electrical study (electromyography) that can detect overactive muscles. Imaging studies, including x rays, may be done to rule out other causes of abnormal posture. A detailed medical history is needed to determine possible causes, including trauma.

Treatment

A variety of oral drugs are available to relax muscles, including baclofen. For a subgroup of patients, L-dopa provides effective relief. Denervation of the involved neck muscles may be performed with injection of alcohol or phenol on to the nerve.

Injection of botulinum toxin (BTX) is considered by many to be the treatment of choice. By preventing release of chemical messages from the nerve endings that stimulate the involved muscles, BTX partially paralyzes the muscles, therefore allowing more normal posture and range of motion. BTX treatment lasts several months, and may be repeated.

Physical therapy can help relieve secondary consequences of torticollis. Regular muscle stretching prevents contracture, or permanent muscle shortening. Pain and spasm may be temporarily lessened with application of heat or ice. Stress management techniques may help prevent worsening. An occupational therapist can suggest home or work modifications to reduce fatigue and improve function. Braces constructed to replace the patient's own sensory tricks may help reduce abnormal posture.

Alternative treatment

Biofeedback may be effective for some patients. Regular massage therapy can reduce additional pain in compensating areas of the body. Two energy-based therapies, acupuncture and homeopathic medicine, can work to rebalance the whole person, helping to correct the torticollis. Antispasmodic herbs may help to relax the muscles. In addition, herbs that can help balance the stimulus from the nervous system are often recommended.

Prognosis

Spontaneous remission is seen in up to 20% of patients, most often those patients with older onset and milder symptoms. Dystonia may spread to affect other regions of the body.

Prevention

There is no way known to prevent torticollis.

Further Reading

For Your Information

Books

• Watts, R.L., and W.C. Koller, eds. Movement Disorders. New York: McGraw-Hill, 1997.

  Organizations

• National Spasmodic Torticollis Association. PO Box 5849, Orange, CA 92863-5849. (800) HURTFUL. http://www.bluheronweb.com/nsta/nsta.htm.
• WE MOVE. One Gustave L. Levy Place, Box 1052, New York, NY 10029. (800) 437-MOV2. http:// www.wemove.org.

Gale Encyclopedia of Medicine. Gale Research, 1999.