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Torticollis

Torticollis, or wry neck, is a condition in which the head is tilted toward one side, and the chin is elevated and turned toward the opposite side. Torticollis can be congenital or acquired. The etiology of congenital torticollis is unclear, but it is thought that birth trauma causes damage to the sternocleidomastoid muscle in the neck, which heals at a shorter length and causes the characteristic head position. Sometimes a mass in the muscle may be noted, but this mass may disappear within a few weeks of birth. more...

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If the condition is detected early in life (before one year of age) it is treated with physical therapy and stretching to correct the tightness. The use of a TOT Collar can also be very effective. This treatment is usually all that is necessary to fix the problem. Particularly difficult cases may require surgical lengthening of the muscle if stretching fails. Also, if the condition does not respond well to stretching, other causes such as tumors, infections, ophthalmologic problems and other abnormalities should be ruled out with further testing. If torticollis is not corrected before one year of age, facial asymmetry can develop and is impossible to correct.

Acquired torticollis occurs because of another problem and usually presents in previously normal children. Trauma to the neck can cause atlantoaxial rotatory subluxation, in which the two vertebrae closest to the skull slide with respect to each other, tearing stabilizing ligaments; this condition is treated with traction to reduce the subluxation, followed by bracing or casting until the ligamentous injury heals. Tumors of the skull base (posterior fossa tumors) can compress the nerve supply to the neck and cause torticollis, and these problems must be treated surgically. Infections in the posterior pharynx can irritate the nerves supplying the neck muscles and cause torticollis, and these infections may be treated with antibiotics if they are not too severe, but could require surgical debridement in intractable cases. Ear infections and surgical removal of the adenoids can cause an entity known as Grisel's syndrome, in which a bony bridge develops in the neck and causes torticollis. This bridge must either be broken through manipulation of the neck, or surgically resected. There are many other rare causes of torticollis.

Evaluation of a child with torticollis begins with history taking to determine circumstances surrounding birth, and any possibility of trauma or associated symptoms. Physical examination reveals decreased rotation and bending to the side opposite from the affected muscle; 75% of congenital cases involve the right side. Evaluation should include a thorough neurologic examination, and the possibility of associated conditions such as developmental dysplasia of the hip and clubfoot should be examined. Radiographs of the cervical spine should be obtained to rule out obvious bony abnormality, and MRI should be considered if there is concern about structural problems or other conditions. Evaluation by an ophthalmologist should be considered in older children to ensure that the torticollis is not caused by vision problems. Most cases in infants respond well to physical therapy. Other causes should be treated as noted above.

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Adult torticollis
From Dynamic Chiropractic, 1/27/03 by Cerf, John

Emergency -Room Chiropractor

Pain medications and muscle relaxants have limited effects in certain individuals. One such man presented to the Emergency Department (ED) complaining of having awoken with severe neck pain and immobility. The attending ED physician diagnosed the patient as suffering from acute torticollis. The patient was medicated first with an intramuscular injection of Toradol and oral Flexeril, which proved ineffective. Injection of the narcotic Demarol followed. Reporting minor relief, the patient was discharged with prescriptions for both a nonsteroidal anti-inflammatory analgesic and a muscle relaxant.

The patient returned to the ED later that evening. He complained that neither his pain nor his mobility had improved, in spite of all the medication. The evening ED shift decided to obtain a chiropractic consultation, hoping to increase the patient's mobility and decrease pain and the need for additional narcotic analgesia.

History and examination revealed findings consistent with a diagnosis of acute spasmodic torticollis. The patient exhibited severely restricted cervical ranges of motion, antalgia, muscle spasm and vertebral joint fixation. Radiographic examination revealed signs of degenerative joint disease, but was negative for fracture or pathology.

I applied electrical muscle stimulation and moist heat to the patient's neck in preparation for spinal manipulation. The purpose of the adjunctive therapy was to help relax muscle and ease pain to facilitate the manual procedures and spinal adjustment. As the patient relaxed with the adjunctive therapy, we discussed the severity of his pain and immobility in contrast to the lack of significant examination and radiographic findings. The patient appeared to understand that the torticollis was a protective splinting caused by the brain's perception of bodily injury. As with many torticollis patients presenting to our ED, there was no history of trauma or illness to explain the severity of the patient's symptoms. Patient history included frequently sleeping near an open window or in front of an air conditioner.

After removing the adjunctive therapy modalities, I performed manual therapy to further increase the patient's mobility before performing cervical adjustments. With the patient seated, I asked him to turn his head as far as possible to the painful side. I held his head still and asked him to try to turn further. I instructed him to push hard, but not enough to move my hands. After a few seconds, I told him to relax. As he relaxed, I also relaxed my grip on his head, allowing his head to move slightly toward the painful side. I had the patient repeat this several times, and then several times to the other side, until he appeared unable to achieve increased range of motion.

For the second part of the manual therapy, I stood behind the patient, held his mastoid and parietal areas between my hands, and lifted gently. I held my forearms against his shoulders and asked him to push up against my resistance. As he pushed, I instructed him to take a deep breath and hold it. The patient's physical and emotion tension increased as he simultaneously contracted his upper trapezius muscles and held his breath. I asked him to concentrate on the feeling of relaxation as he lowered his shoulders and exhaled. As he released the tension on his upper trapezius muscles, I added additional traction force. The patient repeated this procedure several times until less muscle spasm was palpable.

With the patient more relaxed and in less pain, I proceeded to have him lie supine for cervical adjustments. I attempted to put the patient at ease by explaining that we would approach adjustment of his neck in a slow, progressive, "step-wise" fashion. I explained that he might hear a popping sound as the joints moved, which could be loud, as it involved the inner ear, separated from the cervical spine by little more than an inch. I assured him that if at any time during the procedure, he had a sense that the adjustment would hurt, he could let me know and I would defer the adjustment for another day. I also demonstrated the amount of force I would use by making a sample adjusting thrust to his arm. Cervical adjustments were performed bilaterally, with increased mobility noted.

The patient tolerated the entire procedure well and without complications. His range of motion was approximately 90 percent of normal upon discharge from the ED. He did not require any additional prescriptions for medication. Upon leaving. he stopped at the nurse's station to thank the staff for its help and to demonstrate his increased range of motion.

John Cerf, DC

Jersey City, New Jersy

A printable version of Dr. Cerf's article is available online at www.ChiroWeb.com/ columnist/cerf. You may also leave a comment or ask a question at his "Talk Back" forum at the same location.

John Cerf, DC. Dr. Cerf's articles, a "Talk Back" forum and a brief biography of the author are available online at www.ChiroWeb.com/columnist/cerf.

John Cerf, DC

Jersey City, New Jersey

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