What is spasmodic torticollis. How does it affect the neck muscles. What are the main symptoms of this condition. What causes acute torticollis. How is spasmodic torticollis diagnosed and treated. Can torticollis be prevented. What is the long-term outlook for people with this condition.

Understanding Spasmodic Torticollis: A Twisted Tale of Neck Pain

Spasmodic torticollis, also known as cervical dystonia, is a neurological disorder characterized by involuntary contractions of the neck muscles. These contractions cause the head to twist or turn to one side, tilt forward or backward, or pull toward the shoulder. The term “torticollis” literally means “twisted neck” in Latin, aptly describing the main feature of this condition.

This disorder can significantly impact a person’s quality of life, causing pain, discomfort, and embarrassment. Understanding the intricacies of spasmodic torticollis is crucial for those affected and their caregivers. Let’s delve deeper into this condition, exploring its symptoms, causes, and treatment options.

Recognizing the Symptoms: When Your Neck Has a Mind of Its Own

The symptoms of spasmodic torticollis can vary from person to person, but typically include:

• Involuntary turning or tilting of the head
• Neck pain that may radiate to the shoulders
• Muscle stiffness and tenderness
• Headaches
• Tremors in the head or neck
• Raised shoulder on the affected side

These symptoms often worsen with stress, fatigue, or certain activities. They may also fluctuate in severity throughout the day.

How does spasmodic torticollis affect daily life?

The impact of spasmodic torticollis extends beyond physical discomfort. Many individuals with this condition experience:

• Difficulty performing routine tasks
• Impaired ability to drive or operate machinery
• Social anxiety and self-consciousness
• Reduced productivity at work
• Sleep disturbances due to pain and discomfort

Unraveling the Causes: Why Does Torticollis Occur?

The exact cause of spasmodic torticollis remains a mystery in many cases. However, researchers have identified several potential contributing factors:

1. Genetic predisposition
2. Abnormalities in the basal ganglia of the brain
3. Trauma to the neck or head
4. Certain medications
5. Infections
6. Stress and environmental factors

It’s important to note that acute torticollis, which develops suddenly and is often temporary, can have different causes than chronic spasmodic torticollis.

Can torticollis be triggered by specific activities?

While the underlying cause of spasmodic torticollis is often unclear, certain activities or conditions may trigger or exacerbate symptoms:

• Poor sleeping posture
• Prolonged use of electronic devices (tech neck)
• Carrying heavy, unbalanced loads
• Exposure to cold drafts
• Emotional stress

Diagnosing the Twist: How Doctors Identify Torticollis

Diagnosing spasmodic torticollis typically involves a comprehensive approach:

1. Medical history review
2. Physical examination
3. Neurological assessment
4. Imaging tests (in some cases)
5. Electromyography (EMG) to assess muscle activity

While acute torticollis can often be diagnosed based on symptoms alone, chronic cases may require more extensive evaluation to rule out other conditions.

Are there specific tests to confirm spasmodic torticollis?

While there’s no single definitive test for spasmodic torticollis, several diagnostic tools can help confirm the condition:

• CT or MRI scans to check for structural abnormalities
• Blood tests to rule out infections or other systemic disorders
• Genetic testing if a family history is present
• Specialized movement disorder assessments

Treating the Twist: Strategies for Managing Torticollis

Treatment for spasmodic torticollis aims to relieve symptoms, improve function, and enhance quality of life. The approach often involves a combination of therapies:

1. Botulinum toxin injections
2. Physical therapy and exercises
3. Pain management techniques
4. Medications (muscle relaxants, pain relievers)
5. Deep brain stimulation (in severe cases)
6. Complementary therapies (acupuncture, massage)

The effectiveness of treatment can vary, and a personalized approach is often necessary to achieve the best results.

How effective are botulinum toxin injections for torticollis?

Botulinum toxin injections are considered the gold standard treatment for spasmodic torticollis. They work by temporarily paralyzing the affected muscles, reducing involuntary contractions. Benefits include:

• Significant reduction in pain and muscle spasms
• Improved head and neck posture
• Enhanced ability to perform daily activities
• Effects typically last 3-6 months before reinjection is needed

Living with Torticollis: Coping Strategies and Lifestyle Adjustments

Managing spasmodic torticollis often requires more than just medical treatment. Lifestyle adjustments and coping strategies can play a crucial role in improving quality of life:

1. Ergonomic modifications at home and work
2. Stress management techniques
3. Regular exercise and stretching routines
4. Support groups and counseling
5. Adaptive devices and assistive technology

These strategies can help individuals with torticollis maintain independence and reduce the impact of the condition on daily life.

How can stress management help in controlling torticollis symptoms?

Stress is known to exacerbate symptoms of spasmodic torticollis. Effective stress management techniques can help by:

• Reducing muscle tension and spasms
• Improving overall relaxation and well-being
• Enhancing coping mechanisms
• Potentially decreasing the frequency and severity of symptoms

Preventing the Twist: Can Torticollis Be Avoided?

While chronic spasmodic torticollis may not be preventable, there are steps that can be taken to reduce the risk of acute torticollis and manage existing conditions:

1. Maintaining good posture
2. Using proper ergonomics when working or using devices
3. Regular neck exercises and stretches
4. Avoiding prolonged static positions
5. Managing stress effectively

These preventive measures can also help individuals with chronic torticollis minimize flare-ups and maintain better overall neck health.

Can certain neck exercises help prevent or manage torticollis?

Specific neck exercises can be beneficial for both prevention and management of torticollis:

• Gentle neck rotations and stretches
• Isometric exercises to strengthen neck muscles
• Chin tucks to improve posture
• Shoulder blade squeezes to support upper back strength

It’s important to consult with a healthcare professional or physical therapist before starting any new exercise regimen, especially if you have existing neck issues.

The Long-Term Outlook: Living with Spasmodic Torticollis

The prognosis for individuals with spasmodic torticollis can vary widely. While there is currently no cure for the chronic form of the condition, many people experience significant improvement with proper treatment and management:

• Some individuals may achieve long-term remission
• Others may require ongoing treatment to control symptoms
• Quality of life can often be substantially improved with proper care
• Advances in treatment options continue to offer hope for better outcomes

It’s important for those affected by torticollis to work closely with their healthcare team to develop a comprehensive, long-term management plan.

Does spasmodic torticollis worsen over time?

The progression of spasmodic torticollis can vary:

• Some cases may stabilize or even improve with time and treatment
• Others may gradually worsen, especially if left untreated
• Early intervention and consistent management can help slow progression
• Regular monitoring and treatment adjustments are often necessary

Understanding the unpredictable nature of the condition can help individuals and their caregivers better prepare for the future and maintain a proactive approach to management.

Spasmodic torticollis, while challenging, is a condition that can be effectively managed with the right approach. By understanding its symptoms, causes, and treatment options, individuals affected by this disorder can take control of their health and improve their quality of life. Remember, each case is unique, and what works for one person may not work for another. Patience, persistence, and a strong partnership with healthcare providers are key to navigating the twisted path of torticollis and finding relief.

Spasmodic Torticollis (Twisted Neck) | Symptoms, Causes and Treatment

In this series Neck Pain Cervical Spondylosis Whiplash Neck Sprain

Torticollis means ‘twisted neck’. It is also often called ‘wry neck’. 

Torticollis

Twisted Neck

In this article

• What is torticollis?
• Torticollis symptoms
• Do I need any tests for torticollis?
• What causes acute torticollis?
• What are the other causes of torticollis?
• Acute torticollis treatment
• What about medicines?
• What about other treatments?
• How quickly does it get better?

What is torticollis?

Torticollis – another name for having a ‘twisted neck’ or a ‘wry neck’ – often happens suddenly. You go to bed without any symptoms one night and then you simply wake up the following morning with a wry neck. This is known as acute torticollis.

It is a very common cause of neck pain and stiffness. However, although it can be very painful when you are affected by it, most people with the condition do not actually need to see their doctor, as simple treatment such as painkillers can be really effective.

Torticollis symptoms

Developing a wry neck (acute torticollis) occurs when the muscles supporting your neck on one side become painful. These symptoms usually come on very quickly, often overnight, so that you wake up with pain and stiffness down one side of your neck.

• The pain is usually just on one side of your neck and stiffness of the muscles in that area twists the neck to one side.
• You may find it very difficult when you try to straighten your neck, due to pain.
• Occasionally, the pain is in the middle of your neck.
• The pain may spread to the back of your head or to your shoulder.
• The muscles of your affected side may be tender.
• Pressure on certain areas may trigger a ‘spasm’ of these muscles.
• Movement of your neck is restricted, particularly on one side.

Do I need any tests for torticollis?

The good news is that usually you will not need to have any tests to find out what is causing the problem. The diagnosis of sudden-onset wry neck (acute torticollis) is made from the typical symptoms. Many people with milder symptoms diagnose this on their own. Your doctor or a healthcare professional can usually make the diagnosis by performing an examination of your neck.

The examination can usually confirm the diagnosis and will also usually exclude the rarer causes of torticollis. Tests such as an X-rays are not generally needed. Your doctor would only refer you for further tests if a condition other than acute torticollis is suspected.

What causes acute torticollis?

The cause of sudden-onset wry neck (acute torticollis) is often not known. It can happen in people with no previous neck symptoms. It is a common cause of neck pain in young people. There is usually no obvious injury.

However, it may be due to a minor sprain or irritation of a muscle or ligament in the neck. Some reasons for this include:

• Sitting or sleeping in an unusual position without adequate neck support.
• Poor posture when looking at a computer screen.
• Carrying heavy unbalanced loads (for example, a briefcase or shopping bag).
• Allowing certain muscles of the neck to be exposed to cold (sleeping in a draught).

What are the other causes of torticollis?

Cervical dystonia

Cervical dystonia (also known as spasmodic torticollis) is a problem where abnormal movements develop in the muscles of the neck. It most often occurs in people over the age of 40 years.

You cannot control the contraction of the neck muscles which produce abnormal movements and postures of the neck and head. These can be either twisting (torticollis), being pulled forwards (antecollis), backwards (retrocollis), or sideways (laterocollis).

Cervical dystonia can range from being mild to severe. There is no cure. However, regular injections of botulinum toxin, which paralyse the affected muscles, are the most effective treatment.

Other less common causes

More rarely, torticollis in the neck occurs as a result of other conditions. These include:

• Infections of your throat or upper airways. These can cause swelling in the lymph glands in your neck or infections in your skin and underlying tissues. The inflammation can trigger a spasm in your neck muscles.
• Any abnormality or injury of your neck (cervical spine). For example, cervical spine tumours or blood vessel abnormalities.
• As a side-effect of certain medicines – for example, phenothiazines.

Acute torticollis treatment

The aims of treatment for sudden-onset wry neck (acute torticollis) are to relieve the pain and try to reduce the stiffness in your muscles. The following may be advised:

Exercise your neck and keep active

Aim to keep your neck moving as normally as possible. At first the pain may be quite bad and you may need to rest for a day or so. However, gently exercise the neck as soon as you are able to. You should not let it stiffen up.

Gradually try to increase the range of the neck movements. Every few hours gently move your neck in each direction. Do this several times a day. As far as possible, continue with normal activities. You will not cause damage to your neck by moving it.

You should avoid driving until you can move your neck freely and without any pain.

What about medicines?

Painkillers are often helpful.

• Paracetamol at full strength is often sufficient. For an adult this is two 500 mg tablets, four times a day.
• Anti-inflammatory painkillers. Some people find that these work better than paracetamol. They can be used alone or combined with paracetamol. They include ibuprofen which you can buy at pharmacies or obtain on prescription. Other types such as diclofenac or naproxen need a prescription. Some people with stomach ulcers, asthma, high blood pressure, kidney failure, or heart failure may not be able to take anti-inflammatory painkillers.
• A stronger painkiller such as codeine is an option if anti-inflammatories do not suit or do not work well. Codeine is often taken in addition to paracetamol. Constipation is a common side-effect from codeine. To prevent constipation, have lots to drink and eat foods with plenty of fibre.
• A muscle relaxant such as diazepam is occasionally prescribed for a few days if the stiffness in your neck muscles is severe.

What about other treatments?

Some other treatments which may be advised include:

• A good posture. Keeping a regular check on your posture may help. Make sure that your sitting position at work or at the computer is not poor. It is important to ensure that your head is not flexed forward and also that your back is not stooped when you are sitting and working. You should make sure you sit upright. Yoga, Pilates and the Alexander Technique can all improve neck posture but their actual value in treating neck pain is uncertain.
• A firm supporting pillow. This seems to help some people when sleeping. Try not to use more than one pillow.
• Heat packs. These can help relax the stiffness in the affected muscles and are useful for some people.

Remember: soft neck collars are not recommended anymore as they can actually worsen and prolong the stiffness.

How quickly does it get better?

The outlook (prognosis) is good. A wry neck (acute torticollis) often improves within 24-48 hours. However, it may take up to a week for the symptoms to go completely. Occasionally, the symptoms last longer or come back at a later time for no apparent reason. Most people who have had torticollis do not have is again in the future.

• Neck pain – acute torticollis; NICE CKS, September 2018 (UK access only)

• Marques RE, Duarte GS, Rodrigues FB, et al; Botulinum toxin type B for cervical dystonia. Cochrane Database Syst Rev. 2016 May 13(5):CD004315. doi: 10.1002/14651858.CD004315.pub3.

Torticollis in Children and Adolescents

Author(s): Anton Dietzen, MD, Melissa Trovato, MD

Originally published: September 20, 2013 Last updated: February 23, 2021

Disease/ Disorder

Definition

Torticollis is a postural abnormality of the neck leading to head tilt, flexion and rotation.  It can occur in people of all ages, from the newborn to adults.  Classically, torticollis is categorized as congenital or acquired.  Congenital muscular torticollis (CMT) is the most common form.

A newer classification proposed in 2012 uses nonparoxysmal (nondynamic) and paroxysmal (dynamic) torticollis as the two main categories.¹

Etiology

• Nonparoxysmal or nondynamic torticollis¹
  • CMT
  • Osseous torticollis including Arnold Chiari malformation, Klippel-Feil Syndrome and hemivertabrae
  • Central and peripheral nervous system torticollis
  • Ocular torticollis
  • Non-muscular, soft tissue torticollis including unilateral congenital sternocleidomastoid (SCM) absence
• Paroxysmal or dynamic torticollis¹
  • Benign paroxysmal torticollis
  • Spasmodic (cervical dystonia)
  • Sandifer syndrome induced torticollis secondary to gastroesophageal reflux
  • Drug induced torticollis
  • Increased intracranial pressure induced torticollis
  • Torticollis secondary to conversion disorder

Epidemiology including risk factors and primary prevention

• CMT
  • Incidence: 0. 3% to 2%.¹
  • Predilections: Right, male (3:2), first-born, breech and singleton delivery²
  • Risk factors include intrauterine malposition and complicated labor and delivery.

Patho-anatomy/physiology

The patho-anatomy and pathophysiology behind torticollis is dependent on the primary etiology.  In CMT, in the inferior one-third of the affected SCM, a well-circumscribed “tumor” can form, due to a hematoma or a fibroma.  As this shrinks the sternocleidomastoid (SCM) shortens, tilting the head toward and rotating the chin away from the affected SCM.

In general, disruption of arterial or neural supply to the SCM or trapezius can result in torticollis.¹ For example, during an acute infection, muscle spasms or referred pain can lead to abnormal head positioning.

Another common cause of torticollis is from atlantoaxial rotary subluxation (AARS).  Retropharyngeal edema is thought to cause laxity of the atlantoaxial ligaments.   Laxity of these ligaments allows for subluxation of the facets of C1 and C2 causing abnormal tilt and rotation of the head.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

• Age of presentation¹
  • CMT: By 6 weeks of age.
  • Older age of onset suggests other acquired conditions.
• 50-70% of SCM tumors resolve spontaneously by one year old with minimal deficits.²
• Resolution rates by 12 months old with conservative management (manual stretching, home exercise and positioning program) range from 70-97%.⁴
• Early identification and treatment is associated with better outcomes and shorter treatment times. (5)
• 9 to 21% with CMT require surgery, especially if they persist past 1 year of age.⁴
• Osseous abnormalities may need traction or surgery.³
• Long-term development of craniofacial and postural deformities in children with untreated or inadequately treated CMT have been described. ^6,7,8

Specific secondary or associated conditions and complications

• Craniofacial defects: 80% of cases, improves if treated early.⁹
• Scoliosis: Commonly associated with genetic syndromes with bony abnormalities (Klippel-Feil and Larsen). Late-onset, asymptomatic thoracic scoliosis (8-13 degrees) in CMT also described.⁸
• Hip dysplasia: 2 to 20% incidence versus 2% in general population.¹
• Motor developmental delay and disorders of attention, coordination, language and affect: In a cohort of 38 children ages 7 and 8 years with history of CMT, 14 (37.8%) were diagnosed with ADHD, 1 with autism spectrum disorder, 5 (15.5%) with definite motor problems (defined as scores < 5th percentile on Movement Assessment Battery for Children or the Bruininks-Oseretsky Test).¹⁰  Alberta Infant Motor Scores were found to be lower in infants with CMT (n=82) versus healthy controls (n=40) at 2 and 6 months. Reason remains unclear, but authors speculate impaired midline posture results in asymmetrical development of sensory frame of reference for perception and action.¹¹ In another study of 54 children with CMT with an average age of 8.5 months, the Peabody developmental motor scales-second edition was used to evaluate subjects motor development. Results showed motor developmental delay in 37% of children with CMT, affecting gross motor to a greater degree than fine motor.¹²

Essentials of Assessment

History

To help identify the etiology of the torticollis, obtain information in the following areas

• Age of onset.
• History of onset: Acute or insidious, trauma, fever, vomiting, neurologic deficits, exposure to medications.
• Laterality of involvement
  • CMT – Right more common, head tilted toward and chin rotated away from affected SCM.
  • AARS- Head tilted away from and chin rotated toward affected SCM.
• Aggravating activities
  • Supine positioning: Sandifer syndrome.
  • Neck extension: Juvenile idiopathic arthritis and AARS.
• Associated Symptoms
  • Posterior fossa tumor: Increased intracranial pressure signs (vomiting, progressive headache, diplopia), balance/coordination problems.
  • Brachial plexus palsy: Unilateral arm weakness, pain and/or numbness, +/- unilateral ptosis.
  • Infection: Neck tenderness, fever, irritability, dysphagia, drooling, odynophagia and respiratory distress.
  • Sandifer syndrome: Regurgitation, vomiting, hematemesis, anorexia, failure to thrive, asthma, chronic cough and/or hoarseness.
• Time spent in prone while awake.
• Prenatal and birth history.
• Feeding history.
• Developmental history.
• Family history on past interventions and response will aid treatment planning.

Physical examination

• Inspection: Head/neck posture, pharynx, plagiocephaly, facial dysmorphism, scoliosis, metatarsus adductus, and clubfoot can be associated with CMT.
• Palpation: Tenderness or spasms of paracervical and trapezius muscles or spinous processes, thickening or mass of the SCM or trapezius, vertebral deformity, lymph nodes.
• Cervical range of motion (ROM): Average passive range of motion in infants is 110° (100° to 120°) rotation and 70° lateral flexion (65° to 75°).¹³Hip exam: Asymmetry in gluteal folds, ROM, Barlow, Ortolani, Galeazzi maneuvers.
• Postural assessment: Compensatory scoliosis with attempts at head righting
• Neurologic: Visual and auditory fixation and tracking, fundi for papilledema, cranial nerves, sensory testing, tone, and reflexes.
• Functional strength testing: Consider symmetry and compensatory movements.

Functional assessment

• Age-appropriate motor skills (rolling, hand dexterity and dominance).
• Muscle Function Scale (MFS): scale of infant’s head righting response. Infant initially held in a vertical position, then lowered to horizontal position with head position (both sides) sustained for > 5 seconds. Scored: 12
  • Head held below horizontal line.
  • Head held on horizontal line.
  • Head held slightly over horizontal line.
  • Head held high over horizontal line but <45°.
  • Head held high over horizontal line and >45°.
  • Head held very high Mean MFS for <1 year old:¹³

Laboratory studies

• Differential blood count +/- rapid streptococcal test if infection suspected.
• Karyotype testing for trisomy 21, if indicated based on history of dysmorphism.
• Genetic testing (sequence, deletion/duplication analysis) to check for GDF 6 or 3 mutations in Klippel-Feil syndrome, as needed based on history and exam.

Imaging

Newborn and Infants

• In CMT, ultrasound (US) of SCM is study of choice to evaluate muscle fibrosis and monitor for resolution with intervention. (14) Graded^16,
  • Grade 1: Increased SCM thickness
  • Grade 2: Well-demarcated heteroechoic region
  • Grade 3: Diffuse hyperechoic fibrous mass
• Cervical spine radiographs (anteroposterior and lateral views): C1-C2 subluxation or congenital bony abnormalities but low yield (< 1%).¹
• Routine MRI in CMT is not recommended.
• If hip exam normal, routine hip US in CMT is not recommended.¹⁷
• No clear diagnostic guidelines are available for Sandifer syndrome.  Barium swallow test may be considered for suspected cases.

Older Children and Adolescents

• With trauma, cervical radiographs (anteroposterior and lateral views) are the first line. Add open-mouth odontoid view if AARS is suspected. Dynamic CT is useful in assessing C1-C2 rotation in different positions of neck rotation.   If cervical CT is positive, cervical MRI/MRA is obtained to check for spinal cord, ligamentous, and vascular injuries.¹⁸
• Without trauma, CT of the neck is obtained.  If CT negative, brain and cervical spine MRI is obtained to evaluate for central nervous system (CNS) tumor, lesion, or infection such as diskitis.¹⁸

Supplemental assessment tools

• Arthrodial protractor: Cervical lateral flexion and rotation.¹³
• Plagiocephaly anthropometrics
  • Cranial vault asymmetry: Difference between diagonal (frontozygomaticus to opposite eurion) caliper measures; normal < 3 mm, mild/moderate ≤ 12 mm, moderate/severe >12 mm.¹⁹
  • Cranial vault asymmetry index: Difference in cranial diagonal diameter/longer cranial diagonal x 100; significant if >3.5%.

Early predictions of outcomes

CMT

• Early treatment: if < 4 months of age; the average length of treatment was only 3. 2 months and none required surgery.²⁰
• Initial deficit in rotation >15°, birth difficulties, presence of SCM tumor (especially if on the right) were associated with longer treatment duration.⁹
• Severity of SCM fibrosis on US correlate with treatment duration and resolution.(21)¹⁹
• MFS scores and age of initiation of treatment had significant influence on treatment time in 33 infants. ROM deficits, plagiocephaly and gender had no effect.²²
• Deformation of the cervical spine may start as early as 8 months and increases with age and severity of fibrosis when untreated (23)

Sandifer Syndrome

• Responds to antireflux medications, upper body elevation when sleeping.

Benign Paroxysmal Torticollis

• Usually self-limited (resolves by 3 years).
• May be associated with migraine later in course (24)

Environmental

Ask parents about

• Sleeping position
• Feeding set-up
• Crib positioning
• Car seat location

Social role and social support system

Physicians should inquire about home and social situations that could impact counseling and treatment outcomes. The number of members in the household and their level of understanding, typical daily routine of the caregiver/child and the type of care setting (home versus day care) that is available should be considered.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Currently, no standard guidelines exist for the treatment of torticollis. Treatment is largely based on best practice recommendations. Christensen and van Vlimmeren proposed conservative treatment algorithms for CMT.^{22, 25} In 2018, the Academy of Pediatric Physical Therapy published an updated evidence based clinical practice guideline to address education for prevention, referral, screening, examination, prognosis and treatment. (26)

At different disease stages

CMT in < 1 year of age

1. Physical therapy and parental education

• Early (< 4 months old) initiation of physical therapy is optimal. Passive stretching exercise protocols varied: hold times ranging from 10 to 30 seconds and repetitions of 3 to 40. ^9,16,20,27  One study from showed that stretching at 10 stretches per session for 10 to 15 seconds for 10 sessions was more effective at improving head tilt and cervical passive range of motion than at 5 sessions daily over an 8 week period.²⁸
• By 6 to 8 months of age, infants may not tolerate passive stretching. Facilitation of active movements of the unaffected SCM, utilizing righting reactions, may be a good alternative.⁴
• Massage and myofascial release.⁴
• Kinesiology taping.¹⁵
• Therapy frequencies ranges from 5 times/week to monthly.^9,16,20,27
• Handling, positioning, and exercises at home.^{1,22, 25, 27}

2. Orthoses

• Tubular orthosis for torticollis (TOT) collar: Adjunct for >4.5 months old, >6° head tilt; worn during waking hours. ^25,29 TOT collar is approved for use in torticollis by the Food and Drug Administration (FDA).³⁰
• Custom cranial orthosis for plagiocephaly.

3. Botulinum toxin chemodenervation

• Botulinum toxin Type A injections to SCM or upper trapezius may be considered for those who failed with exercises and TOT collar use.
  • Oleszek et al used 100 units in 0.5mL dilution, weight and age-based dosing.³¹
• A 2020 meta-analysis found an 84% effective rate of botulinum toxin for CMT with surgical conversion rate of 9% and adverse reaction rate of 1%, most commonly injection site irritation and transient dysphagia.³²

CMT in >/=1 year old

1. Surgical indications

• ≥ 6 months of conservative management.
• Residual deficits in cervical rotation and lateral flexion >15°.
• Tight band/tumor.⁸

2. Surgical procedures

• Distal unipolar lengthening works well for most. ⁴
• Bipolar lengthening (distal and proximal).
• Z lengthening.
• Radical resection.

Other causes

¹

• Atlantoaxial rotary subluxation
  • Acute (< 1 week) and less severe – Soft cervical collar, rest, analgesics +/- diazepam or muscle relaxants.
  • Severe – Cervical traction, surgery.
• Retropharyngeal abscess: Antibiotics (2nd or 3rd generation cephalosporins), NSAIDs, surgery if no improvement within 24 hours.
• Primary cervical dystonia: Oral anticholinergics (i.e, trihexyphenidyl), clonazepam and other benzodiazepines, baclofen, botulinum toxin injections, deep brain stimulation for intractable cases.
• Sandifer syndrome: Antireflux medication (proton pump inhibitors), head elevation during sleep, surgical fundoplication.
•  Drug induced torticollis: Treat initially with diphenhydramine.

*No randomized clinical trials (RCT) with long-term follow-up found in the literature.

Coordination of care

CMT is ideally managed on an outpatient basis with coordination of care between the treating therapist and pediatric physiatrist. If trial of conservative management fails, discussion with a plastic surgeon or otolaryngologist regarding potential surgical intervention is recommended.

Patient & family education

• Proper stretching techniques.
• Positioning and handling skills incorporated into daily routine:
  • Feeding: Food or bottle presented to side of affected SCM to facilitate neck rotation toward that side.
  • Positioning: should be placed in a crib in such a way that he is forced to rotate his head to affected SCM and tilt toward unaffected SCM in order to see an interesting object such as a toy mobile.
  • Encouraging play in prone and facilitating neck extension to allow bilateral SCM muscle stretching.
  • Turning head to non-favored side while sleeping in supine.
• Proper donning of TOT collar.

Emerging/unique Interventions

• Muscle Function Scale
• Cervical Range of Motion
• Developmental Milestones

Cutting Edge/ Emerging and Unique Concepts and Practice

• Kinesiology taping as a potential adjunct to correct muscular imbalances. Immediate improvements in MFS scores with muscle relaxation taping technique versus facilitation technique has been described, although prospective studies or long-term follow-up have yet to be published.¹⁵
• Preliminary studies show that kinesiology taping improves pain in patients with cervical dystonia.³³
• Potential application of 3D stereophotogrammetry to track changes in facial asymmetries.³⁴
• Two adult cases of CMT were treated with percutaneous myotomies and intramuscular cell-assisted fat grafting with improvement in head positioning and range of motion, one of which had sustained results at 18 months postoperatively.³⁵

Gaps in the Evidence- Based Knowledge

• Factors impacting length of treatment (gender, laterality of involvement and age).
• Efficacy of kinesiotaping.
• Efficacy of cervical orthosis (TOT collar).
• Optimal timeframe and dosing for botulinum toxin.
• The exact relationship between congenital torticollis and neurodevelopment and the effects of treatment and timing of intervention of developmental outcomes.

References

1. Tomczak K, Rosman NP. Torticollis. Journal of Child Neurology. 2012; 00(0):1-14.
2. Do T. Congenital muscular torticollis: current concepts and review of treatment. Curr Opin Pediatr. 2006; 18: 26-29.
3. Subach BR, McLaughlin MR, Albright AL, Pollack IF. Current management of pediatric atlantoaxial rotatory subluxation. Spine. 1998;23:2174-2179.
4. Freed S, Coulter-O’Berry C. Identification and treatment of congenital muscular torticollis in infants. Journal of Orthotics and Prosthetics. 2004;16(4S):18-23.
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Original Version of the Topic

Paola Mendoza, MD, Lainie K. Holman, MD. Torticollis. 9/20/2013.

Previous Revision(s) of the Topic

Nancy Yeh, MD and Melissa Trovato, MD. Torticollis. 8/1/2017.

Author Disclosure

Anton Dietzen, MD
Nothing to Disclose

Melissa Trovato, MD
Nothing to Disclose

Torticollis: treatment, causes, symptoms | Osteo+

Curvature of the neck – torticollis

Torticollis is a disease in which the head tilts and simultaneously turns in the opposite direction. It arises as a result of the pathology of the neck – bones, nerves and its soft tissues. The disease can be both congenital and acquired, with fixed or unfixed head position. As a result of pathological changes, the skull and spine can be deformed, neurological disorders, intellectual development disorders, memory function and concentration decrease, as well as respiratory deterioration. Based on the examination of the doctor, the results of hardware studies, for example, radiography, a diagnosis is made. Therapeutic therapy is possible, both conservative and surgical, and depends on the causes of the disease.

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Contents

General information
Causes of torticollis
Symptoms of torticollis
Diagnosis
Treatment of torticollis
Prevention

General information

9000 2 Torticollis is a pathology in a person’s condition, which is accompanied by a tilt of the head with its simultaneous turn to the other side. common in newborns, but occurs in older children. The cause of the disease is most often a lesion of the anatomy of the neck, this condition occurs with pathology in the area of ​​the GCSM – the sternocleidomastoid muscle. Depending on its cause, orthopedists and surgeons, as well as pediatric infectious disease specialists, and pediatric neurologists can deal with the treatment of this disease, depending on its cause.

Causes of torticollis

Congenital torticollis can form in the fetus even in utero. Causes: abnormal structure of the pelvic bones in the mother or the location of the fetus, some infectious diseases and hereditary diseases, as well as chromosome mutations. Among musculoskeletal anomalies, after congenital clubfoot and hip dislocation, this disease is the third most common, and more often in girls than in boys.

Causes of acquired pathology of curvature of the neck – entanglement of the fetus with the umbilical cord during childbirth, cardiac ischemia, neck injuries. Torticollis at an older age occurs due to muscle injuries, infectious diseases and diseases of the nervous system. The most common and easily treatable torticollis is an acquired form of neck curvature due to rotational subluxation.

Symptoms of torticollis

Congenital torticollis includes the following forms of pathology – idiopathic, myogenic, osteogenic, neurogenic and arthrogenic.

Idiopathic torticollis – is detected as a result of a non-fixed slight tilt of the head. The reasons for its formation are still unknown, however, it has been found that idiopathic torticollis occurs more often during difficult births or due to pathologies during pregnancy. As a result of palpation, the doctor determines that the sternocleidomastoid muscle is in an excessive state of tension. In children with this pathology, perinatal encephalopathy and segmental insufficiency are also often detected in the cervical spine.

Myogenic torticollis. This form of torticollis is the most common, it develops against the background of shortening and compaction of the sternocleidomastoid muscle. Congenital torticollis is early and late. Early torticollis is detected at birth, and late – at 4 weeks of age. The causes of congenital torticollis are muscle fibrosis and a decrease in their elasticity as a result of the transverse position of the fetus or when it is in breech presentation (feet forward), in which the head was tilted towards the affected muscle for a long time and turned in the opposite direction.
On palpation, examination reveals a uniform muscle thickening of the tissue, or a rounded thickening in the middle and lower parts of the muscle. Attempts to move are very painful. If myogenic torticollis is not treated, then the spine is especially curved, disturbances occur in the region of the skull and shoulder girdle. The bones flatten, the face becomes asymmetrical, the ear, eyebrow and eye drop from the side of the lesion. There is sometimes bilateral myogenic torticollis, which is accompanied by a sharp inclination of the head to the sternum and limitation of its movements.

Osteogenic torticollis (Klippel-Feil disease) occurs against the background of a congenital pathology of the vertebrae of the neck, in which a decrease in the size of the vertebrae or their fusion into a single block is possible. An appointment with a doctor in the clinic allows you to correctly identify the deformity of the neck and its shortening. Often, the head, pulled into the shoulders, is turned to the side, while the neck is limited in mobility, and at the back of the head, the hairline is reduced. Osteogenic torticollis is often combined with other skeletal anomalies. In itself, the curvature of the neck does not usually cause a feeling of pain, but it can cause sciatica in the cervical spine.

Neurogenic torticollis develops as a result of dystonic syndrome, an increase in muscle tone in one side of the body while it decreases in the other. It is accompanied by the same disorders in the limbs, for example, the baby’s legs bent to the side, the arms bent and clenched into fists, the child’s torso is twisted during sleep. In the neck, movements, both active and passive, are preserved, but when the child is at rest, his head “goes” into a vicious position.

Arthrogenic torticollis develops against the background of rotational congenital subluxation of the cervical vertebra. Acquired arthrogenic torticollis is adjusting, compensatory, reflex, traumatic and infectious.

In addition, the following forms of the disease are distinguished:

• curvature of the neck in the event of tumors in the spine;
• hysterical torticollis, which is revealed in hysterical psychosis;
• dermatogenic torticollis, which occurs against the background of cicatricial degeneration of skin tissues;
• desmogenic torticollis, which is formed due to inflammation and scars on the muscles, ligaments, in the area of ​​tissue and lymph nodes;
• myogenic torticollis, which is formed after myositis – inflammation of the muscles of the neck;
• neurogenic torticollis, which develops in children with cerebral palsy or after a neuroinfection.

Positioning torticollis develops when the baby has been in the crib for a long time in the wrong position, while there are no pathological changes in the tissues of the organs.
Compensatory and reflex torticollis. Reflex torticollis occurs as a result of mastoiditis – inflammation of the mastoid process, inflammation of the middle ear, purulent processes of the neck, with perichondritis. To reduce pain, the patient tilts his head to the side. Compensatory curvature of the neck develops against the background of strabismus and labyrinthitis – a disease of the inner ear. The tilt of the head, in the first case, allows the patient to use his field of vision better, and in the second case, to reduce the patient’s dizziness. With these forms, the movements of the neck are preserved in full.

Traumatic osteoarticular torticollis – an acute disease occurs, the cause of which is a fracture of the cervical vertebra. The curvature of the neck is accompanied by sharp pains in the neck, restriction of its movements. The development of pain on palpation, bulbar syndrome and pyramidal insufficiency. An acquired type of osteoarticular form is C1 subluxation. It can be detected at any age, but more often in children. In everyday life or during sports activities, the cause of subluxation can be a sharp turn of the head.

Non-traumatic (infectious) osteoarticular torticollis is detected in osteomyelitis, bone tuberculosis and tertiary syphilis. The reason for its development is the melting of the cervical vertebrae or their pathological fractures.

Spastic (cervical dystonia) is a chronic lesion of the central nervous system, accompanied by spontaneous spasms of the neck muscles. In this case, the patient develops a deviation towards the head. Cervical dystonia is a form of acquired spastic torticollis that is more common in adults over the age of 30. The exact causes of spastic torticollis have not yet been established. Provoking factors are mainly considered to be stress, head and neck injuries. With spastic torticollis, the rotation of the head around the axis is combined with tremor and with pain in the neck and back of the head, shoulders. Dystonia is aggravated with a vertical position of the body, as well as with psycho-emotional and physical overwork.

Diagnosis

Diagnosis of congenital torticollis is established on the basis of the collected anamnesis, data from the initial examination and the results of radiography in the cervical spine by a specialist in traumatology and orthopedics, pediatrics and pediatric surgery. During the examination, the pediatrician may ask individual questions. Were there any births with pathologies, about problems during pregnancy, when parents noticed signs of neck curvature – from the first days of the baby’s life or after a certain period of time, etc. They also prescribe an examination of the child by a neurologist to exclude disorders of the nervous system. If necessary, in order to correctly assess the condition of the soft tissues of the neck and prevent complications, ultrasound or MRI is performed.

Diagnosis of acquired torticollis depends on the history and nature of the pathology. Radiography is included in the mandatory examination plan. An X-ray examination is prescribed both for the entire cervical region and for the first two cervical vertebrae. With strabismus, you need to consult an ophthalmologist, if you suspect syphilis, you need to make an appointment with a venereologist, a psychiatrist can help determine the manifestations of hysterical torticollis, and a phthisiatrician can help determine the consequences of tuberculosis.

Treatment of torticollis

Treatment of congenital myogenic torticollis can be conservative or surgical. In the early stages of the disease, the following physiotherapeutic procedures and complex methods of treatment are used: ultrasound therapy, electrophoresis with lidase and potassium iodide, UHF, a program of corrective orthopedic exercises and manual therapy. In most cases, it will take six months to completely eliminate the pathology of torticollis. In the absence of the effect of conservative methods of therapy, a surgical operation is performed, as a result of which the heads of the sternocleidomastoid muscle are intersected. If, compared to the healthy side, the affected muscle is shortened by 40% or more, then plastic surgery is performed. In the period after the operation, plaster is applied for a month, after which it is replaced by wearing a Shants collar. In the acquired form of muscular torticollis, a similar treatment is used.

Congenital form of neurogenic torticollis is treated with medication, physiotherapy, exercise therapy and massage. With a curvature of the neck, which arose against the background of a neuroinfection, the doctor prescribes antibiotics, muscle relaxants and anticonvulsants. When the inflammation subsides, the patient is recommended to wear a Shants collar, and referral to exercise therapy. Surgical correction is carried out in severe cases.

In congenital form of osteogenic torticollis (Klippel-Feil disease), massage and therapeutic exercises are prescribed. Highly placed upper ribs are sometimes removed. With a traumatic form of neck curvature as a result of a fracture, plaster bandages and traction with a Glisson loop are used. Surgical operations are carried out if necessary. Traumatologists with torticollis caused by subluxation impose a Shants collar after closed reduction using the Glisson loop. If there are organic changes in the cervical-shoulder spine that have arisen after an injury, electropulse therapy, electrophoresis, massage and exercise therapy are prescribed.

Desmogenic and dermatogenic forms of torticollis are eliminated only by surgery, excising scar tissue. Then plastic is performed with autografts, allografts or xenografts. If tumors occur against the background of an infectious lesion of the bones, the underlying pathology is treated by performing an operation. Subsequently, restorative rehabilitation is performed.

Prevention

Disease prevention is determined by its etiology. The prognosis depends on the causes of the development of pathology and the duration of its existence. With adequate early treatment, most forms of neck curvature, both congenital and acquired, lend themselves well to correction, with the exception of Klippel-Feil disease, in which severe limitation of movements persists. Untreated torticollis causes a developmental disorder in a child, possibly with subsequent disability. The defect of the neck leads to muscle dystrophy, which causes progressive asymmetry of the face, preventing the development of the skull.

Excessive neck pressure on the blood vessels that deliver blood to the brain first causes migraines and then brain dysfunction. In children, the development of intelligence suffers. In adults, memory and attention deteriorate. Respiratory functions with torticollis are reduced due to a change in the position of the trachea, with congenital pathology at an early age, it is possible that the growth of the chest is lagging on the side of the lesion. Hearing is impaired, sinusitis often develops, strabismus is formed.

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spasm of the neck muscles, as well as may be accompanied by a tremor of the head. Unfortunately, cervical dystonia in adults (spastic torticollis) significantly worsens the quality of life of people, leads to social maladaptation: disability, to the development of social phobias. Patients suffer from pain and depression.

Torticollis in adults: treatment, signs and development of the disease

Torticollis in adults (cervical dystonia) can begin at any age, but most often between 30 and 60 years of age. Statistically, women get spasmodic torticollis slightly more often than men. Torticollis usually develops gradually, and only in rare cases can the onset be acute. Most patients report a slow increase in symptoms and signs of torticollis – from minimal to pronounced – within 5 years.

Signs of torticollis begin with discomfort in the cervical spine, mild pain and a feeling of stiffness. As a result of contraction of the muscles of the neck, there may be a slight twitching of the head, similar to a tremor. All these signs and symptoms can be intermittent, and manifest themselves with emotional excitement, walking, physical activity.

Such signs of cervical dystonia (torticollis) can be regarded as a manifestation of myositis or osteochondrosis. Gradually, the symptoms intensify and force you to see a doctor.

In 1/3 of patients, cervical dystonia transforms into segmental dystonia, when adjacent areas are involved in muscle spasm and additional blepharospasm (squinting of the eye), oromandibular dystonia (movement in the lower half of the face in the form of involuntary opening or closing of the mouth), and writing spasm are formed. About 5-20% of patients may spontaneously improve within 6 months of the onset of the first symptoms of torticollis.

Many people can control pathological postures and movements of the neck and head for some time using special techniques: antagonist gestures or corrective gestures, for example, touching the head or neck with the hand, etc. Such “tricks” are unique and specific only for dystonia and are peculiar ” diagnostic key” in almost 70% of patients. The most common corrective gestures are touching the lower part of the face with a finger or hand in order to return the head to its normal middle position. Other more subtle and inconspicuous tricks: pulling the tip of the nose or ear, sucking beads on the neck or biting a pencil, holding the head by touching the occipital region, resting the occipital region on the back of a chair or wall. It is interesting to note that even mentally imagining this antagonistic gesture evens out the position of the head.

Signs (symptoms) of torticollis may worsen when walking, carrying heavy loads, emotional stress, excitement, general weakness. At the same time, some patients note that the condition worsens while resting, reading or watching TV.

Today there is an effective treatment for spasmodic torticollis in adults. Our clinic occupies a leading position in Moscow in the treatment of this disease.