Torticollis

 

Introduction 

The term torticollis is derived from the Latin words tortus for twisted and collum for neck.

The underlying anatomical distortion causing torticollis is a shortened sternocleidomastoid muscle. This is the muscle of the neck that originates at the sternum and clavicle and inserts on the mastoid process of the temporal bone on the same side.
There are two sternocleidomastoid muscles in the human body and when they both contract, the neck is flexed. The main blood supply for these muscles come from the occipital artery, superior thyroid artery, transverse scapular artery and transverse cervical artery. The main innervation to these muscles is from cranial nerve XI (the accessory nerve) but the second, third and fourth cranial nerves are also involved (Gray’s Anatomy). Pathologies in these blood and nerve supplies can lead to torticollis.

Torticollis is a fixed or dynamic tilt, rotation, or flexion of the head and/or neck. The type of torticollis can be described depending on the positions of the head and neck (see photos above).

Torticollis can be a disorder in itself as well as a symptom in other conditions

Congenital
Osseous
Traumatic
CNS/PNS
Ocular
Non-muscular soft tissue
Spasmodic
Drug induced

More serious causes. Your neck pain may have a more serious cause if it's persistent and getting progressively worse, or you have additional symptoms, such as:
a lack of co-ordination – you may find fiddly tasks increasingly difficult
problems walking
loss of bladder or bowel control
a high temperature (fever)
unexplained weight loss
A serious cause is more likely if you have recently had a significant injury – for example, you were involved in a car accident or had a fall – or you have a history of cancer or conditions that weaken your immune system, such as HIV. See your GP if you are concerned.

Congenital muscular torticollis
The cause of congenital muscular torticollis is unclear. Birth trauma or intrauterine malposition is considered to be the cause of damage to the sternocleidomastoid muscle in the neck. Other alterations to the muscle tissue arise from repetitive microtrauma within the womb or a sudden change in the calcium concentration in the body which causes a prolonged period of muscle contraction.
Any of these mechanisms can result in a shortening or excessive contraction of the sternocleidomastoid muscle, which curtails its range of motion in both rotation and lateral bending. The head typically is tilted in lateral bending toward the affected muscle and rotated toward the opposite side.
Congenital Torticollis is presented at 1–4 weeks of age and a hard mass usually develops. It is normally diagnosed using ultrasonography and a colour histogram or clinically through evaluating the infant's passive cervical range of motion.
Sometimes a mass, such as a sternocleidomastoid tumor, is noted in the affected muscle at the age of two to four weeks. Gradually it disappears, usually by the age of eight months, but the muscle is left fibrotic.

Acquired torticollis
Noncongenital muscular torticollis may result from scarring or disease of cervical vertebrae, adenitis, tonsillitis, rheumatism, enlarged cervical glands, retropharyngeal abscess, or cerebellar tumors. It may be spasmodic (clonic) or permanent (tonic). The latter type may be due to Pott's Disease (tuberculosis of the spine).
A self-limiting spontaneously occurring form of torticollis with one or more painful neck muscles is by far the most common ('stiff neck') and will pass spontaneously in 1–4 weeks. Usually the sternocleidomastoid muscle or the trapezius muscle is involved. Sometimes draughts, colds, or unusual postures are implicated; however in many cases no clear cause is found. These episodes are commonly seen by physicians.
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, a subluxation of the upper cervical joints, mostly the atlantoaxial joint, due to inflammatory laxity of the ligaments caused by an infection. This bridge must either be broken through manipulation of the neck, or, surgically resected.
The use of certain drugs, such as antipsychotics, can cause torticollis.
Antiemetics - Neuroleptic Class - Phenothiazines
There are many other rare causes of torticollis. A very rare cause of acquired torticollis is fibrodysplasia ossificans progressiva (FOP), the hallmark of which is malformed great toes.

Spasmodic torticollis
Torticollis with recurrent, but transient contraction of the muscles of the neck and especially of the sternocleidomastoid. Synonyms are "intermittent torticollis", "cervical dystonia" or "idiopathic cervical dystonia", depending on cause.

You can get a painful or stiff neck if you sleep in an awkward position, use a computer for a prolonged period of time, or strain a muscle because of bad posture.

Anxiety and stress can also sometimes cause tension in your neck muscles, which can lead to pain in your neck.

A twisted or locked neck

Some people suddenly wake up one morning to find their neck twisted to one side and stuck in that position. This is known as acute torticollis and is caused by injury to the neck muscles.
The exact cause of acute torticollis is unknown, but it may be caused by bad posture, sleeping without adequate neck support, or carrying heavy unbalanced loads (for example, carrying a heavy bag with one arm).

Acute torticollis can take up to a week to get better, but it usually only lasts 24 to 48 hours.

Wear and tear in the neck

Sometimes neck pain is caused by the "wear and tear" that occurs to the bones and joints in your neck. This is a type of arthritis called cervical spondylosis.
Cervical spondylosis occurs naturally with age. It does not always cause symptoms, although in some people the bone changes can cause neck stiffness.
Nearby nerves can also be squashed, resulting in pain that radiates from the arms, pins and needles, and numbness in the hands and legs.
Most cases will improve with treatment in a few weeks.

Whiplash

Whiplash is a neck injury caused by a sudden movement of the head forwards, backwards or sideways.
It often occurs after a sudden impact such as a road traffic accident. The vigorous movement of the head overstretches and damages the tendons and ligaments in the neck.
As well as neck pain and stiffness, whiplash can cause tenderness in the neck muscles, reduced and painful neck movements, and headaches.

Pinched nerve

Neck pain caused by a squashed nerve is known as cervical radiculopathy. It's usually caused by one of the discs between the bones of the upper spine (vertebrae) splitting open and the gel inside bulging outwards on to a nearby nerve.
The condition is more common in older people because your spinal discs start to lose their water content as you get older, making them less flexible and more likely to split.
The pain can sometimes be controlled with painkillers and by following the advice below, although surgery may be recommended for some people.

Treatment

Initially, the condition is treated with physical therapies, such as stretching to release tightness, strengthening exercises to improve muscular balance, and handling to stimulate symmetry. Early initiation of treatment is very important for full recovery and to decrease chance of relapse.

For most of the spasmodic types of neck pain described above, the advice is generally the same: carry on with your normal daily activities, keep active, and take painkillers to relieve the symptoms.

• make sure you have good posture when sitting and standing, bad posture can aggravate the pain, and it may have caused it in the first place
• take regular breaks from your desk, driving or any activity where your neck is held in the same position for a long period of time
• if you often feel stressed, try relaxation techniques to help ease any tension in your neck
• take regular doses of paracetamol, ibuprofen, or a combination of the two, to control pain – ibuprofen gel can be rubbed on to your neck as an alternative to taking tablets (biofreeze gel 2016).
• try holding a hot water bottle or heat pack to your neck – this can help reduce the pain and any muscle spasms, although some people find cold packs offer better relief
• avoid sleeping on your front, and make sure your head is in line with your body (not tilted to the side) if you sleep on your side sleep on a low, firm pillow at night – using an orthopaedic pillow has a slightly firmer deeper ridge to support the cervical spine. This pillow adjusts to shape of head and neck and maintains the cervical spine (Osteosolutions 2016).
• make sure your mattress is relatively firm – a soft mattress could mean your neck is bent while you sleep
• avoid wearing a neck collar – there is no evidence to suggest wearing a neck collar will help to heal your neck, and it's generally better to keep your neck mobile
• avoid driving if you find it difficult to turn your head – this may prevent you being able to view traffic
• if your neck is stiff or twisted, try some neck exercises – gently tense your neck muscles as you tilt your head up and down and from side to side, and as you carefully twist your neck from left to right; these exercises will help strengthen your neck muscles and improve your range of movement

How can an Osteopath help?
Osteopaths can use a wide range of gentle manipulations depending on your age, fitness and diagnosis to reduce muscular tension in the neck and improve movement in the joints of the neck and upper back. We may gently massage the soft tissues or  rhythmically “rock” the joints to release tension and sometimes we may gently manipulate the neck to move the joints and you may hear a “click”.
Treatment is different in every individual and sometimes it might involve treating other areas in the back and shoulders as well as the neck.
We may offer advice on your posture at work or in the car and give advice on exercise and stretching to help keep your neck and upper back muscles and joints relaxed.
X-rays, scans and other tests are sometimes required to make a diagnosis and your osteopath may refer to your GP or a specialist for any additional investigations or treatment.

Microcurrent Therapy
Microcurrent therapy sends minute electrical signals into tissue to restore the normal frequencies in cells. It is completely painless and patients can only feel the probe from the machine on their skin. The therapy is thought to increase ATP and protein synthesis as well as enhance blood flow, reduce muscle spasms and decrease pain along with inflammation. It should be used in addition to regular stretching exercises and ultrasound diathermy. Ultrasound diathermy generates heat deep within body tissues to help with contractures, pain and muscle spasms as well as decrease inflammation.

References:

Biofreeze gel (2016). Available online at:<http://www.biofreeze.com> Accessed on 2 June 2016.

Gray’s Anatomy (2016) – The Anatomical Basis of Clinical Practice 41st edition". Retrieved 2 June 2016.

NHS (2016) “Neck pain or a stiff neck” Available online at:< http://www.nhs.uk/Conditions/Neck-pain/Pages/Introduction.aspx > Accessed on 2 June 2016.

Osteosolutions (2016) “CLASSIC Original Orthopaedic Pillow” Available online at:< http://www.osteosolutions.co.uk/products/classic-orthopaedic-pillow/2940#mobile=off > Accessed on 2 June 2016.

Wikipedia (2016) “Torticollis” Available online at:< https://en.wikipedia.org/wiki/Torticollis > Accessed on 2 June 2016.



Created 2 June 2016
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