Torticollis or Acute Wry Neck
Torticollis or an acute wry neck occurs relatively uncommonly and consists of the onset of sudden and severe neck pain which causes the cervical neck muscles to contract reflexly. This leads to the neck being kept in an abnormal posture to minimise pain, a posture known as torticollis. Torticollis is not a diagnosis of itself but a reflection of a problem occurring in the neck or head area, however this article concentrates on torticollis from a mechanical cause. A common report from patients is that they awoke with the severe pain and the neck deformity, assuming it was a result of sleeping awkwardly that night.
Patients report severe neck pain often with muscle spasms and an inability to bring the head to the normal central position. This pain usually settles down in a few days or up to two weeks at most and is managed with painkillers, wearing a collar if required, physiotherapy massage or mobilisations, neck exercise and neck stretching. On examination a patient with torticollis will have their head side flexed towards the painful side and the face rotated away towards the opposite side to some degree. Typical complaints are pain, stiff neck and a limited range of movement, with a sudden onset such as turning the head quickly or drying the hair relatively common.
Once the onset has occurred the patient feels an immediate and often quite severe pain in one side of the neck, often low down, and perhaps some vague referral out towards the shoulder or down the back towards the shoulder blade. With significant shoulder or arm pain then a diagnosis of cervical root compression should be considered. Sudden onset root lesions are less common, with the syndrome typically coming on over a few days, but if the patient reports the symptoms on waking this could be the diagnosis. If so the prognosis is still good but the length of time to recovery will likely be a few weeks rather than a few days.
On examination by a physiotherapist the patient will be distressed by the severity of the pain and may have found it hard to sleep. They may guard the head by moving carefully to avoid jarring the aggravated structures. The head will be stuck in the typical abnormal posture and any attempt to bring it back towards normal will be met with a significant increase in pain. The posture of the head will be recorded by the physio with ranges of motion achievable and the resulting symptoms. The physiotherapist will take the history including previous episodes and how this one came on, either suddenly or during the night.
Any thoracic, shoulder blade, shoulder or arm pain will also be recorded. The physio may decide to test the reflexes of the biceps and triceps muscles to check if the C6 or C7 nerve roots are involved should the symptoms indicate the possibility. The sensibility of the skin to light touch can also be investigated for similar reasons. The physiotherapist is less likely to choose to test the muscle power in the shoulders and arms as this would cause an increase in pain and not reflect the patient''s true muscle strength. The usual questioning to exclude potentially serious underlying causes or complicating medical conditions will be undertaken.
Physiotherapy management of an acute wry neck is based on the same principles for all injuries of soft tissues. Firstly the physio attempts to reduce the inflammation and pain of the injury and thereby the muscle spasms which exacerbate the pain. Analgesics and anti-inflammatory drugs can be very useful as the pain is the primary problem and not some anatomical abnormality of the neck. Typical physiotherapy management includes ice, use of a collar if indicated and gentle tractioning of the neck relax the neck muscles and settle pain.
Progression on to further therapy techniques is planned once the pain is under control such as neck massage, gentle muscle neck stretches for muscle tightness and mobilisation of the joints. The patient is asked to perform active movements within reasonable pain limits. On restoration of more normal neck ranges of motion and head position the next stage of physiotherapy is to increase the neck muscle strength and endurance so that the person can return to normal.