Kinesio-Health: Torticollis

Case of the week: Torticollis

Torticollis is an abnormal posturing of the head secondary to contraction of the neck muscles. This may occur secondary to osseous, ligamentous, or soft tissue injuries, but can also be a condition which occurs along side disease, particularly that of the central nervous system.

Classifications of torticollis:

Congenital Muscular Torticollis (CMT) which is detected at or shortly after birth, and is primarily caused by unilateral shortening and fibrosis of the sternocleidomastoid muscle.
Acquired Torticollis is a noncongenital muscular torticollis resulting from scarring or disease of the cervical vertebrae, adenitis, tonsilitis, rheumatism, enlarged cervical glands, retropharyngeal abscess, or cerebellar tumors. This may present as either spasmodic (clonic) or permanent (tonic).

Spasmodic Torticollis (Cervical Dystonia) is characterized by involuntary movements of the head due to spasms of the neck and shoulder musculature.
Tonic Torticollis is characterized by a constant posturing of the head and neck due to contraction of the neck and shoulder musculature

Torticollis can further be described by type depending on the position of the head and neck:

Rotational Torticollis: This most common type is characterized by rotation or torsion of the head along the longitudinal axis. Muscles commonly involved are ipsilateral splenius capitus, trapezius, and levator scapula, and contralateral sternocleidomastoid.
Laterocollis: This second most common type is characterized by an ear to shoulder positioning, sometimes accompanied with elevation of the shoulder. Muscles commonly involved are splenius capitus, scalene, trapezius, levator scapula, and sometimes sternocleidomastoid.
Anterocollis: Characterized by forward flexion of the head and neck, the sternocleidomastoid and scalene muscles are most commonly invovled. There may also be accompanied difficulty with swallowing, speaking, and vision.
Reterocollis: Characterized by extension of the head and neck due to tightening or spasms of the neck extensors, this may also affect communication, vision, and swallowing.

Apart from the obvious abnormal positioning of the head, other symptoms may include enlargement, stiffness, and painful spasms of the neck and shoulder muscles, limited range of motion of the head and neck, and headaches. Symptoms can range from mild to severe and generally progress slowly over the course of 1-5 years, after which it plateaus.

Treatment depends on the etiology. Congenital cases treated early on with physical therapy to stretch the tight muscles and repositioning of infants have been proven to have a good prognosis. Acquired cases can also be treated with physiotherapy, however the success rates are varied. Specifically with spasmodic torticollis, oral medications (pain relievers and muscle relaxants) in combination with physical therapy and botox injections have promising results, however theses treatments must be continued and repeated at regular intervals to maintain effectiveness. Physical therapy alone may be effective for mild cases through the use of manual therapy to move the neck through a normal range of motion and stretch spasming agonist muscles. When other conservative treatments fail, selective denervation surgery can be used to remove muscle motor nerves that actuate affected muscles. This procedure is irreversible, however fortunately success rates are very high. This must be followed by physical therapy to help the patient acclimatize to the modified neuro-muscular situation.

Due to the deforming nature of torticollis, there are psychosocial aspects to consider as well. Patients may become concerned with personal appearance, which may lead to social isolation and difficulty maintaining employment. With regards to employment, some modifications to a work station may be helpful. A good support system and a positive attitude go a long ways, but referral to a psychologist or similar health care professional may be warranted, and should not be overlooked by focusing solely on the physical aspects.