Acute Wry Neck or Torticollis

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.

At onset of the problem the patient is immediately aware of a sharp, unpleasant pain on one side of the cervical spine, typically in the lower neck and with some pain referral down over the scapula or out towards the shoulder. With significant shoulder and arm pain it is important to consider the diagnosis of a nerve root lesion, however these often come on more slowly over a few days. If the symptoms were noted on waking in the morning then a root lesion could be a possibility, with a good outcome likely but the time scale will be extended to several weeks for full recovery rather than the few days for a joint or muscle strain.

Examination of the patient by a physiotherapist will show a patient who is in some distress from their pain and may find sleeping difficult. They may hold the head carefully to guard against sudden movements of the painful structures. The head posture will be typically abnormal and efforts to restore the posture to normal are rewarded with strong increases in pain levels. The physio will record the neck position and the ranges of movement the patient can perform, with the results in terms of pain. The history will also be taken, to include any previous episodes and what precipitated this event, whether known or not.

The incidence of pain in the shoulder, scapula, arm or thoracic regions will be recorded. The physio may elect to test the biceps and triceps reflexes to check the health of the C6 and C7 nerve roots if the symptoms warrant this. Testing of the light touch sensibility may be appropriate for the same reasons. However, the muscle strength might not be tested by the physio as it could aggravate the pain and an accurate indication would be hard to get. The physiotherapist will ask special questions to ensure that the pain is mechanical and not likely to be due to a serious medical cause.

The aim of physiotherapy for this neck condition is similar to that for all soft tissue injuries. The first goal is to reduce the pain and inflammation in the damaged tissues and so reduce the resulting muscle spasm which is perpetuating the pain. Anti-inflammatory medications and analgesics may be prescribed as to some extent the pain is the presenting problem rather than some underlying abnormality. Physiotherapists may use ice, immobilisation in a collar and gentle manual traction to attempt to relax the cervical musculature and relieve 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.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Gloucester. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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