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.

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.

It is important to enquire after any arm, scapular, thoracic and shoulder pain. The physiotherapist may need to test the C6 and C7 nerve root reflexes of the biceps and triceps muscles respectively should the situation require this and they may also test the sensibility to light touch of the skin for the same purpose. Muscle strength testing may be omitted due to the likelihood of increasing pain and the probability of an inaccurate result. The physio will include asking the standard series of exclusion questions which allow him or her to conclude the problem is mechanical and not due to medical illness.

Physiotherapists follow the same management principles for acute wry neck as for all soft tissue damage. The inflammation and pain of the injury are the first targets of physiotherapy so as to reduce spasm in the muscles which is maintaining the pain. Drugs such as pain killers and anti-inflammatories are employed as the target of treatment is the pain itself and not a specific anatomical lesion. Physio management consists of non-vigorous manual traction to relax the neck musculature, wearing of a collar if required (especially at night) and the pain reduction following ice treatment.

Reduction in the neck pain signals that the physio can start to employ more vigorous manual techniques such as stretching of the neck muscles to further relax them, massage of the neck and joint mobilisation. Active neck exercises are encouraged within the restrictions of the pain to avoid aggravating the situation. Once movements of the neck have improved and head posture is more normal then physiotherapy can progress to muscle strengthening and working on the endurance of the neck muscles to allow normal functioning.