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.

People with acute wry neck complain of severe neck pain and neck muscle spasms which prevent them from bringing their head back into the central line. This usually resolves in several days or up to fourteen and normal treatment consists of painkilling medication, a collar if necessary, physiotherapy such as neck exercises, massage and neck stretching. Examination of a patient will discover the head flexed towards the pain and rotated away from the pain. Patients report that the pain came on with a sudden neck movement or by towelling their hair and that they have neck stiffness, reduced movement and pain.

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.

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.