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.
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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. Acute Neck Pain and Torticollis
When the physiotherapist examines the patient they will find them distressed by the neck pain and likely to have had sleeping difficulties. The head is held carefully and efforts are made to avoid disturbing the inflamed joints or muscles. Head posture will show the torticollis deformity and if normalising the posture is attempted the pain rises quickly to severe levels. Physiotherapists record the posture of the neck and the amount of joint motion which is possible with the resulting pain provoked. A history of the condition will be taken, with record of previous pain events and what brought on this episode. Acute Neck Pain and Torticollis
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.
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A 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. Acute Neck Pain and Torticollis
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