by Heather Barackman
Torticollis, also known as "wryneck" or having a "cocked robin" appearance, usually describes a chronic shortening of the sternocleidomastoid (SCM) muscle that has turned into a pathologic condition. The patient will have a laterally flexed head toward the side of the tighter SCM, with a rotation of the chin toward the unaffected side.1,2 More commonly seen in infants and young children, torticollis manifests in the adult population as well. There are many causes of torticollis; in infants, Neumann states that it frequently results from crowding or malpositioning in the womb, a long or difficult childbirth labor, or breech birth.1
Common classifications of torticollis include:
Congenital Muscular Torticollis (CMT): presents as a tight SCM with the patient’s head laterally flexed toward the affected side and the chin rotated toward the contralateral (unaffected) side in a fixed position.3
Muscular torticollis: results from a shortening or excessive contraction of the SCM muscle. Note: Hip dysplasia is a comorbidity in 2-29% of patients with muscular torticollis.4
Congenital Postural Torticollis (CPT): presentation is similar to that of CMT; however, no muscular tightness or palpable mass in the SCM exists with postural torticollis (of note, CPT has a great prognosis — resolution may occur in as little as three months).4 Passive end range of motion can be reached with attempts at stretching with CPT, though the infant cannot maintain its head in the midline position. The infant is able to intermittently tilt the head with CPT.5
The term torticollis has been confused with another medical condition called cervical dystonia, or spasmodic torticollis (adult-onset torticollis). Cervical dystonia is associated with an underlying CNS pathology; for the purposes of this website, the term "torticollis" will refer to the musculoskeletal pathology and not to the CNS pathology.6
The part of the sternocleidomastoid (SCM) muscle that is attached to the sternum rotates the head; the other part is attached to the clavicle and laterally flexes the head. Both parts join together and attach on the mastoid process and superior nuchal line of the occipital bone.1
Surgery is indicated after a patient has undergone more than six months of manual stretching and continues to have a residual head tilt, lack of PROM, lateral bending of the neck greater than 15 degrees, or a tumor.7
Prevalence ranges from 0.3% to 2% with difficult birth history possibly being implicated in 30-60% of torticollis patients.8
The clinical signs of CMT include:
1. Unilateral fibrosis or shortening of the SCM muscle
2. Lateral flexion of the head toward the affected side with rotation of the chin to the contralateral side with notable loss of AROM and PROM of the cervical spine
3. Palpable mass or tumor in the SCM during first three months of life followed by restricted ROM and fixed torticollis posturing due to fixed/restricted SCM
4. Plagiocephaly, including a flattened parieto-occipital area, an anteriorly shifted ear contralateral to the shortened SCM with frontal flattening on the ipsilateral side and/or facial asymmetry.
5. Compensatory postures in the cervical and thoracic spines, trunk, and extremities to include shoulder elevation and side bending of the trunk on the impaired side.5
As many as 80 etiologies for torticollis have been listed.3 Examples include:
-A vascular insult to the SCM muscle that leads to fibrotic tissue and subsequent muscle shortening.5
-A hematoma in the SCM before birth, abnormal positioning in the womb, or compartment syndrome in the SCM.4
Torticollis is commonly grouped into osseous, nonosseous, and neurologic types of etiology:
Osseous: caused by bony malformations of the cervical spine and skull, to include C1-C2 subluxation (also called Grisel syndrome), inflammatory processes in the upper cervical region that irritate the cervical muscles, nerves, or vertebrae causing spasm that results in torticollis.5
Nonosseous: includes CMT
Neurogenic (often appears after infancy): ocular tumors/abnormalities (the most common source of ocular torticollis is paresis of the superior oblique muscle), Sandifer syndrome (a condition causing gastrointestinal reflux), Arnold Chiari malformations, tumors of the posterior fossa, syringomyelia and spinal cord tumors.5
DIAGNOSTIC TESTS/EVALUATION/SPECIAL ORTHOPEDIC TESTS
X-rays, ultrasound, CT and MRI of the head and neck are often used to diagnose torticollis.3 Other diagnoses need to be ruled out, such as cancer, inflammation, infection, congenital cervical vertebral anomalies, and other structural and functional neurologic causes.4
In adults, PROM in the neck is usually measured in the sitting position with an electrogoniometer (which has good inter- and intra-rater reliability and ICC values ranging from 0.90 to 0.98) or with a strap-on goniometer (which has poor to moderate reliability for measuring passive rotation and lateral flexion, with ICC values ranging from 0.38 to 0.64). Infants’ PROM in the neck is measured from the supine position.8
The primary goal in the treatment of CMT is to prevent neck movement limitation, facial and skull asymmetry and long-term posture change.9 Early detection and start of physical therapy is associated with improved outcomes, shorter treatment duration, and a lower incidence of necessity of surgery.5 PT is the most important therapeutic procedure that can eliminate the need for surgery.3
Manual stretching reportedly resolves 90% of CMT within one year, leaving only 10% of patients requiring surgery. Predictors of fair-to-poor outcomes include the presence of a sternomastoid tumor, initial degree of head rotations being greater than 15 degrees from neutral, and age being greater than one year at the start of initial intervention.4
Infants are often referred to a PT as soon as 1-3 months in age. Not only does the PT instruct the parents how to stretch the short SMC muscle, but also how to strengthen the weak (non-affected side) SCM muscle through active movements of the head.8 Common stretches include side-to-side and ear-to-shoulder stretches of at least 30 seconds duration that are repeated 10-15 times per bout, at least twice a day. Therapists and parents can use mirrors and toys that are on the child’s unaffected side to get their attention and further promote functional stretching of the affected side. This can occur in many situations, to include while the child is on a swing, in a car seat, and baby carriages. Patients should be instructed in positional cues to help out their child.4
SURGERY & POST-OPERATIVE TREATMENT
Surgery is necessary once contractures intensify, after 12 months of physical therapy, or if facial asymmetry develops. One of the most successful surgeries is bipolar release of the SCM with a z-plasty performed on the clavicular pole (92% satisfaction rate).3 Even adults that still present with CMT, or irreversible facial and skeletal deformities can benefit from surgery, because the surgery lessens or eliminates the head tilt, and increases the range of neck motion. Surgery, even in adulthood, has the ability to improve the quality of life for these patients.10
Postoperative treatment after SCM release runs the range from simple stretching with soft dressings, to bracing, to cast immobilization – depending on the surgeon’s preference and severity of the condition. Occasionally, damage to nerves or vascular structures has occurred as a result of surgery, due to the proximity of the SCM to the spinal accessory nerve, facial nerve, anterior and external jugular veins, and carotid vessel.4
ADDITIONAL TREATMENT MODALITIES
Very little research has been completed that supports treating torticollis with a modality. Instead, the most conclusive evidence still recommends using manual stretching, Botox injections, or at a last resort, surgery.
However, two research studies were found that reference utilization of additional modalities as a treatment for torticollis. The research findings have been summarized below, but were notably deficient in describing application of the modality or overall outcomes attributable to the specific modality. In total, the use of these modalities was only on five patients who had been diagnosed with torticollis or cervical dystonia.
- A case report from 2008, concerning a college student that had contracted viral torticollis, referred to a three-day treatment plan in which the student received ultrasound and electrical stimulation as palliative therapy to relieve pain and muscle spasms, along with passive stretching of cervical muscles and manipulation. By the third day, the student had returned to normal cervical ROM and her pain was minimal. The report was inconclusive as to the specific effect of ultrasound and electrical stimulation on the outcomes of pain reduction and return to full range of motion.11
- One study from 2003, that was poorly described and included no quantitative outcome measures of four patients with cervical dystonia, compared six weeks of EMG biofeedback versus physical therapy that included postural reeducation exercises and passive elongation of cervical muscles. The study concluded that physical therapy was comparable to the biofeedback.12
ADDITIONAL WEB BASED RESOURCES
And… two good videos on reshaping a baby's head if they have plagiocephaly (often a comorbidity of torticollis, but is relatively easy to treat):
Part 2 is really cute:
1. Neumann DA. Kinesiology of the Musculoskeletal System. 2nd ed. St. Louis, MO: Mosby; 2010.
2. Magee DJ. Orthopedic Physical Assessment. 5th ed. St. Louis, MO: Saunders; 2008.
3. Petronic I, Brdar R, Cirovic D, Nikolic D, Lukac M, Janic D, Pavicevic P, Golubovic Z, Knezevic T. Congenital muscular torticollis in children: distribution, treatment duration and outcome. Eur J Phys Rehabil Med. 2010;45(2):153-158.
4. Luther B. Congenital Muscular Torticollis. Orthop Nurs. 2002;21(3):21-28.
5. Gray GM, Tasso KH. Differential Diagnosis of Torticollis: A Case Report. Pediatr Phys Ther. 2009;21:369-374.
6. Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis, MO: Saunders; 2009.
7. Cheng JCY, Wong MWN, Tang SP, Chen TMK, Shum SLF, Wong EMC. Clinical Determinants of the Outcome of Manual Stretching in the Treatment of Congenital Muscular Torticollis in Infants. J Bone Joint Surg. 2001;83(5):679-687.
8. Klackenberg EP, Elfving B, Haglund-Akerlind Y, Carlberg EB. Intra-rater reliability in measuring range of motion in infants with congenital muscular torticollis. Adv Physiother. 2005;7:84-91.
9. Ohman A, Beckung E. Functional and cosmetic status in children treated for congenital muscular torticollis as infants. Adv Physiother. 2005;7:135-140.
10. Omidi-Kashani F, Hasahkhani EG, Sharifi R, Mazlumi M. Is surgery recommended in adults with neglected congenital muscular torticollis? A prospective study. BMC Musculoskeletal Disord. 2008;9:158-164.
11. Kaufman, R. Comanagement and Collaborative Care of a 20-Year-Old Female With Acute Viral Torticollis. J Manipulative Physiol Ther. 2009;32(2):160-165.
12. Smania N, Corato E, Tinazzi M. The effect of two different rehabilitation treatments in cervical dystonia: preliminary results in four patients. Funct Neurol. 2003;18:219-225.