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 pain killing 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.

Any thoracic, shoulder blade, shoulder or arm pain will also be recorded. The physio may decide to test the reflexes of the biceps and triceps muscles to check if the C6 or C7 nerve roots are involved should the symptoms indicate the possibility. The sensibility of the skin to light touch can also be investigated for similar reasons. The physiotherapist is less likely to choose to test the muscle power in the shoulders and arms as this would cause an increase in pain and not reflect the patient’s true muscle strength. The usual questioning to exclude potentially serious underlying causes or complicating medical conditions will be undertaken.

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.

Once the pain has started to reduce well the physiotherapist can progress to other manual therapies such as joint mobilisations, neck massage and gentle stretches to the tight muscles. Active range of movement exercises within reasonable comfort are also encouraged. Once normal head posture and cervical range of movement has been restored then the physio will move on to strengthening the neck muscles and work on endurance to cope with the demands of daily life.

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

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