May 29, 2009
May 29, 2009
Neck pain is a frequent reason for clients to see a massage therapist. In this issue, we'll examine torticollis, one cause of neck pain and disability that poses challenges in identification in the treatment room. Torticollis means literally, "twisted neck." A person with torticollis exhibits involuntary muscle contractions that lead to abnormal positions, and/or tremor or spasmodic movements of neck and head. Torticollis may manifest in different forms: congenital, spasmodic, or acute/acquired.
Congenital torticollis presents in infants and occurs at birth or shortly after. The condition may result from improper positioning in the uterus or birthing trauma. There are other roots of infant torticollis, such as structural or neurological. With treatment in the first year, this condition is usually resolved.
While considered rare, spasmodic torticollis, also known as cervical dystonia, may still affect close to 90,000 people in the United States. There are three variations named for the types of neuromuscular dysfunction: tonic (a sustained contraction), clonic (head shaking), and mixed (both). Spasmodic torticollis is a neurological condition that has no known cure and treatment is symptomatic. Clients who present with this condition should be instructed to contact one of several organizations that can provide support, information and resources to this population. Practitioners should also confirm the client has been diagnosed. In some cases, spasmodic torticollis is mistaken for muscular dystrophy, epilepsy or Parkinson's disease. There are significant distinctions between spasmodic and acquired or acute torticollis.
Acute or acquired (sometimes called "wry neck") is the most common form of torticollis characterized by constant muscle spasms in the neck. It appears in a broad spectrum of the population from children to adults. Acquired torticollis is caused by maintaining muscles in shortened positions for a prolonged period. The acute form might manifest as a result of a head or neck injury such as whiplash or concussion, in which symptoms may appear immediately or be delayed. Myofascial trigger points are another factor that either lead to the condition or perpetuate it. The condition seemingly appears "overnight" when, for example, a person has slept with his/her neck in an awkward position or a cold draft on their neck muscles. Other activities likely to produce acquired torticollis include holding the telephone between the head and shoulder, or playing an instrument, such as the violin, for long periods.
The sternocleidomastoid (SCM) muscle is most commonly involved in acute or acquired torticollis. Because it is a contralateral rotator, any position that rotates the head to the opposite side for long periods may lead to the condition. A history that includes the nature of the onset, the length of time the condition has been present, and physician diagnosis should allow distinction between the neurological spasmodic form and the muscular variation.
The practitioner will be able to palpate - and usually observe - shortening and hypertonicity in the muscle. Visual indicators are similar with each variation of torticollis. The head and neck are held in a non-neutral position, often with rotation to the opposite side. The SCM on the affected side is likely to be more prominent than on the opposite side. In the clonic variation of spasmodic torticollis, there will be some shaking of the head.
The muscles of the cervical region may feel tight due to local muscle spasm. In some cases, especially if the condition is chronic, a degree of fibrotic change may develop and there may be palpable contracture in the muscles. Active and passive motions that turn the head in the opposite direction of the contraction are likely painful and limited. There may be pain associated with further rotation to the contracted side depending on the severity of the condition and the percentage of muscle fibers recruited for the activity.
Acquired torticollis is not serious and symptoms generally resolve in a couple of weeks. This condition also responds well to massage; however, care should be used in treatment, as the muscles are often painful from spasm and trigger-point activity. In order to rule out more serious neurological or structural disorders, it is a wise idea to have the client evaluated by another health professional prior to treatment.