Torticollis

Torticollis (cervical dystonia or spasmodic torticollis) is a type of movement disorder, in which the muscles controlling the neck cause sustained twisting or frequent jerking.

In torticollis, certain muscles controlling the neck undergo repetitive or sustained contraction, causing the neck to jerk or twist to the side. Cervicaldystonia causes forward twisting, and is called antecollis. Backward twistingis known as retrocollis. The abnormal posture caused by torticollis is oftendebilitating, and is usually painful.

Torticollis most commonly begins between age 30-60, with females affected twice as often as males. According to the National Spasmodic Torticollis Association, torticollis affects 83,000 people in the United States. Dystonia tendsto become more severe during the first months or years after onset, and may spread to other regions, especially the jaw, arm, or leg. Torticollis should not be confused with other causes of abnormal neck posture, such as orthopedicor congenital problems.

The nerve signals responsible for torticollis are thought to originate in thebasal ganglia, a group of brain structures involved in movement control. Theexact defect is unknown. Some cases of dystonia are due to the inheritance of a defective gene, whose function was unknown as of mid-1998. Other cases are correlated with neck or head trauma, such as from an automobile accident. Use of certain antipsychotic drugs, or neuroleptics, can induce dystonia.

There are three types of torticollis:

  • Tonic, in which the abnormal posture is sustained
  • Clonic, marked by jerky head movements.
  • Mixed, a combination of tonic and clonic movements

Symptoms usually begin gradually, and may be intermittent at first, worseningin times of stress. Symptoms usually progress over two to five years, and then remain steady. Symptoms may be relieved somewhat when lying down. Many people with torticollis can temporarily correct their head position by sensory tricks, as touching the chin or cheek on the side opposite the turning. The reason for the effectiveness of this "geste antagoniste," as it is called, is unknown.

Pain in the neck, back, or shoulder affects more than two-thirds of all people with torticollis. Pain may spread to the arm or hand.

Diagnosis of torticollis is aided by an electrical study (electromyography) that can detect overactive muscles. Imaging studies, including x rays, may bedone to rule out other causes of abnormal posture. A detailed medical historyis needed to determine possible causes, including trauma.

A variety of oral drugs are available to relax muscles, including baclofen. For a subgroup of patients, L-dopa provides effective relief. Denervation of the involved neck muscles may be performed with injection of alcohol or phenolon to the nerve.

Injection of botulinum toxin (BTX) is considered by many to be the treatmentof choice. By preventing release of chemical messages from the nerve endingsthat stimulate the involved muscles, BTX partially paralyzes the muscles, therefore allowing more normal posture and range of motion. BTX treatment lastsseveral months, and may be repeated.

Physical therapy can help relieve secondary consequences of torticollis. Regular muscle stretching prevents contracture, or permanent muscle shortening. Pain and spasm may be temporarily lessened with application of heat or ice. Stress management techniques may help prevent worsening. An occupational therapist can suggest home or work modifications to reduce fatigue and improve function. Braces constructed to replace the patient's own sensory tricks may helpreduce abnormal posture.

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