Torticollis

(wry neck)

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 Definition
Torticollis is Latin word and torti mean oblique and collis
mean neck. So it mean twisted neck in which head tilted
to the affected side and the chin is rotated to the other
side due to shortening of SCM. It is a very treatable
condition, but should be taken seriously.

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 Classification
1- Congenital muscular torticollis (CMT)
2- Acquired torticollis
3- spasmodic torticollis

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 Causes
1- The etiology of CMT is unclear but it may be
due to:
• Intrauterine malposition may occur if the fetus' head
is in the wrong position while growing in the utro.
• If the muscles or blood supply to the fetus' neck are
injured.
This results in a shortening or excessive contraction of
the sternocleidomastoid muscle

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2- The etiology of Acquired torticollis may be
due to another problem such as:
• Trauma to the neck can cause atlantoaxial rotatory
subluxation, in which the two vertebrae closest to the
skull slide with respect to each other, tearing stabilizing
ligaments.
• Tumors of the skull base (posterior fossa tumors) can
compress the nerve supply to the neck and cause
torticollis.
• Infections in the posterior pharynx can irritate the
nerves supplying the neck muscles and cause torticollis.
• The use of certain drugs, such as antipsychotics can
cause torticollis.
• an ocular muscle impairment
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2- The etiology of spasmodic torticollis (a
painful neurological movement disorder, It is
also known as Cervical Dystonia) may be due
to: idiopathic, a small number of patients
develop the disorder as a result of another
disorder or disease. Most patients first
experience symptoms midlife

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 There are three clinical groups of congenital
torticollis (The conditions presents from birth
through the first 3 months of life during which time
infants' neck muscles are developing)

1. Palpable SCM tumor (there is mass)

Some children get a benign bump in the muscle some
week after they are born which always disappears
but sometimes there is a remaining scare tissue and a
tight lateral band that prevents full motion.
2. Muscular SCM- tightening and thickening of SCM
without mass.
3. Postural torticollis - posturing but no tightness or
tumor, may be due to congenital absence of
cervical ms.
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 Sign and symptoms
1- limited ROM for ipsilateral rotation and
contralateral bending.
2- Inability to maintain head in mid position due to
ms imbalance and tightness.
3- Skull asymmetry/ plagiocephaly also called
flattened head(When the child has a favorite side
and spends most time lying with head in the
same position the head gets flattened on this
side. This deformity can develop very quickly but
can also decrease or disappear totally if the head
is relived from pressure.

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4- It is difficult for the child to turn their head for visual
tracking, hold their head in an upright position and
perform appropriate upper extremity movements
necessary for feeding, play and interact with the
environment and arm preference and affect reaching,
rolling and sitting .
5- other musculoskeletal asymmetries may
include:
• Trunk curvature toward the affected SCM.
• Persistence of asymmetrical tonic neck reflex.
• Tilting of pelvis due to hip joint abducted at face side
and adducted on occipital side.
6- delay cognitive development and whole 9
 Secondary effects of untreated torticollis

1- Plagiocephaly is an asymmetric skull deformity in infants

that is caused by the flattening of one occiput that leads to
the secondary flattening of the contralateral forehead.
2- Facial hypoplasia is inhibition in the growth of the
mandible and maxilla due to muscle inactivity. Clinically
significant facial hemihypoplasia develops over 8 months;
however, it is obvious in patients at the age of 2-3 years.
3- Musculoskeletal effects include the compensatory
ipsilateral elevation of the shoulder, as well as cervical and
thoracic scoliosis. Wasting of additional muscles in the
neck may be present due to sternocleidomastoid
inactivity. 10
 Assessment
1- History:
• Family history (if there is similar condition)
• Labor history and birth history (nature of labor, use of forceps, birth
presentation breech or cephalic and multiple birth, and other congenital
anomalies).
• any possibility of trauma or associated symptoms
2- Observation:
• Position of head in relation to the other body parts.
• Sternomastoid mass or tumor.
• Degree of facial asymmetry (underdevelopment of ipsilateral
jaw, inferior and posterior position of ipsilateral ear, deformity
of ear as bat ear, asymmetry of eye smaller, deviation of the
chin point and nasal tip and facial scoliosis).
• Spine problems.
• Shoulder is higher on one side of the body

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3- Palpation:
• Palpate Sternomastoid tumor or mass for it’s presence
and extent.
• Note any pain with neck movement
• Tightness or contractures.
4- Measurement:
• ROM (active by using toys or reflexes) (passive to detect
limitation)
A big protractor being used to
measure lateral flexion (side bending)
in the neck, the child is lying in supine
position.

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A goniometer is being used to
measure rotation in the neck.

Neck rotation measured with an

arthrodial protractor in sitting
position.

An arthrodial protractor is being used to

measure rotation in the neck. The infant in
supine position, with the shoulders stabilized
and the neck supported by the examiner over
the edge the examination couch.
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• Round measurement to sternomastoid tumor to measure it’s
size.
5- Reflex assessment: according to age of child especially
righting reactions
6- Motor development assessment
7- Hip asymmetry and club foot should be assessed through:
Measuring hip abduction, leg length and observe thigh and
abnormal skin folds. As incidence of hip dysplasia about 8% to
20% in children with CMT at the same side.
8- X-rays for cervical spines should be obtained to rule out
obvious bony abnormality to exclude a fracture or dislocation
of the spinal bones in your neck, ultrasonography is the most
commonly ordered test and MRI should be considered if there
is concern about structural problems.
9- Evaluation by an ophthalmologist should be considered in
children to ensure that the torticollis is not caused by vision
problems (IV cranial nerve palsy, nystagmus-associated).
10- assess flexibility and strength of arm, leg and trunk
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 Goals of Physical Therapy when
Treating Torticollis:
• Improve child's ability to turn head between right and left sides
• Improve child's ability to bring chin to chest
• Improve child's ability to orient their head to midline against
gravity
• Encourage child to lift head against gravity while lying on
stomach
• Achieve normal weight bearing and shifting over upper
extremities
• Encourage symmetrical use of upper extremities
• Allow child to experience proper weight shifting during
developmental activities including sitting, rolling, creeping and
walking .
• Prevent a permanent shortening of the involved muscle and
skull asymmetry.
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 Treatment Methods
1- Stretching ex’s:
Stretching done 4-6 times daily, three times per
week. Repeating each stretch time 10 sec with
10 sec rest.
Stretching protocol
• Patient position is supine with head and neck
outside supporting surface.
• The best stretching is done with two persons,
one stabilizes the shoulder and the other
stretch the neck. 16
• Stretching should include all motion of the
neck with gentle traction prior to any motion.
• To maintain ROM, the infant must develop
strength and active use of antagonist ms to
help develop good midline control.
Procedures:
1- child is in supine with head and neck outside
supporting surface to allow full neck motion.
2- one person stabilize shoulders at sternum, clavicle ,
ribs and scapula.
3- the second person holds under the occiput and
applies gentle traction to cervical spine to align it in
neutral and lengthen the muscles.
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1. For the following stretching
exercises, the parent sits with the
back against the wall and knees bent.

2. Place the child in your lap, with the

child on her back and knees tucked.

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Exercise 1. is designed to improve rotation of your child’s head
to the right and left. Place one hand on your child’s chest. Place
the other hand on the side of the child’s face. Gently but firmly
turn the head so that the chin moves toward the shoulder, hold
for 10 seconds, and release.

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Exercise 2. is designed to improve bending of your
child’s head to the side. Place one hand on your child’s
upper chest and shoulder area so that the body does
not move. Hold the top of your child’s head with the
other hand. Gently but firmly tilt the head toward the
shoulder, hold 10 seconds, and release.

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Ex 3: Suckling ex’s to stretch SCM (side bending ex):
Child position: side lying on affected side
One hand support shoulder and other hand hole both lower limb
then slowly raise the L.L upward.
Ex 4: during carrying
1. Hold the child facing away from you, in a side-lying position,
with the affected side resting against your forearm.
2. Place your arm between the child’s legs and support the child’s
body.
3. Carry the child in this position as much as possible.

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 2- strengthing ex’s (active correction)
1- Through using ball ex’s for facilitation of righting
reactions, or from hold baby in space and using of
toys :
a- Place baby on tummy on ball. Sit on floor behind the ball,
and hold baby's hips for stability. Slowly roll ball towards
floor so that baby's head is moving towards floor. They will
use their neck muscles to pull their head up, trying to keep
it perpendicular to the floor. It also helps to have someone
sit in front of the ball encouraging baby to look up. Rolling
the ball back and forth also helps them get a sense of
movement/balance.
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b- Does the same thing as above, only instead of rolling the
ball totally forward move the ball slightly forward and
then gently side to side. This will encourage baby to use
one arm and then the other (depending on which way
you are rolling) to stabilize their body on the ball.
c- Does the same thing from sitting forward, backward,
side to side.

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3- Orthotic management

a- tubular orthosis for torticollis (TOT):

The TOT Collar for Torticollis Treatment is designed to
provide a noxious stimulus to the lateral aspect of the
skull. The user moves away from this stimulus towards a
new, central corrected position. The TOT Collar is ready to
fit.

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Indications for TOT
1- If they 4 months of age or older.
2- there is constant head tilt for 5 degrees or greater.
3- the infant have adequate ROM and lateral head righting
reactions to lift head away from the collar side.
Advantages:
1- active strengthening ex’s can be done while wearing the
collar.
2- easily adjusted, easy to put on and remove and -easy
to keep clean.
3- low profile, unobtrusive appearance .

Duration of wearing TOT:

Minimum of 2-3 months and may be needed for 8 months,
during waking time. Then gradually decreased when
head tilt less than 5 degrees. 25
b- foam collar:

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c- Cap and jacket splint:

Which allow to gain full stretch, but it is not

preferable as it restrict child in one position
for long period so prevent active correction.

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4- Home routine

a- teach mother how to stretch SCM ms and

encourage active correction.
b- teach mother how to carry and hold.
c- how to position the child during sleep, supine
put pillow to maintain head in mid position,
side lying on affected side on pillow.
d- teach mother how to present toys to facilitate
reaching.

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5- Surgical treatment

Indication:
1- persistent SCM contracture limiting head movement.
2- torticollis in children older than 12 years.
3- SCM contractures with facial hemihypoplasia.
4- plagiocephaly (flattened head).
contraindications:
Surgical management of congenital muscular torticollis is
generally avoided until the child is aged at least 1 year,
until conservative methods are unsuccessful, and until
other differential diagnoses are excluded. 29
Goals of surgery:
1- To achieve best cosmetic appearance.
2- restore neck ROM.
3- improve craniofacial asymmetry.
Post operative treatment:
1- immediately after operation, the child lies supine
without pillows and use sand bag toward affected side
to prevent asymmetrical return of head.
2- use TOT or cap and jacket splint to maintain ms length.
3- stretching and active correction after 36 hours of
operation to maintain ms length.
4- facilitate righting reaction, head control, rolling…etc
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Thank you
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