It is a dystonic condition defined by an abnormal and asymmetric position of the head or neck, which can be due to a variety of causes.
A contracture is usually in response to prolonged hypertonic spasticity in a concentrated muscle area, such as is seen in the more tense muscles of people with conditions such as spastic cerebral palsy.
A contracture is a permanent or almost permanent shortening of a muscle or joint, tendon, skin or tissues immediately beneath the skin, or tissues around a major joint that causes a structural change and loss of movement.
The term torticollis is derived from the Latin words “tortis” to twist and “collum” to neck. The most common case does not have an obvious cause, and pain and difficulty in turning the head usually disappear after a few days, even without treatment.
Contractures are essentially muscles or tendons that have been too tight for too long, so they shorten. Once they occur, it is often argued that they can not stretch or exercise (they must be released with orthopedic surgery ).
Neck contractures can also be due to ischemia , as in Volkmann’s contracture. Excessive accumulation of matrix metalloproteinases and myofibroblasts at the wound margins can cause contracture.
Signs and symptoms
Torticollis is a fixed or dynamic tilt or rotation, with flexion or extension of the head and / or neck. The type of torticollis can be described according to the positions of the head and neck.
- Laterocollis : the head is tilted towards the shoulder.
- Rotational torticollis : the head rotates along the longitudinal axis.
- Anterocollis : forward flexion of the head and neck.
- Retrocollis : hyperextension of head and neck backwards.
A combination of these movements can often be observed. Torticollis can be a disorder in itself and a symptom of other conditions.
Other symptoms include:
- Neck Pain.
- Occasional formation of a mass.
- Sternocleidomastoid muscle thickened or tight.
- Sensitivity in the cervical spine.
- Tremor in the head
- Uneven shoulder heights.
- Decreased neck movement
How to start a contracture?
A cervical contracture develops when the normally elastic tissues of the neck are replaced by abnormal, non-elastic foreign tissues.
Since this invasive and strange fibrous tissue does not stretch as well as the tissue it replaced, the contracture prevents the tissue from stretching as before and disrupts normal movement.
It is not too inaccurate to think that the contracture tissue is something like an internal scar that can not be seen, but that in any case affects the body to a great extent.
The contracture, because they shorten the tissue, also change the appearance of the invaded tissue:
- The nodules, lumps or cords appear where they were not previously.
- Twisted, curved or claw-like deformations can develop.
- Altered symmetry of the body, such as a bent spine or a clawed hand.
Cervical contracture develops after the tissue has been too tight for a long time, allowing tissue changes to occur.
By the time the contracture can no longer be exerted or stretched, the tissue must be released by orthopedic surgery.
Massive neck contracture, decreased range of movement of the spine and low back pain are present due to the fibrous infiltration of the large lumbar muscles and deep gluteus.
When the contracture affects the neck after the injury and torticollis develops, this can also lead to fibrous infiltration of the neck muscles, so that complete neck movement is impossible.
This is the reason why these spinal problems defy easy treatment; The muscles have undergone changes in the tissues and can not respond easily or quickly to any therapy that has been thrown into the problem.
A multitude of conditions can lead to the development of torticollis, which include: muscle fibrosis, congenital abnormalities of the spine, or toxic or traumatic brain injuries.
An approximate categorization discerns between congenital torticollis and acquired torticollis. Other categories include:
- Non-muscular soft tissue
- Induced by drugs.
The contracture can arise from common and extreme causes:
- The lack of use and prolonged immobility.
- Deep tissue or internal scarring after a traumatic injury.
- Deep tissue damage as a result of third-degree burns.
- Damage to the nerve
- Inability to move due to pain.
- Severe loss of blood supply or ischemia to a part of the body, in which tissue destruction occurs due to lack of oxygenation.
- Disorders of the brain and nervous system (spastic cerebral palsy or cerebrovascular accident).
Congenital muscular torticollis
Congenital muscular torticollis is the most common torticollis that is present at birth. The cause of congenital muscular torticollis is unclear.
It is considered that birth trauma or intrauterine malposition are the cause of damage to the sternocleidomastoid muscle in the neck.
Other alterations in muscle tissue arise from repetitive microtrauma within the uterus or a sudden change in the concentration of calcium in the body that causes a prolonged period of muscle contraction.
Any of these mechanisms can result in a shortening or excessive contraction of the sternocleidomastoid muscle, which reduces its range of motion in both rotation and lateral flexion.
The head is usually inclined in lateral flexion towards the affected muscle and turned to the opposite side. In other words, in the direction towards the shortened muscle with the chin tilted in the opposite direction.
Congenital torticollis occurs at 1-4 weeks of age and a hard mass usually develops. It is usually diagnosed by ultrasonography and a color histogram or clinically by assessing the range of passive movement of the cervix.
Congenital torticollis constitutes the majority of cases observed in clinical practice. The reported incidence of congenital torticollis is 0.3-2.0%.
Occasionally, a mass, such as a sternocleidomastoid tumor, is seen in the affected muscle at age two to four weeks. Little by little it disappears, usually at the age of eight months, but the muscle is left fibrotic.
Non-congenital muscular torticollis can be the result of scarring or disease of the cervical vertebrae, adenitis, tonsillitis, rheumatism, enlargement of the cervical glands, retropharyngeal abscess or cerebellar tumors.
It can be spasmodic (clonic) or permanent (tonic). The last type may be due to Pott’s disease (tuberculosis of the spine).
A self-limited form of spontaneous torticollis with one or more painful neck muscles is by far the most common (“stiff neck”) and will pass spontaneously in 1-4 weeks.
Usually, the sternocleidomastoid muscle or the trapezius muscle is involved. Sometimes, they involve drafts, colds or unusual postures; however, in many cases no clear cause is found. These episodes are commonly seen by doctors.
Tumors of the base of the skull (tumors of the posterior fossa) can compress the supply of nerves to the neck and cause torticollis, and these problems must be treated surgically.
Infections in the posterior pharynx can irritate the nerves that supply the neck muscles and cause torticollis, and these infections can be treated with antibiotics if they are not too severe, but may require surgical debridement in difficult to treat cases.
Ear infections and surgical removal of the adenoids can cause an entity known as Grisel’s syndrome, a subluxation of the upper cervical joints, mainly the atlantoaxial joint, due to the inflammatory laxity of the ligaments caused by an infection.
There are many other rare causes of torticollis. A very rare cause of acquired torticollis is progressive ossifying fibrodysplasia, whose hallmark is malformed large fingers.
Torticollis with recurrent but transient contraction of the muscles of the neck and especially the sternocleidomastoid is called spasmodic torticollis. The synonyms are “intermittent torticollis”, “cervical dystonia” or “idiopathic cervical dystonia”, depending on the cause.
It is an extremely painful chronic neurological disorder that causes the neck to involuntarily turn to the left, right, up or down. The agonist and antagonist muscles contract simultaneously during dystonic movement.
The causes of the disorder are predominantly idiopathic. A small number of patients develop the disorder as a result of another disorder or disease.
Most patients experience middle-aged symptoms for the first time. The most common treatment for spasmodic torticollis is the use of botulinum toxin type A.
Spasmodic torticollis is a form of focal dystonia, a neuromuscular disorder consisting of sustained muscle contractions that cause repetitive and twisted movements and abnormal postures in a single region of the body.
There are two main ways to classify spasmodic torticollis: the age of onset and the cause. The disorder is classified as early onset if the patient is diagnosed before 27 years of age, and late onset thereafter.
The causes are classified as primary (idiopathic) or secondary (symptomatic). Spasmodic torticollis can also be categorized by the direction and rotation of the head movement.
The torticollis may not be related to the sternocleidomastoid muscle, but is due to the damage of the trochlear nerve (fourth cranial nerve), which irrigates the superior oblique muscle of the eye.
The superior oblique muscle is involved in the depression, abduction and introsion of the eye. When the trochlear nerve is damaged, the eye is extruded because the superior oblique is not working.
The affected person will have vision problems unless he deflects the head from the affected side, causing the intorsion of the eye and balancing the extortion of the eye.
This can be diagnosed by the Bielschowsky test, also called head tilt test, where the head is turned to the affected side. A positive test occurs when the affected eye rises, seeming to float.
The underlying anatomical distortion that causes the torticollis or contracture is a shortened sternocleidomastoid muscle. This is the neck muscle that originates in the sternum and the clavicle and inserts into the mastoid process of the temporal bone on the same side.
There are two sternocleidomastoid muscles in the human body and when both contract, the neck flexes.
The main blood supply for these muscles comes from the occipital artery, the superior thyroid artery, the transverse scapular artery and the transverse cervical artery.
The main innervation of these muscles comes from the cranial nerve XI (the accessory nerve), but the second, third and fourth cervical nerves are also involved. The pathologies in these supplies of blood and nerves can lead to torticollis.
The evaluation of a child with torticollis begins with the taking of antecedents to determine the circumstances surrounding the birth and any possibility of trauma or associated symptoms.
Physical examination reveals decreased rotation and flexion to the side opposite the affected muscle. Some say that congenital cases most often involve the right side, but there is no complete agreement on this in the published studies.
The evaluation should include a thorough neurological examination, and the possibility of associated conditions such as hip dysplasia and clubfoot should be examined .
X-rays of the cervical spine should be obtained to rule out obvious bony abnormalities, and magnetic resonance imaging should be considered if there are concerns about structural problems or other conditions.
Ultrasound is another diagnostic tool that uses high-frequency sound waves to visualize muscle tissue. A color histogram can also be used to determine the cross-sectional area and thickness of the muscle.
The evaluation by an optometrist or an ophthalmologist should be considered in children to ensure that the torticollis is not caused by vision problems (IV paralysis of the cranial nerve, “null position” associated with nystagmus, etc.).
The differential diagnosis for torticollis involves:
- Paralysis of the cranial nerve IV.
- Spasmus nutans.
- Sandifer syndrome.
- Miastenia gravis.
It is believed that the cervical dystonia that appears in adulthood is idiopathic in nature, since specific imaging techniques often do not find a specific cause.
Initially, the condition is treated with physical therapies, such as stretching to release tension, strengthening exercises to improve muscle balance and management to stimulate symmetry. Sometimes a tubular orthosis for neck torticollis is applied.
The early start of treatment is very important for complete recovery and to decrease the chances of relapse.
The majority of professional contracture treatment is preventive in nature. Most physical therapy, occupational therapy, and other exercise regimens for people with spasticity focus on trying to prevent contractures from occurring in the first place.
The treatment is designed for patients who exhibit early stages of muscle spasticity and connective tissue.
However, research on sustained connective tissue traction in approaches such as adaptive yoga has shown that contracture can be reduced, while at the same time addressing the tendency to spasticity.
Professional yoga instruction can help prevent and restore joint mobility.
Physiotherapy is an option to treat torticollis in a non-invasive and cost-effective way. Although outpatient physiotherapy is effective, home therapy by a parent or guardian is equally effective in reversing the effects of congenital torticollis.
The usual course of treatment consists mainly of medical care, physiotherapy and occupational therapy:
Muscle relaxant, anti-inflammatory or analgesic. Stretching exercises. Botox (botulinum toxin) is sometimes injected into the muscles of patients with paralysis to weaken them as a strategy to postpone surgery.
The manipulation under anesthesia of an affected joint could be useful for severe contractures that do not respond to standard conservative care.
Muscle conditioning exercises that target the antagonist muscles of those that are spastic. Adjustment or chiropractic manipulation and related techniques are useful to improve movement of the main joints and spinal problems.
Massage therapy is often beneficial in restoring tissue length and increasing local circulation to joint structures, which results in better elasticity.
The lateral flexion of the neck and the general range of motion can be recovered more quickly in newborns when parents perform physical therapy exercises several times a day.
Physiotherapists should teach parents and guardians to perform the following exercises:
- Stretch the muscle prone position both actively and passively.
- Stretching the muscle in a lateral position supported by a pillow (have the baby lie on the side with the neck resting on the pillow). The affected side should be against the pillow to deflect the neck to the unaffected side.
- The posture should be controlled in strollers, seats and swings (using pillows or U-neck blankets to keep the neck in a neutral position).
- Active rotation exercises in the supine position, sitting or upside down (use toys, lights and sounds to attract the attention of the baby and turn your neck towards the unaffected side).
- Passive rotation of the cervix (very similar to stretching when supported by a pillow, with the affected face down).
- Place the baby in the crib with the affected side next to the wall, so you must turn to the unaffected side to look out.
Physiotherapists often encourage parents and caregivers of children with torticollis to modify the environment to improve the movements and position of the neck. Modifications may include:
- Addition of neck supports to the car seat to achieve optimal neck alignment.
- Reduce the time spent in one position.
- Use toys to encourage the child to look in the direction of limited neck movement.
A Korean study recently introduced an additional treatment called microcurrent therapy that may be effective in the treatment of congenital torticollis.
For this therapy to be effective, children must be less than three months old and have torticollis that involves the entire sternocleidomastoid muscle with a palpable mass and a muscle thickness of more than 10 mm.
Microcurrent therapy sends tiny electrical signals to the tissue to restore normal frequencies in cells. The microcurrent therapy is completely painless and children can only feel the probe of the machine on their skin.
It is believed that microcurrent therapy increases the synthesis of ATP and proteins, in addition to improving blood flow, reducing muscle spasms and decreasing pain along with inflammation.
It should be used in addition to regular stretching exercises and ultrasound diathermy. Ultrasound diathermy generates deep heat in the tissues of the body to help with contractures, pain and muscle spasms, in addition to reducing inflammation.
This combination of treatments shows remarkable results in the length of time children spend in rehabilitation programs: Micocurrent therapy can reduce the duration of a rehabilitation program by almost half, with full recovery after 2.6 months.
About 5-10% of cases do not respond to stretching and require surgical release of the muscle.
Surgical release involves the free dissection of the two heads of the sternocleidomastoid muscle. This surgery can be minimally invasive and performed laparoscopically.
Usually, surgery is performed on those who are more than 12 months old. Surgery is for those who do not respond to physical therapy or injection of botulinum toxin or who have a very fibrotic sternocleidomastoid muscle.
After surgery, the child will be required to wear a soft collar (also called Callot plaster). There will be an intense physiotherapy program for 3-4 months, as well as strengthening exercises for the neck muscles.
Other treatments include:
- Rest and analgesics for acute cases.
- Diazepam or other muscle relaxants.
- Botulinum toxin.
- Encourage active movements for children 6-8 months of age.
- Ultrasound diathermy.
Ignoring or delaying appropriate contracture treatment can make it impossible or difficult to restore or improve lost mobility.
After prolonged confinement in bed or post-surgical care, it is important to tell your doctor about any unusual sensation of restricted movement, muscle pain, or feeling that the trunk or limb tissues feel thicker or denser than before.
Those under long-term hospital care, and those with neurological diseases such as muscular dystrophy, cerebral palsy or stroke, should be monitored for the development of contractures. Timely treatment can provide the best recovery and possible outcome.
As with most things in life, the earlier and more aggressively applied is the treatment for contracture, the better the eventual prognosis.
Studies and evidence from clinical practice show that 85-90% of cases of congenital torticollis are resolved with conservative treatment. It is possible that the torticollis resolves spontaneously, but it is possible that there is a relapse.
In veterinary literature, generally, only the lateral bending of the head and neck is called torticollis, while the analogous to rotating torticollis in humans is called head tilt.
The most frequent form of torticollis in domestic pets is the inclination of the head, but occasionally there is a lateral flexion of the head and neck to the side.
The causes of tilt of the head in domestic animals are diseases of the central or peripheral vestibular system or alleviate posture due to neck pain. Known causes of head tilt in pets include:
- Encefalitozoon cuniculi (or E. cuniculi) infection in rabbits.
- Infection of the inner ear.
- Hypothyroidism in dogs.
- Disease of the VIII cranial nerve N. Vestibulocochlearis through trauma, infection, inflammation or neoplasia.
- Brainstem disease through a stroke, trauma or neoplasia.
- Damage to the vestibular organ due to toxicity, inflammation or altered blood supply.
- Vestibular geriatric syndrome in dogs.