As part of a class presentation, we attempted to make this to briefly explain what Torticollis meas, the Types of presentation of Torticollis, and Management strategies for a Physiotherapist for Congenital Torticollis especially. I hope this helps. :) The pictures and information had been taken from internet, complied to make a brief presentation for the purpose of class presentation. I do not own any content.

1. Torticollis
( Wry neck)
By Fabiha Fatima and Falak.

3. So what is “Torticollis” ?
– Torticollis, also known as wry neck, is a dystonic
condition defined by an abnormal, asymmetrical
head or neck position, which may be due to a variety
of causes.
– The term torticollis is derived from the Latin
words tortus for twisted and collum for neck

4. Presentation of
Torticollis :-
– Torticollis is a fixed or dynamic tilt, rotation, with
flexion or extension of the head and/or neck. The
type of torticollis can be described depending on
the positions of the head and neck:-
– LATEROCOLLIS : the head is tipped toward 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
backward

5. Signs and Symptoms
– Torticollis can be a disorder in itself as well as a symptom in
other conditions.
– Other symptoms include:
– Neck pain
– Occasional formation of a mass
– Thickened or tight sternocleidomastoid muscle
– Tenderness on the cervical spine
– Tremor in head
– Unequal shoulder heights
– Decreased neck movement

6. Types of Torticollis :-
1
Congenital
muscular
torticollis
(CMT)
2
Postural
torticollis
3
Ocular
torticollis
(Trochlear
torticollis)
4
Spasmodic
torticollis
(wryneck)
5
Acute
torticollis

7. Congenital muscular torticollis
The congenital muscular
torticollis is the most
common torticollis which is
present at birth. The cause
of congenital muscular
torticollis is unclear.
Supposed causes include :-
Birth trauma
•Intrauterine malposition
•Repetitive microtrauma
within the womb to the SCM
•Sudden change in calcium
concentration in body,
causing prolonged period of
muscle contraction
Congenital Torticollis is
presented at 1–4
weeks of age and a
hard mass usually
develops.
It is normally diagnosed
using ultrasonography
and a colour histogram or
clinically through
evaluating the infant's
passive cervical range of
motion.

8. Acquired torticollis
Non-congenital muscular
torticollis may result from :-
• Scarring Or Disease Of Cervical
Vertebrae
• Adenitis
• Tonsillitis,
• Rheumatism
• Enlarged Cervical Glands
• Retropharyngeal Abscess
• Cerebellar Tumors
Types
Spasmodic
(Clonic)
Permanent (Tonic)

9. Acquired
Torticollis:
Types
Self- Limiting : One or more of the
neck muscle is painful
It resolves in 1-4 weeks
SCM or upper Trapezius is usually the most involved
Draughts or cold or abnormal posture is implicate
Tumors of the Posterior Fossa
These can compress the nerve
supplying the neck muscle and have to
be treated surgically
Infections
Pharynx
Ear
Adenectomy – cam cause Grisel’s syndrome which can cause
subluxation of the upper cervical joints.
Drug induced : Antipsychotics & Antiemetics
Fibrodysplasia ossificans progressiva (FOP)

10. Other Types of
Torticollis
– Spasmodic Torticollis
– Recurrent or transient
contraction of the muscles of
the neck muscles.
– SCM is mostly involved
– Cervical dystonia, idiopathic
cervical dystonia, intermittent
torticollis"
– Trochlear torticollis
(Congenital fourth nerve palsy)
– This is unrelated to the SCM
– Caused by damage to the
Trochlear nerve (CN IV) that
supplies the Superior Oblique
muscle of the eye.

11. Torticollis may
lead to
additional
problems :-
– Flattening of the skull (plagiocephaly or brachycephaly)
in infants.
– Movement that favors one side of the body, affecting
the arms, trunk, and hips. This can lead to strength
imbalances, such as an elevated shoulder and side-
bending of the trunk. This movement pattern can lead
to delayed gross motor development.
– Developmental hip dysplasia.
– Scoliosis.
– Limited ability to turn the head to see, hear, and
interact with surroundings, which can lead to delayed
cognitive development.
– Delayed body awareness or lack of self-awareness and
interaction.
– Difficulty with balance.
– Asymmetrical vision changes.

12. Additional
Problem

13. Diagnosis
– General History taking
– Birth History
– History of Trauma
– Neurological examination
– X-ray of cervical spine
– MRI
– USG – Muscular tissue, Color
Histogram
– Optometrist evaluation

14. Assessment :
– Observation of any asymmetries including facial, cranial, neck and
positional preference and presence of plagiocephaly.
– Observation of skin creases.
– Observation of infant in developmentally appropriate positions to
detect asymmetry and screen developmental milestones.
– Cervical active and passive range of movement testing.
– Upper and lower limb ROM screen, checking for hip dysplasia, which
can be associated with CMT, and spine asymmetry.
– Pain at rest and during movements.
– Palpation of sternocleidomastoid for size and elasticity and presence
of mass.
– Screen of visual tracking.
– Screen muscle tone.
– Identification of Red flags and appropriate onward referral:
– poor tracking
– abnormal muscle tone
– other features inconsistent with CMT
– poor progress with treatment

15. Management :
Physical Therapy (Goals)
To correct the
deformity by
release of the
contracted soft
tissues and
To maintain the
correction by
suitable exercise
regime; avoiding
recurrence.

16. Physiotherapy
Management
– Early mild cases
– Children with a mild degree of deformity reporting
early for the treatment can be managed with
physiotherapy.
– The physiotherapy procedures employed are:
– I. Evaluation: Careful evaluation of ROM and the
degree of deformity.
– II. Massage: Massage can relax the muscle preceding
the stretching maneuvers.
– III. Thermo Therapy Modality: Carefully administered
thermo-therapy modality induces relaxation.
– IV. Passive movements: The child is placed in supine
position with head beyond the edge of the table with
the neck in extension by positioning a pillow under
the thoracic region; Shoulders are stabilized by an
assistant.

17. Physiotherapy Management
– To attain relaxation, all the movements of the cervical
spine are done in a form of slow relaxed passive
movements.
– This should be followed by sustained passive stretching to
the affected sternomastoid. E.g. when the right
sternomastoid is involved the head should be gradually
bent inside flexion to the left, held there for a while and
then rotated gradually to the right. Try to gain as much
overcorrection as possible by applying gradual traction to
gain further stretching.

18. Physiotherapy
Management
– Maintenance of Correction: Once the correction is
achieved. It has to be maintained by passively holding or
keeping a sandbag.
– E.g: Kineso taping, Cervical Brace, Cervical collars
– The same maneuver can be repeated during the
subsequent visits.
– Active correction: Active correction is best achieved by
assisting the child head to follow an object moved in the
proper arc of correction. The bright-colored sound
producing object is ideal to attract the child attention.
– PNF: patients with neck extension can be used to an
advantage with emphasis on stretch and traction.

19. Physiotherapy
Management
– Home treatment programme: This assumes an important role as these
manipulations needs to be repeated. The mother should be trained properly for
this. The best method is to put the child in prone and the teach the mother to
carefully move the head towards the affected side and the child is encouraged to
look back over the right shoulder.
– Positioning: Exact positioning of the head during sleep is important. The child
should be made to sleep on the opposite side of the lesion and the position of
head adjusted by pillow or sandbag in a maximally corrected posture during
sleep. This positioning has two advantages:- First, there is natural relaxation of the
muscle- Secondly, whatever correction is achieved, it is maintained for a longer
period during sleep. However, the mother should intermittently check the
correction.
– Older children and adults: With advancing age the deformity gets organized and
does not get corrected by conservative management.

21. Surgical Management
– Subcutaneous tenotomy, open tenotomy, bipolar tenotomy, and
radical resection of a sternomastoid tumor or the SCM.
– The sterna and the clavicular heads of sternomastoid are divided
close to the origin along with the release of the tight fascia. The
head is then immobilized in a plaster cast in over-corrected
position for 2 to 4 weeks. Mobilization is begun as soon as the
cast is removed.

22. Post surgical
PT
management
– Hot packs for pain relief.
– Active movements of
sternocleidomastoid to prevent post
surgery weakness.
– Free active movements in the direction of
correction followed by resistive exercises.
– Self correction in front of mirror.
– Specially molded cervical collar and
maintenance of correction during sleep.