View source for Torticollis

{{short description|Abnormal, asymmetrical head or neck position}}
{{redirect|Wry neck|the bird|Wryneck}}
{{Infobox medical condition (new)
| name            = Torticollis
| synonyms        =
| synonym         =
*Crick in the neck
*wry neck 
*stiff neck loxia<ref group="note">Not be confused with the genus '''Loxia''' covering those bird species known as "[[crossbills]]", which was assigned by Swiss naturalist [[Conrad Gesner]] because of the obvious similarities.</ref>
| image           = Gray1194.png
| caption         = The muscles involved with torticollis
| pronounce       =
| field           = [[Orthopedics]]
| symptoms        =
| complications   =
| onset           =
| duration        =
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| risks           =
| diagnosis       = [[Ultrasonography]]
| differential    =
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'''Torticollis''', also known as '''wry neck''', is an extremely painful, [[Dystonia|dystonic condition]] defined by an abnormal, asymmetrical [[Human head|head]] or [[neck]] position, which may be due to a variety of causes. The term ''torticollis'' is derived {{ety|la|tortus|twisted||collum|neck}}.<ref name="DoibrainMissing">{{cite journal |last1=Dauer |first1=W. |last2=Burke |first2=RE |last3=Greene |first3=P |last4=Fahn |first4=S |year=1998 |title=Current concepts on the clinical features, aetiology and management of idiopathic cervical dystonia |journal=Brain |volume=121 |issue=4 |pages=547–60 |doi=10.1093/brain/121.4.547 |pmid=9577384 |doi-access=free}}</ref><ref name="The Differential Diagnosis of Torticollis in Children">{{cite journal |last1=Cooperman |first1=Daniel R. |title=The Differential Diagnosis of Torticollis in Children |journal=Physical & Occupational Therapy in Pediatrics |date=January 1997 |volume=17 |issue=2 |pages=1–11 |doi=10.1080/J006v17n02_01 }}</ref>

The most common case has [[Idiopathic disease|no obvious cause]], and the pain and difficulty in turning the head usually goes away after a few days, even without treatment in adults.

==Signs and symptoms==
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.<ref name="DoibrainMissing" /><ref>{{cite journal |pmid=11708764 |year=2001 |last1=Velickovic |first1=M |last2=Benabou |first2=R |last3=Brin |first3=MF |title=Cervical dystonia pathophysiology and treatment options |volume=61 |issue=13 |pages=1921–43 |journal=Drugs |doi=10.2165/00003495-200161130-00004|s2cid=46954613 }}</ref><ref>{{Cite web|url=https://www.mayoclinic.org/diseases-conditions/cervical-dystonia/symptoms-causes/syc-20354123|title=Cervical dystonia - Symptoms and causes - Mayo Clinic|website=www.mayoclinic.org|access-date=2017-11-02}}</ref>
* '''laterocollis''': the head is tipped toward the shoulder
* '''rotational torticollis''': the head rotates along the longitudinal axis towards the shoulder<ref name="auto1">{{Cite journal |last=Dauer |first=W. |date=1998-04-01 |title=Current concepts on the clinical features, aetiology and management of idiopathic cervical dystonia |journal=Brain |volume=121 |issue=4 |pages=547–560 |doi=10.1093/brain/121.4.547 |pmid=9577384 |doi-access=free }}</ref>
* '''anterocollis''': forward flexion of the head and neck<ref>{{cite journal |pmid=18758411 |year=2008 |last1=Papapetropoulos |first1=S |last2=Tuchman |first2=A |last3=Sengun |first3=C |last4=Russell |first4=A |last5=Mitsi |first5=G |last6=Singer |first6=C |title=Anterocollis: Clinical features and treatment options |volume=14 |issue=9 |pages=CR427–30 |journal=Medical Science Monitor}}</ref> and brings the chin towards the chest<ref name="auto1"/>
* '''retrocollis''': hyperextension of head and neck backward<ref>{{cite journal |doi=10.1159/000109265 |title=Retrocollis: Classification, Clinical Phenotype, Treatment Outcomes and Risk Factors |year=2008 |last1=Papapetropoulos |first1=Spiridon |last2=Baez |first2=Sheila |last3=Zitser |first3=Jennifer |last4=Sengun |first4=Cenk |last5=Singer |first5=Carlos |journal=European Neurology |volume=59 |pages=71–5 |pmid=17917462 |issue=1–2|s2cid=30159732 }}</ref> bringing the back of the head towards the back<ref name="auto1"/>
A combination of these movements may often be observed. Torticollis can be a disorder in itself as well as a symptom in other conditions.

Other signs and symptoms include:<ref name=":1">{{Cite journal|last=Saxena|first=Amulya|date=2015|title=Pediatric torticollis surgery treatment & management|journal=Medscape}}</ref><ref>{{cite web|title=Torticollis: MedlinePlus Medical Encyclopedia|url=https://medlineplus.gov/ency/article/000749.htm|website=medlineplus.gov}}</ref>
* [[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

==Causes==
A multitude of conditions may lead to the development of torticollis including: muscular [[fibrosis]], congenital spine abnormalities, or toxic or [[traumatic brain injury]].<ref name="The Differential Diagnosis of Torticollis in Children"/>
A rough categorization discerns between [[congenital]] torticollis and acquired torticollis.<ref>{{Cite web |date=2021-04-28 |title=Torticollis (Wryneck) |url=https://www.hopkinsmedicine.org/health/conditions-and-diseases/torticollis-wryneck |access-date=2022-10-24 |website=www.hopkinsmedicine.org |language=en}}</ref>

Other categories include:<ref name="Tomczak Rosman 2013"/>
* [[Osseous]]
* Traumatic
* CNS/PNS
* Ocular
* Non-muscular soft tissue
* Spasmodic
* Drug induced
* Oral ties (lip and tongue ties)

===Congenital muscular torticollis===
Congenital muscular torticollis is the most common torticollis that is present at birth.<ref>{{Cite web |title=Torticollis |url=http://www.childrenshospital.org/conditions-and-treatments/conditions/torticollis |access-date=2017-09-21 |website=www.childrenshospital.org |archive-date=2017-09-21 |archive-url=https://web.archive.org/web/20170921095625/http://www.childrenshospital.org/conditions-and-treatments/conditions/torticollis }}</ref> Congenital muscular torticollis is the third most common congenital musculoskeletal deformity in children.<ref name="auto">{{cite journal |last1=Xiao |first1=Yuanyi |last2=Chi |first2=Zhenhai |last3=Yuan |first3=Fuqiang |last4=Zhu |first4=Daocheng |last5=Ouyang |first5=Xilin |last6=Xu |first6=Wei |last7=Li |first7=Jun |last8=Luo |first8=Zhaona |last9=Chen |first9=Rixin |last10=Jiao |first10=Lin |title=Effectiveness and safety of massage in the treatment of the congenital muscular torticollis: A systematic review and meta-analysis protocol |journal=Medicine |date=28 August 2020 |volume=99 |issue=35 |article-number=e21879 |doi=10.1097/MD.0000000000021879 |pmc=7458238 |pmid=32871916}}</ref> The cause of congenital muscular torticollis is unclear. [[Birth trauma (physical)|Birth trauma]] or intrauterine malposition is considered to be the cause of damage to the [[sternocleidomastoid muscle]] in the neck.<ref name="The Differential Diagnosis of Torticollis in Children"/> Other alterations to the muscle tissue arise from repetitive microtrauma within the womb or a sudden change in the calcium concentration in the body that causes a prolonged period of muscle contraction.<ref name=":2">{{Cite journal |last=Carenzio |first=G |date=2015 |title=Early rehabilitation treatment in newborns with congenital muscular torticollis |journal=Phys Rehabil Med |volume=51 |issue=5 |pages=539–45 |pmid=25692687}}</ref>

Any of these mechanisms can result in a shortening or excessive contraction of the sternocleidomastoid muscle, which curtails its [[range of motion]] in both rotation and lateral bending. The head is typically tilted in lateral bending toward the affected muscle and rotated toward the opposite side. In other words, the head itself is tilted in the direction of the shortened muscle, with the chin tilted in the opposite direction.<ref name="Tomczak Rosman 2013">{{cite journal |last1=Tomczak |first1=Kinga K. |last2=Rosman |first2=N. Paul |title=Torticollis |journal=Journal of Child Neurology |date=March 2013 |volume=28 |issue=3 |pages=365–378 |doi=10.1177/0883073812469294 |pmid=23271760 |s2cid=216099695}}</ref>

Congenital torticollis is presented at 1–4 weeks of age, and a hard mass usually develops. It is normally diagnosed using ultrasonography and a color histogram or clinically by evaluating the infant's passive cervical range of motion.<ref>{{Cite journal |last=Boricean |first=ID |date=2011 |title=Understanding ocular torticollis in children |journal=Oftalmologia |volume=55 |issue=1 |pages=10–26 |pmid=21774381}}</ref>

Congenital torticollis constitutes the majority of cases seen in paediatric clinical practice.<ref name="Tomczak Rosman 2013"/> The reported incidence of congenital torticollis is 0.3-2.0%.<ref>{{cite journal |last1=Cheng |first1=JC |last2=Wong |first2=MW |last3=Tang |first3=SP |last4=Chen |first4=TM |last5=Shum |first5=SL |last6=Wong |first6=EM |year=2001 |title=Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases |journal=The Journal of Bone and Joint Surgery. American Volume |volume=83-A |issue=5 |pages=679–87 |doi=10.2106/00004623-200105000-00006 |pmid=11379737 |s2cid=999791}}</ref> Sometimes a mass, such as a sternocleidomastoid tumor, is noted in the affected muscle. Congenital Muscular Torticollis is also defined by a fibrosis contracture of the sternocleidomastoid muscle on one side of the neck.<ref name="auto"/> Congenital torticollis may not resolve on its own, and can result in rare complications including [[plagiocephaly]].<ref>{{Cite web |title=Clinical Practice Guidelines: Congenital Torticollis |url=https://www.rch.org.au/clinicalguide/guideline_index/Congenital_Torticollis/ |access-date=2022-10-24 |website=www.rch.org.au}}</ref> Secondary complications associated with Congenital Muscular Torticollis include visual dysfunctions, facial asymmetry, delayed development, cervical scoliosis, and vertebral wedge degeneration which will have a serious impact on the child's appearance and even mental health.<ref name="auto"/>

[[Benign paroxysmal torticollis]] is a rare disorder affecting infants. Recurrent attacks may last up to a week. The condition improves by age 2. The cause is thought to be genetic.<ref>{{Cite journal |last1=Rosman |first1=Paul |last2=Douglass |first2=Laurie |last3=Paolini |first3=Jan |date=30 January 2009 |title=The Neurology of Benign Paroxysmal Torticollis of Infancy: Report of 10 New Cases and Review of the Literature |url=https://journals.sagepub.com/doi/abs/10.1177/0883073808322338?journalCode=jcna |journal=[[Journal of Child Neurology]] |volume=24 |issue=2|pages=155–160 |doi=10.1177/0883073808322338 |pmid=19182151 |s2cid=35657143 |url-access=subscription }}</ref>

===Acquired torticollis===
Noncongenital muscular torticollis may result from muscle spasm, trauma, scarring or disease of cervical vertebrae, adenitis, tonsillitis, rheumatism, enlarged cervical glands, retropharyngeal abscess, or cerebellar tumors.<ref>{{Cite web |title=Clinical Practice Guidelines: Acquired Torticollis |url=https://www.rch.org.au/clinicalguide/guideline_index/Acquired_Torticollis/ |access-date=2022-10-24 |website=www.rch.org.au}}</ref> It may be spasmodic (clonic) or permanent (tonic). The latter type may be due to [[Pott's Disease]] (tuberculosis of the spine).<ref>{{cite journal |last1=Boussetta |first1=Rim |last2=Zairi |first2=Mohamed |last3=Sami |first3=Sami Bouchoucha |last4=Lafrem |first4=Rafik |last5=Msakeni |first5=Ahmed |last6=Saied |first6=Walid |last7=Nessib |first7=Nebil |title=Torticollis as a sign of spinal tuberculosis |journal=Pan African Medical Journal |date=2020 |volume=36 |page=277 |doi=10.11604/pamj.2020.36.277.22977 |pmc=7545976 |pmid=33088406 }}</ref>
* A self-limiting spontaneously occurring form of 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 draughts, colds, or unusual postures are implicated; however, in many cases, no clear cause is found. These episodes are commonly seen by physicians.{{citation needed|date=October 2020}}
Most commonly this self-limiting form relates to an untreated dental occlusal dysfunction, which is brought on by clenching and grinding the teeth during sleep. Once the occlusion is treated it will completely resolve. Treatment is accomplished with an occlusal appliance, and equilibration of the dentition.{{citation needed|date=September 2025}}
* Tumors of the skull base ([[posterior cranial fossa|posterior fossa]] tumors) can compress the nerve supply to the neck and cause torticollis, and these problems must be treated surgically.
* Infections in the posterior [[pharynx]] can irritate the nerves supplying the neck muscles and cause torticollis, and these infections may be treated with antibiotics if they are not too severe, but could require surgical [[debridement]] in intractable 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, mostly the atlantoaxial joint, due to inflammatory laxity of the ligaments caused by an infection.<ref>{{Cite journal|last1=Bocciolini|first1=C|last2=Dall'Olio|first2=D|last3=Cunsolo|first3=E|last4=Cavazzuti|first4=PP|last5=Laudadio|first5=P|date=August 2005|title=Grisel's syndrome: a rare complication following adenoidectomy|journal=Acta Otorhinolaryngologica Italica|volume=25|issue=4|pages=245–249 |pmc=2639892|pmid=16482983}}</ref>
* The use of certain drugs, such as [[antipsychotic]]s, can cause torticollis.<ref name="pmid16208529">{{cite journal |doi=10.1007/s00415-005-0006-x |title=Diagnosis and management of acute movement disorders |year=2005 |last1=Dressler |first1=D. |last2=Benecke |first2=R. |journal=Journal of Neurology |volume=252 |issue=11 |pages=1299–306 |pmid=16208529|s2cid=189867541 }}</ref>
* [[Antiemetic|Antiemetics]] - Neuroleptic Class - [[Phenothiazine]]s
* There are many other rare causes of torticollis.  A very rare cause of acquired torticollis is [[fibrodysplasia ossificans progressiva]] (FOP), the hallmark of which is malformed great toes.

===Spasmodic torticollis===
{{Main|Spasmodic torticollis}} Torticollis with recurrent, but transient contraction of the muscles of the neck and especially of the sternocleidomastoid, is called spasmodic torticollis. Synonyms are "intermittent torticollis", "cervical dystonia" or "idiopathic cervical dystonia", depending on cause.<ref>{{Cite web |title=Cervical dystonia - Symptoms and causes |url=https://www.mayoclinic.org/diseases-conditions/cervical-dystonia/symptoms-causes/syc-20354123 |access-date=2022-10-24 |website=Mayo Clinic |language=en}}</ref>

=== Trochlear torticollis ===
{{Main|Congenital fourth nerve palsy}}
Torticollis can be caused by damage to the [[trochlear nerve]] (fourth cranial nerve), which supplies the [[Superior oblique muscle|superior oblique]] muscle of the eye. The superior oblique muscle is involved in depression, abduction, and intorsion of the eye. When the trochlear nerve is damaged, the eye is extorted because the superior oblique is not functioning. The affected person will have vision problems unless they turn their head away from the side that is affected, causing intorsion of the eye and balancing out the extorsion of the eye. This can be diagnosed by the Bielschowsky test, also called the [[Head tilt test|head-tilt test]], where the head is turned to the affected side. A positive test occurs when the affected eye elevates, seeming to float up.<ref>{{EMedicine|article|1200187|Trochlear Nerve Palsy (Fourth Nerve Palsy)}}</ref>

== Anatomy ==
The main job of the sternocleidomastoid muscle is to help move the head and neck by turning the head to one side and bending the neck forward.<ref name=":7">{{Cite web |date=2017-02-27 |title=Torticollis in Children and Adolescents {{!}} PM&R KnowledgeNow |url=https://now.aapmr.org/torticollis/ |access-date=2024-03-26 |language=en-US}}</ref> The sternocleidomastoid muscle gets its blood from different arteries in the neck, which bring oxygen and nutrients to keep the muscle healthy. Torticollis can happen when there are issues with the sternocleidomastoid muscle, like if it's too short, causing the head and neck to be in an odd position.<ref name=":7" /> Torticollis can also be caused by problems with bones, muscles, or the spine in the neck, leading to difficulty moving the head and neck normally.<ref name=":7" /> Knowing about the sternocleidomastoid muscle and how it works is crucial for doctors to diagnose and treat torticollis correctly, so they can find and fix the problem causing it. Differences in how the sternocleidomastoid muscle is supplied with blood or nerves can affect how torticollis develops or how well treatments work, so it's important for doctors to consider these variations when planning treatment.<ref name="auto2">{{Cite web |title=Torticollis |url=https://www.yalemedicine.org/conditions/torticollis |access-date=2024-03-26 |website=Yale Medicine |language=en}}</ref> Having a good understanding of the neck's anatomy helps doctors accurately diagnose torticollis and choose the best treatments to help patients feel better.

The sternocleidomastoid muscle gets signals from nerves in the neck and head to contract and move properly. The underlying anatomical distortion causing torticollis is a shortened [[sternocleidomastoid muscle]]. This is the muscle of the neck that originates at the sternum and clavicle and inserts on the mastoid process of the temporal bone on the same side.<ref name="Tomczak Rosman 2013"/> There are two sternocleidomastoid muscles in the human body and when they both contract, the neck is flexed. The main blood supply for these muscles come from the occipital artery, superior thyroid artery, transverse scapular artery and transverse cervical artery.<ref name="Tomczak Rosman 2013"/> The main innervation to these muscles is from cranial nerve XI (the accessory nerve) but the second, third and fourth cervical nerves are also involved.<ref name="Tomczak Rosman 2013"/> Pathologies in these blood and nerve supplies can lead to torticollis.{{citation needed|date=October 2020}}

==Diagnosis==
{{Multiple issues|section=yes|
{{expand section|1=diagnosis of non-congenital torticollis|date=October 2015}}
{{unreferenced section|date=October 2015}}
}}
Evaluation of a child with torticollis begins with history taking to determine circumstances surrounding birth and any possibility of trauma or associated symptoms. Physical examination reveals decreased rotation and bending to the side opposite from the affected muscle. Some{{who|date=October 2015}} say that congenital cases more often involve the right side, but there is not complete agreement about this in published studies. Evaluation should include a thorough neurologic examination, and the possibility of associated conditions such as developmental [[Hip dysplasia (human)|dysplasia of the hip]] and [[clubfoot]] should be examined.  Radiographs of the cervical spine should be obtained to rule out obvious bony abnormality, and MRI should be considered if there is concern about structural problems or other conditions.

[[Ultrasonography]] can be used to visualize muscle tissue, with a colour histogram generated to determine cross-sectional area and thickness of the muscle.<ref name=":3" />

Evaluation by an optometrist or an ophthalmologist should be considered in children to ensure that the torticollis is not caused by vision problems ([[Trochlear nerve|IV cranial nerve]] [[:wikt:palsy|palsy]], [[Pathologic nystagmus|nystagmus]]-associated "null position", etc.).

Differential diagnosis for torticollis includes<ref name="Tomczak Rosman 2013"/><ref>{{Cite journal|last=Mokri|first=Bahram|date=December 2014|title=Movement disorders associated with spontaneous CSF leaks: a case series|journal=Cephalalgia: An International Journal of Headache|volume=34|issue=14|pages=1134–1141|doi=10.1177/0333102414531154 |pmid=24728303|s2cid=3100453}}</ref>
* [[Cranial nerve IV palsy]]
* Spasmus nutans<ref>{{cite web | url=https://www.medscape.com/answers/1199177-94142/what-is-spasmus-nutans | title=Acquired Nystagmus: Background, Pathophysiology, Epidemiology | date=30 June 2023 }}</ref>
* [[Sandifer syndrome]]
* [[Myasthenia gravis]]
* [[Cerebrospinal fluid leak]]

Cervical dystonia appearing in adulthood has been believed to be idiopathic in nature, as specific imaging techniques most often find no specific cause.<ref>{{Cite journal|last=Crowner|first=Beth E.|date=2007-11-01|title=Cervical Dystonia: Disease Profile and Clinical Management|journal=Physical Therapy|volume=87|issue=11|pages=1511–1526|doi=10.2522/ptj.20060272|pmid=17878433 |doi-access=free}}</ref>

== Treatment ==
Teaching people how to sit and stand properly can help reduce strain on the neck muscles and improve posture. Changing habits like bad posture or repetitive movements can help ease symptoms of torticollis.<ref name="auto2"/> Wearing a special collar can also support the neck and keep it in the right position during daily activities. Using electrical devices have also been shown to reduce pain, make muscles work better, and relax tight muscles.<ref>{{cite journal |last1=Płomiński |first1=Janusz |last2=Olesińska |first2=Jolanta |last3=Kamelska-Sadowska |first3=Anna Malwina |last4=Nowakowski |first4=Jacek Józef |last5=Zaborowska-Sapeta |first5=Katarzyna |title=Congenital Muscular Torticollis—Current Understanding and Perinatal Risk Factors: A Retrospective Analysis |journal=Healthcare |date=20 December 2023 |volume=12 |issue=1 |page=13 |id={{ProQuest|2912741403}} |doi=10.3390/healthcare12010013 |doi-access=free |pmid=38200919 |pmc=10778664 }}</ref> Injecting a substance like Botox into overactive muscles can weaken them temporarily, allowing for better movement.<ref>{{Cite web|url=https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=520953330#:~:text=Botulinum%20toxin%20is%20used%20to,their%20neck%20will%20get%20stronger|title=Botox}}</ref> If other treatments don't work, surgery might be needed to fix the muscles or bones causing torticollis.

=== Physical therapy ===
Physical therapy is an option for treating torticollis in a non-invasive and cost-effective manner.<ref name=":6">{{Cite journal|last1=Kaplan|first1=Sandra L.|last2=Coulter|first2=Colleen|last3=Fetters|first3=Linda|title=Physical Therapy Management of Congenital Muscular Torticollis|journal=Pediatric Physical Therapy|volume=25|issue=4|pages=348–394|doi=10.1097/pep.0b013e3182a778d2|pmid=24076627|year=2013|s2cid=5343916 |doi-access=free}}</ref> Physical therapy is seen as an early conservative intervention to minimize the intensity of the musculoskeletal disorder, leading to short durations of care as well as improved outcomes from treatment. The Physical Therapy Management of Congenital Muscular Torticollis Evidence-Based Clinical Practice Guidelines (CMT CPG) reflects the recommendations and guidelines for physical therapists in diagnosing, treating and educating families of infants with congenital muscular torticollis. Physical therapists that reported using the 2013 CMT CPG in their practices saw patient torticollis resolution in as little as 6-months increase from 42%-61%. As of currently, there is an updated 2024 CMT CMG from the [[American Physical Therapy Association]].<ref>{{Cite journal |last1=Sargent |first1=Barbara |last2=Coulter |first2=Colleen |last3=Cannoy |first3=Jill |last4=Kaplan |first4=Sandra L. |date=October 2024 |title=Physical Therapy Management of Congenital Muscular Torticollis: A 2024 Evidence-Based Clinical Practice Guideline From the American Physical Therapy Association Academy of Pediatric Physical Therapy |journal=Pediatric Physical Therapy |language=en |volume=36 |issue=4 |pages=370–421 |doi=10.1097/PEP.0000000000001114 |pmid=39356257 |pmc=8568067 |issn=0898-5669}}</ref><ref>{{Cite journal |last1=Castilla |first1=Adrianna |last2=Gonzalez |first2=Mariah |last3=Kysh |first3=Lynn |last4=Sargent |first4=Barbara |date=2023-01-11 |title=Informing the Physical Therapy Management of Congenital Muscular Torticollis Clinical Practice Guideline: A Systematic Review |url=https://journals.lww.com/10.1097/PEP.0000000000000993 |journal=Pediatric Physical Therapy |volume=35 |issue=2 |pages=190–200 |language=en |doi=10.1097/PEP.0000000000000993 |pmid=36637442 |issn=0898-5669|url-access=subscription }}</ref> In the children above 1 year of age, surgical release of the tight sternocleidomastoid muscle is indicated along with aggressive therapy and appropriate splinting. Occupational therapy rehabilitation in congenital muscular torticollis concentrates on observation, orthosis, gentle stretching, myofascial release techniques, parents' counseling-training, and home exercise program. While outpatient infant physiotherapy is effective, home therapy performed by a parent or guardian is just as effective in reversing the effects of congenital torticollis.<ref name=":2"/> It is important for physical therapists to educate parents on the importance of their role in the treatment and to create a home treatment plan together with them for the best results for their child. 

Five components have been recognized as the "first choice intervention" in PT for treatment of torticollis and include 

* neck passive range of motion, 
* neck and trunk active range of motion, 
* development of symmetrical movement, 
* environmental adaptations, and 
* caregiver education

In therapy, parents or guardians should expect their child to be provided with these important components, explained in detail below.<ref name=":4" /> Lateral neck [[flexion]] and overall range of motion can be regained quicker in newborns when parents conduct physical therapy exercises several times a day.<ref name=":2" />

Physical therapists should teach parents and guardians to perform the following exercises:<ref name=":2" />
* Stretching the neck and trunk muscles actively. Parents can help promote this stretching at home with infant positioning.<ref name=":4" /> For example, prone positioning will encourage the child to lift their chin off the ground, thereby strengthening their bilateral neck and spine extensor muscles, and stretching their neck flexor muscles.<ref name=":4" /> Active rotation exercises in supine, sitting or prone position by using toys, lights and sounds to attract infant's attention to turn neck and look toward the non-affected side.<ref name=":4" />
* [[Stretching]] the muscle in a prone position passively.<ref name=":4" /> Passive stretching is manual, and does not include infant involvement. Two people can be involved in these stretches, one person stabilizing the infant while the other holds the head and slowly brings it through the available range of motion.<ref name=":4" /> Passive stretching should not be painful to the child, and should be stopped if the child resists.<ref name=":4" /> Also, discontinue the stretch if changes in breathing or circulation are seen or felt.<ref name=":4" />
* Stretching the muscle in a lateral position supported by a pillow (have infant lie on the side with the neck supported by pillow). Affected side should be against the pillow to deviate the neck towards the non-affected side.{{citation needed|date=October 2020}}
* Environmental adaptations can control posture in strollers, car seats  and swings (using U-shaped neck pillow or blankets to hold neck in neutral position){{citation needed|date=October 2020}}
* Passive cervical rotation (much like stretching when being supported by a pillow, have affected side down)<ref>{{Citation |last=Graham |first=John M. |title=Torticollis-Plagiocephaly Deformation Sequence |date=2007 |work=Smith's Recognizable Patterns of Human Deformation |pages=141–156 |publisher=Elsevier |doi=10.1016/b978-072161489-2.10025-6 |isbn=978-0-7216-1489-2}}</ref>
* Position infant in the crib with affected side by the wall so they must turn to the non-affected side to face out{{citation needed|date=October 2020}}

Physical therapists often encourage parents and caregivers of children with torticollis to modify the environment to improve neck movements and position. Modifications may include:
* Adding neck supports to the car seat to attain optimal neck alignment
* Reducing time spent in a single position
* Using toys to encourage the child to look in the direction of limited neck movement
* Alternating sides when bottle or breastfeeding<ref name=":4" />
* Encouraging prone playtime. Although the [[Safe to Sleep|Back to Sleep campaign]] promotes infants sleeping on their backs to avoid [[sudden infant death syndrome]] during sleep, parents should still ensure that their infants spend some waking hours on their stomachs.<ref name=":4" />
Environmental Modifications for Torticollis Management:

* Placing the baby in a crib with the affected side facing the wall can encourage them to turn their head the other way, promoting better movement.<ref name="Blanco-Diaz Marcos-Alvarez Escobio-Prieto et al 2023">{{cite journal |last1=Blanco-Diaz |first1=Maria |last2=Marcos-Alvarez |first2=Maria |last3=Escobio-Prieto |first3=Isabel |last4=De la Fuente-Costa |first4=Marta |last5=Perez-Dominguez |first5=Borja |last6=Pinero-Pinto |first6=Elena |last7=Rodriguez-Rodriguez |first7=Alvaro Manuel |title=Effectiveness of Conservative Treatments in Positional Plagiocephaly in Infants: A Systematic Review |journal=Children |date=7 July 2023 |volume=10 |issue=7 |page=1184 |id={{ProQuest|2843032121}} |doi=10.3390/children10071184 |doi-access=free |pmid=37508680 |pmc=10378416 |hdl=10261/350376 |hdl-access=free }}</ref>

=== Manual therapy ===
A meta-analysis shows physical therapists specializing in manual therapy have developed effective interventions for the management of Congenital Muscular Torticollis (CMT), primarily centered around massage and passive stretching techniques. These interventions are tailored to address the specific needs of pediatric patients, with a focus on stretching the sternocleidomastoid muscle.<ref name="Blanco-Diaz Marcos-Alvarez Escobio-Prieto et al 2023"/> Various protocols have been proposed, including stretching exercises held for specific durations and repetitions, aimed at increasing blood flow, and promoting muscle relaxation.

Additionally, massage maneuvers such as rhythmic muscle mobilization techniques are employed to mobilize cervical structures and induce relaxation.<ref name="Blanco-Diaz Marcos-Alvarez Escobio-Prieto et al 2023"/> The systematic review highlights the efficacy of manual therapy and passive stretching in improving cervical range of motion (ROM) in children with CMT. Furthermore, the involvement of caregivers in home exercise programs is emphasized as crucial for optimizing treatment outcomes and promoting motor development while preventing secondary complications.

A systematic review, looked into the possible benefits of using manipulation techniques to counteract infant torticollis. The study considered the impact of manipulation on an infant's sleep, crying, and restlessness as well.<ref name=":5">{{cite journal |last1=Brurberg |first1=Kjetil G. |last2=Dahm |first2=Kristin Thuve |last3=Kirkehei |first3=Ingvild |title=Manipulasjonsteknikker ved nakkeasymmetri hos spedbarn |trans-title=Manipulation techniques for infant torticollis |language=no |journal=Tidsskrift for den Norske Legeforening |date=2018 |volume=138 |issue=1 |doi=10.4045/tidsskr.17.1031 |pmid=30644674 |s2cid=203804340 |doi-access=free |hdl=11250/2582088 |hdl-access=free }}</ref> This review did not report any adverse effects of using manipulation techniques. It was shown that using manipulation techniques on their own had little to no statistical differences from a placebo group, immediately. When manipulation techniques were combined with physical therapy, there was a change in symptoms compared to the use of physical therapy alone. When targeting the cervical spine, manipulation techniques were shown to shorten treatment duration in infants with head asymmetries.<ref name=":5" />

=== Microcurrent therapy ===
A Korean study has recently{{When|date=July 2016}} introduced an additional treatment called microcurrent therapy that may be effective in treating congenital torticollis. For this therapy to be effective the children should be under three months of age and have torticollis involving the entire sternocleidomastoid muscle with a palpable mass and a muscle thickness over 10&nbsp;mm. Microcurrent therapy sends minute electrical signals into tissue to restore the normal frequencies in cells.<ref name=":3">{{Cite journal|last=Kwon|first=D.R.|date=2014|title=Efficacy of micro current therapy in infants with congenital muscular torticollis involving the entire sternocleidomastoid muscle|journal=Clinical Rehabilitation|volume=28|issue=10|pages=983–91|doi=10.1177/0269215513511341|pmid=24240061|s2cid=206484848}}</ref> Microcurrent therapy is completely painless and children can only feel the probe from the machine on their skin.<ref name=":3" />

Microcurrent therapy is thought to increase ATP and protein synthesis as well as enhance blood flow, reduce muscle spasms and decrease pain along with inflammation.<ref name=":3" /> It should be used in addition to regular stretching exercises and ultrasound diathermy. [[Ultrasound|Ultrasound diathermy]] generates heat deep within body tissues to help with contractures, pain and muscle spasms as well as decrease inflammation. This combination of treatments shows remarkable outcomes in the duration of time children are kept in rehabilitation programs: Micocurrent therapy can cut the length of a rehabilitation program almost in half with a full recovery seen after 2.6 months.<ref name=":3" />

About 5–10% of cases fail to respond to stretching and require surgical release of the muscle.<ref>{{cite journal |pmid=12360024 |year=2002 |last1=Tang |first1=SF |last2=Hsu |first2=KH |last3=Wong |first3=AM |last4=Hsu |first4=CC |last5=Chang |first5=CH |title=Longitudinal followup study of ultrasonography in congenital muscular torticollis |issue=403 |pages=179–85 |journal=Clinical Orthopaedics and Related Research |doi=10.1097/00003086-200210000-00026 |volume=403|s2cid=20606626 }}</ref><ref>{{cite journal |doi=10.1016/S0003-9993(99)90165-X |title=Correlation of clinical and ultrasonographic features in congenital muscular torticollis |year=1999 |last1=Hsu |first1=Tsz-Ching |last2=Wang |first2=Chung-Li |last3=Wong |first3=May-Kuen |last4=Hsu |first4=Kuang-Hung |last5=Tang |first5=Fuk-Tan |last6=Chen |first6=Huan-Tang |journal=Archives of Physical Medicine and Rehabilitation |volume=80 |issue=6 |pages=637–41 |pmid=10378488}}</ref>

=== Surgery ===
Surgical release involves the two heads of the sternocleidomastoid muscle being dissected free. This surgery can be minimally invasive and done laparoscopically. Usually surgery is performed on those who are over 12 months old. The surgery is for those who do not respond to physical therapy or botulinum toxin injection or have a very fibrotic sternocleidomastoid muscle.<ref name=":1" /> After surgery the child will be required to wear a soft neck collar (also called a Callot's cast). There will be an intense physiotherapy program for 3–4 months as well as strengthening exercises for the neck muscles.<ref>{{Cite journal|last=Seung|first=Seo|date=2015|title=Change of facial asymmetry in patients|journal=Medscape}}</ref>

=== Other treatments ===

Other treatments include:<ref name=":2" />
* Rest and [[analgesics]] for acute cases
* [[Diazepam]] or other [[muscle relaxants]]
* [[Botulinum toxin]]<ref>{{Cite journal|last1=Samotus|first1=Olivia|last2=Lee|first2=Jack|last3=Jog|first3=Mandar|date=2018-03-20|title=Personalized botulinum toxin type A therapy for cervical dystonia based on kinematic guidance|journal=Journal of Neurology|volume=265|issue=6|pages=1269–1278|doi=10.1007/s00415-018-8819-6 |pmid=29557988|s2cid=4043479}}</ref><ref>{{Cite journal|last1=Safarpour|first1=Yasaman|last2=Jabbari|first2=Bahman|date=2018-02-24|title=Botulinum Toxin Treatment of Movement Disorders|journal=Current Treatment Options in Neurology|volume=20|issue=2|page=4|doi=10.1007/s11940-018-0488-3 |pmid=29478149|s2cid=3502413}}</ref>
* Encouraging active movements for children 6–8 months of age
* [[Diathermy#Ultrasound|Ultrasound diathermy]]

=== Overview ===
CMT is a neck problem that babies are born with or develop soon after birth, causing their neck to be stiff and bent in an awkward position.<ref name="Blanco-Diaz Marcos-Alvarez Escobio-Prieto et al 2023"/> Besides the sternocleidomastoid muscle, other muscles in the neck can also be affected by CMT, leading to problems moving the head and neck normally.<ref name="Blanco-Diaz Marcos-Alvarez Escobio-Prieto et al 2023"/> The main goal of treating CMT is to make the sternocleidomastoid muscle stronger and more flexible, so the neck can move better and symptoms can improve.

== Prognosis ==
Studies and evidence from clinical practice show that 85–90% of cases of congenital torticollis are resolved with conservative treatment such as physical therapy.<ref name=":4" /> Earlier intervention is shown to be more effective and faster than later treatments. More than 98% of infants with torticollis treated before 1 month of age recover by 2.5 months of age.<ref name=":4" /> Infants between 1 and 6 months usually require about 6 months of treatment.<ref name=":4" /> After that point, therapy will take closer to 9 months, and it is less likely that the torticollis will be fully resolved.<ref name=":4">{{Cite journal|last1=Kaplan|first1=Sandra L.|last2=Coulter|first2=Colleen|last3=Sargent|first3=Barbara|date=October 2018|title=Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy|journal=Pediatric Physical Therapy|volume=30|issue=4|pages=240–290|doi=10.1097/PEP.0000000000000544|pmid=30277962|pmc=8568067 |s2cid=52909510 }}</ref> It is possible that torticollis will resolve spontaneously, but chance of relapse is possible.<ref name="Tomczak Rosman 2013"/> For this reason, infants should be reassessed by their physical therapist or other provider 3–12 months after their symptoms have resolved.<ref name=":4" />

==Other animals==
[[File:Mvc-872s.jpg|thumb|A [[guinea pig]] with a head-tilt]]
In veterinary literature usually only the lateral bend of head and neck is termed torticollis, whereas the analogon to the rotatory torticollis in humans is called a '''head tilt'''. The most frequently encountered form of torticollis in domestic pets is the head tilt, but occasionally a lateral bend of the head and neck to one side is encountered.<ref>{{Cite web | url=http://www.bio.miami.edu/hare/tilt.html | title=Head Tilt (Torticollis) in Rabbits: Don't Give Up | website=www.bio.miami.edu}}</ref>

===Head tilt===
Causes for a head tilt in domestic animals are either diseases of the central or peripheral [[vestibular system]] or relieving posture due to neck pain. Known causes for head tilt in domestic animals include:
* ''[[Encephalitozoon cuniculi]]'' infection in rabbits<ref>{{cite journal |doi=10.1007/s00436-009-1679-3 |title=[[Encephalitozoonosis]] in rabbits |year=2009 |last1=Künzel |first1=Frank |last2=Joachim |first2=Anja |journal=Parasitology Research |volume=106 |issue=2 |pages=299–309 |pmid=19921257|s2cid=11727371 }}</ref>
* [[Parasite|parasitic infestation]] by the [[nematode]] (roundworm) ''[[Baylisascaris procyonis]]'' in rabbits
* [[Otitis interna| Inner ear infection]]
* [[Hypothyroidism]] in dogs<ref>{{cite journal |doi=10.1111/j.1939-1676.1994.tb03245.x |title=Neurological Manifestations of Hypothyroidism: A Retrospective Study of 29 Dogs |year=1994 |last1=Jaggy |first1=André |last2=Oliver |first2=John E. |last3=Ferguson |first3=Duncan C. |last4=Mahaffey |first4=E. A. |last5=Glaus Jr |first5=T. Glaus |journal=Journal of Veterinary Internal Medicine |volume=8 |issue=5 |pages=328–36 |pmid=7837108|doi-access= }}</ref>
* Disease of [[cranial nerve VIII]] ([[vestibulocochlear nerve]]) through trauma, infection, inflammation, or [[neoplasia]]
* Disease of the [[brain stem]] caused by [[stroke]], trauma, or [[neoplasia]]
* Damage to the [[Vestibular system|vestibular organ]] due to toxicity, inflammation or [[ischemia|impaired blood supply]]
* Geriatric vestibular syndrome in dogs

==Notes==
{{Reflist|group=note}}

==References==
{{Reflist}}

== External links ==
{{Commons}}
* [http://www.rabbit.org/journal/3-8/head-tilt.html Head Tilt: Causes and Treatment]

{{Medical resources
|  DiseasesDB      = 31866
|  ICD10           = {{ICD10|M|43|6|m|40}}
|  ICD9            = {{ICD9|723.5}}
|  ICDO            =
|  OMIM            =
|  MedlinePlus     = 000749
|  eMedicineSubj   = emerg
|  eMedicineTopic  = 597
|  eMedicine_mult  = {{eMedicine2|orthoped|452}}
|  MeshID          = D014103
}}
{{Dorsopathies}}

[[Category:Ailments of unknown cause]]
[[Category:Deforming dorsopathies]]
[[Category:Rabbit diseases]]
[[Category:Symptoms]]