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Acute Neck Pain and Torticollis
An acute wry neck is a condition characterised by sudden onset of severe neck pain accompanied by an involuntary contraction of the neck muscles which leads to an abnormal head posture being maintained. The abnormal posture or torticollis is a symptom of the underlying process and can have a number of causes, but the cause discussed in this article is acute mechanical neck pain leading to an acquired torticollis. A common presentation for a patient is acute neck pain and torticollis on waking in the morning, often interpreted as the result of having slept in an awkward position at some point overnight.
People with acute wry neck complain of severe neck pain and neck muscle spasms which prevent them from bringing their head back into the central line. This usually resolves in several days or up to fourteen and normal treatment consists of painkilling medication, a collar if necessary, physiotherapy such as neck exercises, massage and neck stretching. Examination of a patient will discover the head flexed towards the pain and rotated away from the pain. Patients report that the pain came on with a sudden neck movement or by towelling their hair and that they have neck stiffness, reduced movement and pain.
Once the onset has occurred the patient feels an immediate and often quite severe pain in one side of the neck, often low down, and perhaps some vague referral out towards the shoulder or down the back towards the shoulder blade. With significant shoulder or arm pain then a diagnosis of cervical root compression should be considered. Sudden onset root lesions are less common, with the syndrome typically coming on over a few days, but if the patient reports the symptoms on waking this could be the diagnosis. If so the prognosis is still good but the length of time to recovery will likely be a few weeks rather than a few days.
When the physiotherapist examines the patient they will find them distressed by the neck pain and likely to have had sleeping difficulties. The head is held carefully and efforts are made to avoid disturbing the inflamed joints or muscles. Head posture will show the torticollis deformity and if normalising the posture is attempted the pain rises quickly to severe levels. Physiotherapists record the posture of the neck and the amount of joint motion which is possible with the resulting pain provoked. A history of the condition will be taken, with record of previous pain events and what brought on this episode.
Any thoracic, shoulder blade, shoulder or arm pain will also be recorded. The physio may decide to test the reflexes of the biceps and triceps muscles to check if the C6 or C7 nerve roots are involved should the symptoms indicate the possibility. The sensibility of the skin to light touch can also be investigated for similar reasons. The physiotherapist is less likely to choose to test the muscle power in the shoulders and arms as this would cause an increase in pain and not reflect the patient’s true muscle strength. The usual questioning to exclude potentially serious underlying causes or complicating medical conditions will be undertaken.
Physiotherapy management of an acute wry neck is based on the same principles for all injuries of soft tissues. Firstly the physio attempts to reduce the inflammation and pain of the injury and thereby the muscle spasms which exacerbate the pain. Analgesics and anti-inflammatory drugs can be very useful as the pain is the primary problem and not some anatomical abnormality of the neck. Typical physiotherapy management includes ice, use of a collar if indicated and gentle tractioning of the neck relax the neck muscles and settle pain.
Once the pain has started to reduce well the physiotherapist can progress to other manual therapies such as joint mobilisations, neck massage and gentle stretches to the tight muscles. Active range of movement exercises within reasonable comfort are also encouraged. Once normal head posture and cervical range of movement has been restored then the physio will move on to strengthening the neck muscles and work on endurance to cope with the demands of daily life.
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Cambridge. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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Filed under back pain by on Dec 12th, 2009. 
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