Physical Therapy Guide to Torticollis
Torticollis is a condition that occurs when the muscle that runs from the breastbone and collarbone up and toward the back of the neck becomes tight, weakened, or thickened, causing the chin to point toward one shoulder, while the head tilts toward the opposite shoulder. The most common form of the condition is congenital muscular torticollis, which affects infants and is generally observed within the first 2 months of life.
In 1992, the American Academy of Pediatrics began its "Back to Sleep" campaign to reduce Sudden Infant Death Syndrome. The campaign successfully decreased SIDS by 40% in the United States, but it had an unintended result of contributing to the development of CMT in approximately 1 in every 250 infants. Talk to your family physician and/or pediatrician if you have questions about the "Back to Sleep" campaign.
Torticollis also can occur in adults. Head tilt in children or adults also can accompany other symptoms of more serious conditions.
If symptoms such as trouble breathing or swallowing, weakness in the arms or legs, impaired speech, difficulty walking, a pins-and-needles feeling or numbness in the arms or legs, or urinary or fecal incontinence accompany the head tilt, seek immediate medical attention.
What Is Torticollis?
Torticollis is the tilt and/or rotation of the head because of tight and weak neck muscles. It occurs when the muscle that runs up and toward the back of the neck (the sternocleidomastoid muscle) becomes tight, weakened, or thickened. There are 5 forms of the condition:
- Congenital muscular torticollis is the most common form of the condition. It affects infants and is generally diagnosed within the first 2 months of life. CMT is often caused by birth trauma, or by sleeping or remaining in 1 position for a prolonged period of time.
- Postural torticollis is diagnosed when the infant’s head tilt comes and goes. It is diagnosed within the first 5 months of life and often is the result of a lack of a variety of positions, such as when the child is consistently placed in a car seat or other baby "container" for extended periods of time.
- Ocular torticollis is caused by a vision problem in one eye, causing the individual to tilt his or her head to see better.
- Spasmodic torticollis (wryneck) occurs in older children and adults. It can be caused by infection, inflammation, trauma, or the side effects of certain medications and/or drugs, such as amphetamines.
- Acute torticollis occurs when a child or adult bends or twists the neck too far, or experiences some type of trauma. There may be pain when the head is moved from side to side or up and down; the neck muscle may be tender to touch.
Abnormalities associated with torticollis include:
- Osseous abnormalities, caused by improper alignment of the cervical spine (at the spinal points C1-C2) when ligaments are damaged due to an infection. The types of infection that can cause this condition include severe upper respiratory, ear, or sinus infections; cervical adenitis; or cervical abscess. Any inflammatory process that irritates the muscles, nerves, or vertebrae—including surgery or trauma—can produce a reflex spasm resulting in this form of torticollis.
- Neurogenic abnormalities, such as a spinal cord tumor or progressive spinal cord diseases, which can cause an acute episode of torticollis, usually in older children. Children may experience headaches, vomiting, and positive neurological signs, like limb weakness (either one side or both sides) and speech difficulties. Seek immediate medical attention if any of these symptoms occur.
Torticollis may lead to additional problems, such as:
- 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.
- 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.
Signs and Symptoms
An infant, child, or adult with torticollis may keep the head tilted and toward one side of the body and rotated to the other side of the body, as attempting to straighten the neck is difficult or painful. For example, if the muscle on the left side of the neck is shortened, weak, or in spasm, the head may tilt toward the left shoulder and rotate toward the right.
There may be tightness in the neck or a noticeable lump in the neck muscle called a pseudotumor. Pain may or may not be present, depending on the type of torticollis involved.
How Is It Diagnosed?
Torticollis in adults is generally diagnosed by a doctor. Experienced pediatric physical therapists may diagnose the need for treatment of congenital muscular torticollis and positional torticollis in infants and children. However, most states in the United States require a prescription from a doctor in order for the physical therapist to provide treatment for this condition.
Once the type of torticollis is determined, your physical therapist can provide treatment. In most cases, torticollis is a muscular problem, and physical therapists are musculoskeletal experts.
How Can a Physical Therapist Help?
Regardless of the patient's age, physical therapy is the primary treatment for all forms of torticollis. Physical therapists provide treatment to address the impairments caused by torticollis. Early treatment produces the best outcomes. If not treated, torticollis can become a permanent condition.
The physical therapist will work with a child’s caregiver or an adult patient to develop and reach mutual goals. The physical therapist will design an individualized treatment plan to:
- Strengthen neck muscles
- Correct muscle imbalance
- Gain pain-free movement (range of motion)
- Improve postural control and symmetry
- Improve the body’s alignment by easing muscle tension
These goals may be achieved through:
- Gentle stretching of the neck and back muscles
- Strengthening of the neck and back muscles
- Massage of the affected area
- Guidance for correct positioning of infants
- Taping to elongate the muscles to facilitate stretching
- A home-exercise program to continue gentle rehabilitation at home
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a variety of conditions, including torticollis. However, you may want to consider:
- A physical therapist who is experienced in treating individuals with torticollis.
- A pediatric physical therapist for a child who is affected by the condition.
- A physical therapist who is a board-certified clinical specialist or who has completed training in pediatric or neurologic physical therapy. This type of physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you are looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapist’s experience in helping people who have torticollis.
- During your first visit with the physical therapist, be prepared to describe your or your child’s symptoms in as much detail as possible, including what makes the symptoms worse.
The American Physical Therapy Association believes that consumers should have access to information that could help them make health care decisions and prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of torticollis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
American Physical Therapy Association. Guide to Physical Therapist Practice 3.0. Accessed October 2, 2018.
Stringer H. PTs offer hope for treating flat head syndrome in babies. Today in PT. June 7, 2010:30–31. (Article summary not available.)
Gray GM, Tasso KH. Differential diagnosis of torticollis: a case report. Pediatr Phys Ther. 2009;21:369–374. Article Summary in PubMed.
Ohman AM, Beckung ER. Reference values for range of motion and muscle function of the neck in infants. Pediatr Phys Ther. 2008;20:53-58. Article Summary in PubMed.
Freed SS, Coulter-O’Berry C. Identification and treatment of congenital muscular torticollis in infants. J Prosthet Orthot. 2004;16:S18–S23. (Article summary not available.)
Mezue WC, Taha ZM, Bashir EM. Fever and acquired torticollis in hospitalized children. J Laryngol Otol. 2002;116:280-284. Article Summary in PubMed.
Long T, Tascano K. Handbook of Pediatric Physical Therapy. 2nd ed. Baltimore, MD: Lippincott Williams and Wilkins; 2002.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
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