Torticollis literally means “twisted neck”, and is often referred to as “wryneck”. There are many types of torticollis, with varying causes. A child with torticollis will hold their head tilted to one side with their chin pointing to the other. While the condition looks like it would be painful, in most cases it is not. As noted before, torticollis can cause plagiocephaly, as a baby with torticollis will often keep the head turned in the same position, therefore putting pressure on the same side of the back of the head. In order to treat the plagiocephaly, the torticollis must also be addressed.
Causes & Types of Torticollis
Each type of torticollis has different causes. In order to understand what causes torticollis, you need to know a little bit about the anatomy of the neck and head. In many cases, the development of torticollis occurs because of a problem in the sternocleidomastoid (SCM) muscle. This muscle runs between the head and shoulders, and allows us move our heads up and down and side to side. If one side of the muscle is shorter or there is a problem with the flexibility of the muscular tissue, a baby can develop torticollis. There are numerous less-common causes for the condition, which we will discuss in this section.
Congenital torticollis is almost always caused by one of three things:
- Your baby’s position in the womb
- Birth-related trauma to the SCM muscle
- Abnormal development of the SCM muscle
Rarely, congenital torticollis can occur as a result of genetics. It can also occasionally be a symptom of other conditions, so if you suspect torticollis in your infant, be sure to have them evaluated by your medical professional.
Frequently congenital torticollis that is not symptomatic of other conditions occurs together with positional plagiocephaly. In some cases, this is the result of the baby’s position in the womb. The conditions can occur concurrently as a result of a difficult birth, as well.
Positional plagiocephaly can occur as a result of torticollis when an infant is incapable of turning their head, and as a result a flat spot develops on the part of the skull that is most commonly laid against a flat surface such as a crib mattress. Approximately 80-90% of infants with otherwise uncomplicated congenital torticollis also have positional plagiocephaly.
Babies and children can develop acquired torticollis as a result of many underlying conditions. Some of these conditions can be severe, while others are generally mild. They include the following:
- Mild viral infections
- Gastro-esophageal Reflux Disease (GERD, or Reflux)
- Minor head trauma
- Minor neck trauma
- Medication reactions (dystonic reactions)
- Cervical spine abnormalities
- Respiratory infections
- Soft-tissue infections in the neck
- Spasmus nutans (leads to head bobbing and uncontrolled eye movements, generally benign)
- Sandifer syndrome (very rare, causes GERD and neck spasms)
- Grisel’s syndrome (occurs as a complication of pharyngitis, and involves the dislocation of the C1 and C2 vertebrae)
Benign Paroxysmal Torticollis
The causes of this condition aren’t known. It involves episodes or attacks of symptoms which can include vomiting, head tilting, irritability and/or drowsiness. Attacks can last from several hours to several days, and may indicate that your baby will be prone to migraine headaches as an adult.
Ocular torticollis is not a result of musculoskeletal problems in the neck or spine. The condition occurs when a child has a problem with vision in one eye, and cranes their neck to improve their sight. The condition often indicates muscular problems of the eye itself.
Approximately 1 in 300 infants is born with torticollis.
Torticollis is usually diagnosed within the first four months of a child life, with most cases being noticed within the first month by either a caretaker or the baby’s pediatrician. The tilting of the neck may be very slight, but the presence of a lump on the baby’s neck in the sternocleidomastoid muscle can indicate the presence of torticollis.
Your baby’s pediatrician will want to rule out the rarer and potentially dangerous causes of torticollis. To do this, they may request diagnostic imaging and other tests. If it is clear that your child’s torticollis is related to their position in the womb, or a rough delivery, the doctor might skip this step.
Effects on Development
Torticollis that goes untreated in babies can lead to other musculoskeletal problems. Babies with torticollis may experience some delays in motor skills and coordination. These effects can linger into childhood, making a child seem ‘clumsy’. Children with torticollis may develop problems with sucking and swallowing, can be prone to having their mouths hang open. They may also go on to develop more severe conditions such as scoliosis. For this reason, it is essential to follow your doctor’s advice and to seek out treatment for your child’s torticollis.
The treatment of torticollis depends on its severity. Mild cases can often be resolved by repositioning, tummy time, stretching, and targeted exercise of the shorter muscle. For more severe cases, physical therapy may be recommended. The picture to the left shows a common posture recommended for carrying infants with torticollis to stretch the shortened SCM muscle.
In about 15% of cases, neither physical therapy nor repositioning and exercise prove effective. The next step is an orthotic device called a TOT collar, and if this also fails, surgery may be recommended. Surgery for torticollis is rarely necessary, although it is fairly simple, and involves loosening the tighter neck muscle. It should always be followed by physical therapy and exercise to encourage the muscle to grow properly again.
If your doctor has recommended physical therapy for your baby’s torticollis, you might be curious about what to expect.
If your child has torticollis, one of the best steps you can take as a parent to begin correcting the condition is to exercise your baby’s neck muscles gently as directed by your doctor or therapist.
At-home exercises and repositioning can be incorporated into your daily routines, as well. This can make it easier for your baby, and feel more like play time rather than therapy. Place your child’s favorite toy on the side opposite to the one they normally keep their head turned towards. Encourage your baby to look in the direction opposite of their torticollis by making it interesting visually and with music or lights. Praise your baby every time they turn in the correct direction.
You can also help alleviate your baby’s torticollis when driving in the car. Use padding or positioning devices to adjust your child’s head position to front or to face the opposite direction from the affected side.
Physical Therapy Techniques for Torticollis – What to Expect
Your baby’s physical therapist will design a comprehensive treatment plan that will most likely include heat applied to the affected muscle, postural and positional training, stretching, targeted muscle strengthening, and massage.
Physical therapy for torticollis has been poorly studied to date, and its usefulness is unknown, although it does appear to be effective in the majority of cases. Another technique frequently used by physical therapists is therapeutic taping, a technique developed in the 1980’s for athletes recovering from sports injuries. The effectiveness of taping is unknown.
If physical therapy does not work, they may suggest either traction or a Tubular Orthosis for Torticollis (TOT) collar. TOT collars are not worn at night, and in some cases are only used for a few hours each day.
What happens if torticollis goes untreated?
Failure to treat torticollis can result in limited neck movement as well as cranial and facial deformities including flattening of the head and face on the side affected by torticollis. Infants and children with torticollis may exhibit a preference for using one side of the body, and as a result may be slower in achieving motor skills milestones. This preference for one side of the body may also lead to musculoskeletal adjustments that cause other physical problems. In extreme cases, untreated severe torticollis can lead to scoliosis.
If your child has been diagnosed with torticollis, please seek treatment right away. Torticollis treatment is most successful when it begins by 2-3 months of age.