What are the treatment options for torticollis?

Treatment Options for Torticollis

Physical therapy with stretching exercises is the first-line treatment for torticollis, with surgical intervention reserved for cases that fail to respond to conservative management after 6-12 months. 1

Types and Diagnosis

Torticollis presents as an abnormal head posture with lateral inclination of the head to one shoulder and chin deviation to the opposite side. The most common types include:

• Congenital Muscular Torticollis (CMT): Most common form in children, involving tightness or contracture of the sternocleidomastoid muscle 1
• Acquired Torticollis: May result from trauma, infection, or neurological conditions
• Benign Paroxysmal Torticollis: Characterized by recurrent episodes of abnormal head postures, usually before 3 months of age 1

Treatment Algorithm

First-Line Treatment: Conservative Management

1. Physical Therapy:

   • Manual stretching exercises of the sternocleidomastoid muscle
   • Should be initiated as early as possible, ideally within the first year of life
   • Typical treatment duration: 3-4 months 1

2. Positioning Techniques:

   • Encourage active rotation toward the affected side
   • Position toys and stimuli to promote head turning to the affected side 1

3. For Associated Conditions:

   • Address positional plagiocephaly with repositioning strategies and potentially helmet therapy 1

Second-Line Treatment: Interventional Approaches

1. Botulinum Toxin Injections:

   • Effective intermediate treatment for resistant cases 2
   • Can help reduce muscle contracture and improve range of motion

2. Orthotic Devices:

   • Cervical bracing may be used in conjunction with physical therapy 1

Third-Line Treatment: Surgical Management

Indicated when:

• Torticollis persists despite 6-12 months of conservative treatment
• Significant facial or cranial asymmetry is developing 1

Surgical options:

1. Bipolar Release: Release of both sternal and clavicular attachments of the sternocleidomastoid muscle 3
2. Unipolar Release: Release of either the superior or inferior attachment 4
3. Muscle Lengthening Procedures: For less severe cases 5

Age-Related Considerations

• Infants and Young Children (under 1 year):

  • Excellent outcomes (>90% success) with conservative management 1
  • Physical therapy alone is often sufficient

• Children (1-5 years):

  • Increased rates of requiring surgical intervention 1
  • May still achieve good results with combined approaches

• Older Children and Adults:

  • More challenging to treat
  • Surgical release with post-surgical physical therapy can be effective 3
  • Craniofacial asymmetry may persist despite correction of the torticollis 6

Post-Treatment Management

• After surgical release, immobilization with a brace for 1-2 weeks 3
• Resume physical therapy within 2 weeks of operation to prevent recurrent contracture 5
• Regular follow-up to monitor progress and address any complications

Prognosis

• Best outcomes achieved when treatment begins before 1 year of age 1
• Reversal of craniofacial asymmetry more successful at younger ages
• In adults with longstanding torticollis, surgical release can improve range of motion and reduce pain, but facial asymmetry and skeletal changes may remain 6

Potential Complications

• Recurrence of contracture if post-surgical therapy is inadequate
• Persistent craniofacial asymmetry, especially in cases treated after age 1
• Surgical complications may include vascular injury, nerve damage, or incomplete correction

Early intervention is crucial for optimal outcomes in torticollis management, with physical therapy being the cornerstone of treatment in most cases.