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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.

Patients report severe neck pain often with muscle spasms and an inability to bring the head to the normal central position. This pain usually settles down in a few days or up to two weeks at most and is managed with painkillers, wearing a collar if required, physiotherapy massage or mobilisations, neck exercise and neck stretching. On examination a patient with torticollis will have their head side flexed towards the painful side and the face rotated away towards the opposite side to some degree. Typical complaints are pain, stiff neck and a limited range of movement, with a sudden onset such as turning the head quickly or drying the hair relatively common.

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.

The incidence of pain in the shoulder, scapula, arm or thoracic regions will be recorded. The physio may elect to test the biceps and triceps reflexes to check the health of the C6 and C7 nerve roots if the symptoms warrant this. Testing of the light touch sensibility may be appropriate for the same reasons. However, the muscle strength might not be tested by the physio as it could aggravate the pain and an accurate indication would be hard to get. The physiotherapist will ask special questions to ensure that the pain is mechanical and not likely to be due to a serious medical cause.

The aim of physiotherapy for this neck condition is similar to that for all soft tissue injuries. The first goal is to reduce the pain and inflammation in the damaged tissues and so reduce the resulting muscle spasm which is perpetuating the pain. Anti-inflammatory medications and analgesics may be prescribed as to some extent the pain is the presenting problem rather than some underlying abnormality. Physiotherapists may use ice, immobilisation in a collar and gentle manual traction to attempt to relax the cervical musculature and relieve 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 Physiotherapist, physiotherapy, physiotherapists in Glasgow, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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