J Manipulative Physiol Ther. 2009 (Feb); 32 (2): 160165 ~ FULL TEXT
Rod Kaufman, DC
Clinic Division of Southern California,
Department of Health Sciences,
Southern California University of Health Sciences,
Castaic, Calif, USA.
OBJECTIVE: This case study describes a patient diagnosed with acute viral torticollis and illustrates the relevant aspects of differential diagnosis and the collaborative efforts between the chiropractic and allopathic disciplines in establishing an optimum treatment protocol provided by comanagement of the case.
CLINICAL FEATURES: A 20-year-old female student experienced a sudden onset of neck pain and inability to move her neck in conjunction with an antalgic attitude of her cervical spine in lateral flexion and rotation. Physical examination revealed an elevated temperature indicating the possibility of infection. Associated symptoms included headache, nausea, vomiting, and malaise.
INTERVENTION AND OUTCOME: The patient was initially assessed in a teaching clinic of a university medical health center for acute meningitis. A consultation was requested by the senior attending physician for an opinion by the chiropractic services of the university health center to assess the patient for nuchal rigidity and to provide treatment of the torticollis. After an evaluation of the status of the patient, a diagnosis of acute viral torticollis was established, and chiropractic manual therapy was initiated with a significant improvement in the ability of the patient to execute cervical ranges of motion without undue limitation and pain. Follow-up chiropractic care resulted in resolution of the torticollis without residual symptoms.
CONCLUSION: Acute viral torticollis occurring in a young adult with associated symptoms of fever, headache, nausea, and vomiting presents a diagnostic challenge in excluding the possibility of meningitis. Appropriate clinical and physical examination procedures are essential to exclude the latter while providing the clinician with the confidence to proceed with conservative management of the patient. Comanagement and collaborative care between the medical and chiropractic disciplines offered the patient a treatment plan with prompt resolution of symptoms.
Key Indexing Terms: Torticollis, Neck Pain, Chiropractic, Complementary Therapies
From the FULL TEXT Article:
Although infectious diseases may not be the primary entities encountered in chiropractic practice, musculoskeletal ailments such as torticollis are commonly seen, and the latter may have a viral etiology. Such a presentation generally occurs with an abrupt onset of fever, malaise, and acute neck pain with the patient unable to turn his head because of muscle spasm. Specifically, posturing of the head occurs with unilateral spasm of the sternocleidomastoid muscle such that the patient will position the head with the occiput rotated to the affected side and the chin rotated to the contralateral side. 
The presentation of acute cervical torticollis related to infection tends to be seen more frequently in children with the primary etiologies consisting of upper respiratory tract infection, sinusitis, otomastoiditis, cervical adenitis, and retropharyngeal abscess or celluitis. 
In the adult patient, an acute onset of torticollis develops more commonly from a minor turning of the head, after vigorous movement or injury, or during sleep.  In addition, more than 1 muscle is involved with spasm evident in the occipitalis, sternocleidomastoid, trapezius, splenius cervicis, and/or levator scapulae muscles.  In the latter presentation, however, constitutional symptoms such as fever, malaise, and other symptoms such as nausea and vomiting are usually not associated with the onset of the torticollis. Furthermore, the presentation of a rigid neck in conjunction with fever, headache, malaise, and nausea or vomiting may herald the onset of a more ominous illness such as meningitis.  Figure 1 summarizes the aforementioned principle etiologies in the differential diagnosis of torticollis.
Fig 1: Principle differential diagnoses of torticollis.
I. Acute presentation
1. Upper respiratory tract
4. Cervical adenitis
5. Retropharyngeal abscess
1. Overstretching/Tearing of cervical musculature
2. Fracture, dislocation, and subluxation
II. Chronic presentations
a. Congenital contracture of sternocleidomastoid muscle
b. Congenital anomalies of bone
c. Cervical dystonia
In general, acute neck pain with inability to turn the head in association with headache, fever, fatigue, nausea, and vomiting prompts the patient to seek medical care. The portal of entry for medical assistance in this case may consist of an emergency department, urgent care clinic, a primary care physician, or a university-based teaching clinic. In the latter instance, a university-based teaching clinic may be likely to offer a multidisciplinary approach lacking in the aforementioned portals of the emergency department, urgent care clinic, or by a solo primary care physician. An example of such an approach exists through the cooperative efforts of the Southern California University of Health Sciences and the California State University at Northridge.
A case of acute viral torticollis presenting in a young patient is described to illustrate the collaborative efforts of a combined medical and chiropractic approach in diagnosing and managing this condition.
This case reflects the challenges and rewards in the comanagement and collaborative care of an acute viral myositis. From the standpoint of a clinical teaching model, each of the disciplines, allopathic and chiropractic, benefit from the interaction on behalf of the patient. For example, a chiropractic intern, under the direct supervision of a supervising doctor of chiropractic, performed a history and examination of the patient and executed a treatment plan. The series of tasks was also reviewed by the medical physician initially in charge of the case, providing important feedback relative to the differential diagnosis of the condition. The ability of the chiropractic intern to integrate the information gleaned from the cross-referral of the patient constitutes an assessed competency of collaborative care and referral. The medical provider coparticipated in the multidisciplinary approach to patient care, thereby interacting on several levels including diagnosis and treatment. Thus, both providers developed a greater appreciation of a combined therapeutic approach for the management of an acute musculoskeletal entity.
A series of diagnostic challenges accompanied this case relative to the differential diagnosis and the etiology of ailment. First, a primary diagnosis of bacterial meningitis needed to be excluded. In the adults presenting with community-acquired acute bacterial meningitis, the sensitivity of the classic triad of fever, neck stiffness, and altered mental status is low, but almost all present with at least 2 of the 4 symptoms of headache, fever, neck stiffness, and altered mental status.  The mortality associated with bacterial meningitis remains high, and the strongest risk factors for an unfavorable outcome are those that are indicative of systemic compromise, a low level of consciousness, and infection with Streptococcus pneumoniae.  Viral (aseptic) meningitis in the adult patient must also be considered in the differential diagnosis. Enteroviruses are the most common cause, and the principle diagnostic criteria exhibited by this entity are presented in Figure 2.7 It should be noted that fever, headache, vomiting, and stiff neck are prominent symptoms in the latter entity. 
Fig 2: Diagnostic criteria of acute viral (aseptic) meningitis in the adult patient.
I. Positive clinical findings
a. Most frequent presenting symptoms
1. Fever, neck stiffness, headache, and vomiting
II. Positive laboratory findings
a. Enteroviruses are most commonly identified etiology
b. Cerebrospinal fluid reveals
2. Predominance of lymphocytes
3. Elevated protein levels
In establishing meningitis, there are 3 classic meningeal signs: Kernig sign, Brudzinski sign, and nuchal rigidity. In a retrospective evaluation of 297 patients, the classic signs of meningitis did not have diagnostic value.  However, confusion exists in the execution and interpretation of Kernig and Brudzinski tests. For example, Kernig sign is described in physical examination texts; however, the test for Kernig sign as currently performed differs from Kernig original description.9 Furthermore, Brudzinski described several signs of meningitis; his nape of the neck sign is best known. However, the contralateral leg signs described by Brudzinski are unfamiliar to most clinicians. Brudzinski believed that knowledge of all the meningeal signs was of use because some may be present, whereas others may be absent.  Specific criteria also help rule out the possibility of meningitis. For example, meningitis may be excluded from the differential diagnosis if a patient does not have fever, neck stiffness, or changes in mental status.  In equivocal cases presenting with fever and headache, jolt accentuation of headache is a useful adjunctive maneuver to determine the necessity of performing a lumbar puncture. 
Lumbar puncture is the primary test for meningitis and is important for the critical distinction between a bacterial or viral cause.  A lumbar puncture yielding cerebrospinal fluid with a blood glucose ratio of 0.4 or less with a white blood cell count of 500/mul or higher and a lactate level of 31.53 mg/dL or more establishes the diagnosis of bacterial meningitis in the adult patient.  In contrast, pleocytosis with an elevated lymphocyte count and elevated protein levels are characteristic of viral (aseptic) meningitis in the adult patient.  However, in a prospective evaluation of community-acquired meningitis in adult patients, most cases are nosocomial.  In addition, in contrast with the patient in this case, most cases of adult onset meningitis occur in males with predisposing factors such as a head injury or cerebrospinal fluid leakage. 
Collaborative efforts in this case involved clinical decisions regarding if radiological assessment of the patient was necessary. The need for diagnostic imaging in a young adult with an acute onset of torticollis is dependent on the history and clinical presentation. A history of recent trauma, although absent in this case, is a clinical red flag of the need for a cervical x-ray series in a patient presenting with an acute torticollis.  Trauma-induced facet dislocations, occipital condyle fractures, and atlantoaxial subluxations may herald the initiation of an acute torticollis and require careful assessment of radiographs for detection.  Inflammatory processes that may require radiographic assessment are those involving the spine such as juvenile onset arthritis, ankylosing spondylitis, and pyogenic cervical spondylitis.  They are, however, unusual causes of acute torticollis in a young adult and are accompanied by ancillary constitutional symptoms and affectations of adjacent spinal and extraspinal regions of the body.  Advanced imaging techniques such as magnetic resonance imaging may need to be considered in some cases of acute torticollis that arise from unusual causes such as occult fractures, spinal cord syrinx, or central nervous system neoplasms.  These etiologies should be suspected when conservative care fails to resolve the torticollis or if cranial nerve manifestations such as optic disc edema is detected upon physical examination of the patient. 
Laboratory assessment of an acute torticollis in a young adult is also dependent upon the history and clinical examination of the patient. In general, laboratory tests such as a complete blood count may be considered when the differential causes of a stiff, painful neck include entities such as encephalitis, leukemia, or infection.  A sedimentation rate may be of value in disclosing generalized inflammation found in arthritis, infection, or malignancy. 
Although it is beyond the scope of this article to discuss all of the causes and presentations of acute and chronic torticollis presenting in different ages and patient populations, important noninclusive observations can be established. For example, congenital muscular torticollis associated with a contracture of the sternocleidomastoid muscle is a common etiology of torticollis presenting in infants.  The condition of infants with congenital muscular torticollis usually improves with a regimen of manual cervical stretching.  Unusual nonmuscular causes of torticollis in the infant also must be considered and include ocular torticollis caused by eye muscle weakness, Sandifer syndrome resulting from gastroesophageal reflux, neural axis abnormalities, and benign paroxysmal torticollis. 
The age of the patient is helpful in determining the need for a cervical x-ray series and/or advanced imaging. For example, acute torticollis is commonly seen in the pediatric emergency department. It usually results from an inflammatory process that irritates the cervical muscles, nerves, or vertebrae.  The most common causes of the inflammation are upper respiratory tract infection, sinusitis, otomastoiditis, cervical adenitis, retropharyngeal abscess, or cellulitis.  The inflammation induced by any of these entities may produce rotatory subluxation of the atlantoaxial joint, and the latter may be recognized on plain films or may require computed tomography and magnetic resonance imaging for diagnosis.15 The detection of rotatory atlantoaxial is important in these cases because it may require invasive care for definitive treatment. 
Chronic or recurrent torticollis in an adult patient usually presents as spasmodic torticollis, also known as cervical dystonia. In essence, cervical dystonia is a neurological condition thought to originate in the basal ganglia portion of the brain.  An imbalance of a neurotransmitter such as acetylcholine may be responsible for the condition. This neurotransmitter is secreted from the basal ganglia and induces nerve stimulation of certain muscles of the neck. The increased nerve stimulation of the cervical musculature causes spasms to occur, which produces various antalgic postures of the neck. 
The antalgic posture characterizing spasmodic torticollis usually includes 1 of 4 presentations. Retrocollis is a form of cervical dystonia that produces patterned, repetitive muscle contractions that result in neck extension. This presentation is frequently associated with neuroleptic exposure and a history of head and neck trauma.  Anterocollis presents with a forward flexion posture of the head and neck and may be associated with a focal myopathy.  Rotational collis presents with an upright posture of the head, which is rotated to either the left or right side of the body, in contrast to laterocollis, in which the head is laterally flexed toward either shoulder. In 1 study of 300 patients with cervical dystonia, torticollis was present in 82%, laterocollis in 42%, retrocollis in 29%, and anterocollis in 25%, although most (66%) had a combination of these abnormal postures. 
The etiology of many cases of torticollis is precipitated by a viral illness, whereas other cases arise from disturbance of the immune response.  In a study of the immunoregulatory lymphocyte subset of various cases of torticollis, a significant decrease of both helper and suppressor lymphocytes was identified in the group, together with in-vitro evidence of depressed suppressor cell function.  Therefore, an impairment of the immune response may play a significant role in the disorder.
Treatment of torticollis is dependent on the cause and presentation of the entity. Conservative management generally involves the application of manipulation, physical therapy, or acupuncture with apparent success in some cases. [23, 24] It is the opinion of the author that manipulation was successful in relieving pain and restricted mobility of the cervical spine for this patient because it momentarily separated articular structures, thereby stretching contracted muscles while it mobilized and dispersed tissue breakdown products associated with inflammation. The application of a spray vapocoolant preceding the manipulation was used as an adjunct therapy with the goal of inducing temporary analgesia and relaxation. The additional application of ultrasound and muscle stimulation before manipulation provided palliative therapy designed at relieving local pain and spasm in the cervical spine. The latter approach appeared to be successful in this case because the patient improved significantly on the second visit after the onset of symptoms although the natural history of viral torticollis typically self-limits the condition in 2 weeks. 
Manipulation has been utilized with reported success in the management of cervical dystonia and in the treatment of atlantoaxial rotatory subluxation. [26, 27] However, care should be exercised in using manipulative procedures in infants. Quadriplegia after chiropractic manipulation has been reported in an infant presenting with congenital torticollis resulting from a holocord astrocytoma with extensive acute necrosis believed to be a result of the neck manipulation.  A similar case involved forced active rotation and head retraction during manual therapy administered by a physical therapist on a 3-month-old baby. The infant experienced bleeding into the adventitia of both vertebral arteries at the level of C1 and did not survive. 
Acupuncture has been successful in the treatment of acute torticollis in a pilot study, especially in cases presenting within the first 24 hours after onset of symptoms. 
Iontophoresis has also been used in the treatment of torticollis, but the long-term effectiveness of the procedure is described as minimal with patients requiring additional interventions such as injections with botulinum toxin. 
It should be noted that 1 case report cannot be construed as the source for the treatment and management of all such as cases of acute viral torticollis. Further studies are needed in the management of this entity. Case reports cannot be generalized as to the care and management of a specific disease and/or clinical presentation for the general population. The evaluation of the therapeutic efficacy of an intervention should be evaluated by a rigorous clinical trial. 
Acute viral torticollis presenting in a young adult with constitutional symptoms presented an opportunity for a management plan involving the combined efforts of 2 disciplines resulting in a successful outcome for the patient. In addition, such an approach offers an advantage as an educational tool by providing dialogue and feedback between health care providers and students in the context of a collaborative effort. Torticollis may be a manifestation of serious underlying pathology requiring an extensive diagnostic workup of the patient before the introduction of manipulative procedures or other forms of manual therapy. Although manipulation has been reported to be successful in the management of torticollis, additional studies should be performed in the assessment of the risks and benefits of manual therapy as an intervention in the care of the various presentations of this condition.
Wang, YF, Mu-Huo, T, and Sun, YC.
Torticollis due to atlantoaxial rotatory fixation.
J Clin Neurosci. 2008; 3: 316318
Bredenkamp, JK and Maceri, DR.
Inflammatory torticollis in children.
Arch Otolaryngol Head Neck Surgery. 1990; 3: 310313
Maile, S and Slongo, T.
Atlantoaxial rotatory subluxation: realignment and discharge within 48 hours.
Eur J Emerg Med. 2007; 3: 167169
Oostenbrink, R and Moons, KG.
Signs of meningeal irritation at the emergency department.
Pediatr Emerg Care. 2001; 3: 161164
Levy, M, Wong, E, and Fried, D.
Diseases that mimic meningitis.
Clin Pediatr. 1990; 5: 258261
Van de Beek, D, de Gans, J, and Spanjaard, L.
Clinical features and prognostic factors in adults with bacterial meningitis.
N Engl J Med. 2004; 18: 18491859
Dumaidi, K, Frantzidou, F, Papa, A, and Diza, E.
Enterovirus menigitis in Greece from 2003-2005: diagnosis, CSF laboratory findings,
and clinical manifestations.
J Clin Lab Anal. 2006; 5: 177183
Thomas, KE, Hasbun, R, Jekel, J, and Quagliarello, VJ.
The diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity
in adults with suspected meningitis.
Clin Infect Dis. 2002; 1: 4652
Verghese, A and Gallemore, G.
Kernig's and Brudzinski's signs revisited.
Rev Infect Dis. 1987; 6: 11871192
Attia, J, Hataia, R, Cook, DJ, and Wong, JG.
The rational clinical examination. Does this adult patient have acute meningitis?.
JAMA. 1999; 2: 175181
Negrini, B, Kelleher, KJ, and Wald, ER.
Cerebrospinal fluid findings in aseptic versus bacterial meningitis.
Pediatrics. 2000; 2: 316319
Straus, SE, Thorpe, KE, and Holroyd-Leduc, J.
How do I perform a lumbar puncture and analyze the results
to diagnose bacterial meningitis?.
JAMA. 2006; 11: 20122022
Ewald, AJ and McKeag, DB.
Meningitis in the athlete.
Curr Sports Med Rep. 2008; 1: 2227
Schut, ES and de Gans, J.
Community acquired bacterial meningitis in adults.
Pract Neurol. 2008; 1: 823
Torticollis in infants and children: common and unusual causes.
Instr Course Lect. 2006; 55: 647653
Hicazi, A and Acaroglu, E.
Atlantoaxial rotatory subluxation revisited: a computed tomographic analysis
of acute torticollis in pediatric cases.
Spine. 2002; 24: 27712775
Straussberg, R, Harel, L, and Amir, J.
Pseudotumor cerebri manifesting as stiff neck and torticollis.
Pediatr Neurol. 2002; 2: 225227
Koukouni, V and Martino, D.
The entity of young primary cervical dystonia.
Mov Disorder. 2007; 6: 843847
Papapetropoulos, S, Baez, S, and Zitser, J.
Retrocollis: classification, clinical phenotype, treatment and risk factors.
Eur Nueurol. 2008; 2: 7175
Zetterberg, L and Halvorsen, K.
Objective assessment of cervical dystonia.
Acta Neurol Scand. 2005; 4: 448453
Jankovic, J, Leder, S, Warner, D, and Schwartz, K.
Cervical dystonia: clinical findings and associated movement disorders.
Neurology. 1991; 7: 10881091
Moore, AP, Behan, PO, and Behan, WM.
Lymphocyte subset abnormalities in patients with spasmodic torticollis.
Acta Neurol Scand. 1986; 5: 371378
Cervical dystonia: disease profile and clinical management.
Phys Ther. 2007; 11: 15111526
Management of secondary muscular torticolis using acupuncture.
Acta Chir Orthop Traumatol Cech. 1967; 5: 449452
Orthopaedics. Principles and their application. 4th ed.
Lippincott, Philadelphia; 1984
Chiropractic correction of atlantoaxial rotatory fixation.
J Manipulative Ther. 1996; 4: 268272
Reduction of cervical dystonia after an extended course of chiropractic manipulation.
J Manipulative Ther. 2004; 6: 421426
Shafrir, Y and Kaufman, BA.
Quadriplegia after chiropractic manipulation in an infant with congenital torticollis
caused by a spinal cord astrocytoma.
J Pediatr. 1992; 2: 266269
Jacobi, G, Riepert, T, Kieslich, M, and Bohl, J.
Fatal outcome during physical therapy (Vojta's method) in a 3 month old infant.
Klin Padiatr. 2001; 2: 7685
Acupuncture for acute torticollis: a pilot study.
Am J Chin Med. 2003; 5: 803807
Davis, DH, Duane, DD, and Swenson, MK.
Long term outcome of iontophoresis treatment for torticollis.
Stereotact Funct Neurosurg. 1996; 4: 198201
Considerations of study design.
Nutr Clin Pract. 2007; 6: 593598
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