Changes

September 2023 — reviewed.  A literature search was conducted in September 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Minor structural changes have been made to the topic to align with up-to-date evidence. A short section detailing some complications which can arise in people with acute torticollis has been added.

Update

Goals

To support primary healthcare professionals to:

• Make an accurate diagnosis of acute torticollis.
• Provide appropriate treatment in primary care.
• Offer appropriate advice.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

Non-steroidal anti-inflammatory drugs (NSAIDs):

• Regularly review the appropriateness of NSAID prescribing, particularly in older people and/or those at higher risk of gastrointestinal (GI), cardiovascular or renal morbidity and mortality.
  • Consider switching to a lower-risk NSAID or stopping treatment where appropriate.
• Consider alternatives to oral NSAIDs, such as topical NSAIDs, physiotherapy or a different analgesic, such as paracetamol or an opioid, before prescribing NSAIDs.
• When prescribing NSAIDs, choose those with the lowest cardiovascular, renal and/or GI risk, depending upon the individual person's risk factors.
  • If more than one product is suitable, choose the product with the lowest acquisition cost. 
• Do not prescribe NSAIDs when contraindicated, and only prescribe NSAIDs to people at risk of renal impairment or failure when use is unavoidable.
• Use the lowest effective dose and the shortest duration of treatment necessary to control symptoms.
  • Ibuprofen (1,200 mg a day or less) or naproxen (1,000 mg a day or less) are generally preferred for safety reasons.
• Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis or rheumatoid arthritis, those who are elderly, those with lower back pain, axial spondyloarthritis, psoriatic arthritis or other peripheral spondyloarthritides, and those at moderate or high risk for GI adverse effects.

[PrescQIPP, 2020]

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• Torticollis (or wry neck) is a painful condition which can include the following symptoms:
  • Spasm of neck muscles.
  • Abnormal neck movements.
  • Awkward position of the head and neck. 
• It is classified as congenital (which is not usually painful) or acquired, which may or may not be painful.

[Cohen, 2015; Athanassacopoulos, 2016; BMJ Best Practice, 2022a]

What causes it?

• The exact cause of acute torticollis is often difficult to establish, and multiple aetiologies have been identified. It may present due to issues with posture as a result of:
  • Poor positioning at a computer screen.
  • Inappropriate seating. 
  • Sleeping without adequate neck support.
  • Carrying heavy unbalanced loads (for example, briefcase or shopping bag).
  • Sedentary lifestyle.
• Other common causes may include:
  • Neck trauma — in some cases, the inciting incident may be very subtle and even unnoticed.
  • Dystonia — rare and often idiopathic but can present as:
    • An acute or delayed complication of using medications with dopamine receptor antagonistic properties (for example, antipsychotics, domperidone, metoclopramide or prochlorperazine).
    • A symptom of diseases which cause dysfunction of the basal ganglia (for example, perinatal asphyxia/cerebral palsy, Huntington's disease, and Wilson's disease).

[Barry, 1995; Athanassacopoulos, 2016; Cohen, 2017; BMJ Best Practice, 2022a; BMJ Best Practice, 2022b]

How common is neck pain?

• The lifetime prevalence of neck pain is estimated to be around 40–70%.
  • The estimated one-year incidence of neck pain is between 10 and 21%.
• Prevalence increases until the 50–55 age group, after which the risk declines.
• It is more common in women than in men.
• There is an increased prevalence in people working in clerical and service industries and agriculture. 
• Acquired torticollis is rare, with an estimated prevalence of 1 in 10,000–20,000 people.
  • The true prevalence of acquired torticollis is likely underestimated due to under-reporting of the condition.

[Dianat, 2020; BMJ Best Practice, 2022a; BMJ Best Practice, 2022b; Kazeminasab, 2022]

What are the risk factors for neck pain?

• Risk factors for neck pain include:
  • People who are aged 40–59 years.
  • Certain occupations that involve people maintaining awkward postures for sustained durations (for example, office and computer workers, manual labourers, and healthcare workers).
    • Although a higher incidence of neck pain has been observed for some occupations, several studies have described work and family life imbalance, a hostile work environment, job insecurity, and long working hours as occupational risk factors.
  • Female sex.
  • History of mental stress and other psychological conditions, including anxiety, depression and sleep disorders.
  • Previous neck pain.
  • Sleep disorders.
  • Sedentary lifestyle.
  • Smoking.
  • Trauma.
  • Obesity.
  • Rheumatological disease.

 [Cohen, 2015; Yang, 2016; Cohen, 2017; Dianat, 2020; BMJ Best Practice, 2022a; Kazeminasab, 2022]

What is the prognosis for people with neck pain?

• Most cases of acute neck pain resolve within 2 months.
  • However, half of people continue to experience low-grade symptoms or recurrences for more than a year.
• Acute torticollis is usually expected to ease within 48 hours and resolve within 7-10 days.

[Cohen, 2015; Athanassacopoulos, 2016; Cohen, 2017; NI Direct, 2023] 

What are the complications?

• People experiencing an acute torticollis may be at risk of occupational disability. 
• Depression is a common comorbidity for people with acquired torticollis. If identified, depression should be managed appropriately. See the CKS topics on Depression in children and Depression for more information.

[BMJ Best Practice, 2022a]

How should I assess someone with suspected acute torticollis?

• Acute torticollis is diagnosed clinically — in typical cases which present within 1–2 days of symptom onset, investigations are not usually required. 
• Take a detailed medical history and conduct a physical examination to distinguish neuropathic pain from mechanical neck pain.
• Ask about:
  • Signs and symptoms of acute torticollis and duration of symptoms.
  • Occupational history.
  • Medical history (for example, rheumatoid arthritis, which can cause atlantoaxial rotatory subluxation).
  • Symptoms of anxiety or depression.
  • Previous injury or infection.
  • History of cancer — in these people, aetiology of pain should be assumed to be cancer until it is excluded.
  • Presence of fever — in these people, neck pain should be assumed to be secondary to an infection until proven otherwise.
  • Any recent changes in medication —  rarely the use of dopamine receptor antagonists such as antipsychotics, domperidone or metoclopramide can result in dystonic reactions.
• Assess the appearance of the neck and the range of motion. 
• Palpate the neck for tenderness.
• Evaluate for evidence of neurological involvement (for example, decrease in sensation or strength, or abnormal reflexes, gait or co-ordination).
• Inspect the skin — for example, for papulovesicular rash in a prodromal distribution, petechiae or palpable purpura.
• Consider performing the Spurling test as part of an assessment to exclude cervical radiculopathy.
  • With the person in a seated position, the neck is flexed towards the side of the pain and pressure is applied to the top of the head. Pain radiating into the limb on the affected side is highly suggestive of cervical radiculopathy.
  • Note: This test should not be performed in people with rheumatoid arthritis, cancer, infection or possible neck injury.
• Consider looking for Kernig's sign (painful/resisted extension of leg bent at hip and knee) and Brudzinski's sign (reflective flexion of the knees when patient is on his/her back and the neck is bent forwards) to demonstrate nuchal rigidity if meningitis is suspected.
• Identify and urgently refer people with red flags indicative of serious spinal pathology.
• Exclude other causes of neck pain.

What are the signs and symptoms of acute torticollis?

• Clinical features of acute torticollis include: 
  • Sudden onset of severe unilateral pain that may be referred to the head or shoulder, with deviation of the neck to one side — this may be described as a sensation of cramp or spasm in the neck, shoulder or upper back.
  • Restricted and painful neck movements.
  • Diffuse tenderness on the affected side with palpable spasm, possibly with tender points of muscle spasm (trigger points).
  • No history of trauma preceding the onset of pain, but there may be a history of exposure to cold, prolonged or unusual positioning of the neck.
    • For some people, there may be a history of neck trauma, but neck trauma is not a well-established cause or trigger factor for acute torticollis.
  • Headache may also be present in some people.

What else might it be?

• The differential diagnosis of neck pain is broad but includes trauma and non-musculoskeletal disease processes that can be classified as neoplastic, inflammatory, infectious, vascular, endocrinological, neurological or genetic. For example:
  • Acute disc prolapse — the most common cause of severe secondary torticollis.
  • Acute trauma (for example, whiplash-type injury).
  • Adverse drug reactions (for example, antipsychotic drugs, metoclopramide, amphetamines, cocaine).
  • Arthritis of the cervical spine.
  • Cervical strain/fracture/dislocation/radiculopathy/myelopathy.
  • Malignancy.
  • Meningitis.
  • Neurological disorders leading to dystonia (for example, stroke, encephalitis).
  • Psychogenic dystonia.
  • Genetic conditions and disorders leading to dystonia (for example, Wilson's disease, Huntington's disease or primary torsion dystonia [DYT-1]).

What investigations should I arrange for people with suspected torticollis?

• Investigations are not normally necessary for people with acute torticollis. 
• Consider referral for further investigations if:
  • The presentation is atypical.
  • Red flag symptoms are present.
  • Cervical injury is suspected.
  • History reveals a recent infection. 
  • There is suspicion of malignancy. 
  • Alternative diagnoses or secondary diagnoses are suspected.
• Investigations may include:
  • Laboratory investigations — for example, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), full blood count (FBC), or fungal and viral cultures.
  • Imaging — which may be considered as part of a referral for specialist investigation in secondary care, for example, cervical spine X-ray, cranial CT imaging, cervical spine MRI, cervical spine CT scan and CT myelography, or bone scan.

Scenario: Management

From age 16 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of acute torticollis.

Search dates

August 2018 - September 2023.

Key search terms

The terms listed below are the core search terms that were used for EBSCO MEDLINE (searched 13th July 2018). Search filters were not applied, and all results were screened. The strategy was adapted for The Cochrane Library databases. 

S10 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9

S9 AB "locked neck" OR TI "locked neck"

S8 AB (asymmetr* N3 neck) OR TI (asymmetr* N3 neck)

S7 AB ( ("head tilt*" OR "tilted head") ) OR TI ( ("head tilt*" OR "tilted head") )

S6 AB (neck N2 tilt*) OR TI (neck N2 tilt*)

S5 AB (neck N2 stiff*) OR TI (neck N2 stiff*)

S4 AB (twist* N2 neck*) OR TI (twist* N2 neck*)

S3 AB ( (wryneck or wry neck) ) OR TI ( (wryneck or wry neck) )

S2 AB (torticollis N3 acute*) OR TI (torticollis N3 acute*)

S1 (MH "Torticollis")

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.