PHTY 3120Block 3

Lecture 4

TREATMENT OF ACUTE WRY NECK

Syndrome Categories:1. "Locked" apophyseal joint2. Discogenic Wry Neck3. Spasmodic Torticollis4. TraumaticMost important to differentiate between all types as very mush influences treatment approach.

"Locked" Apophyseal Joint:Pathology is unknown. Possibilities are entrapped or extrapped menisci, acute nipping of synovialfringe and reactive inflammation, swelling and muscle spasm. Most common segments are C1-2 orC2-3 (corresponds to the largest meniscii in the cervical zygapophyseal joints).

History:• Often younger person, teenagers and in the 3rd decade, Females>>males.• Few to 24 hours in duration on presentation• Determine any past history (not uncommon for previous episodes).• incident, e.g. turned quickly• localized unilateral neck pain (patient can localise with one finger).Physical Examination- Posture. Head laterally turned away from side of pain, with a variable degree of rotation

away from the side of pain (contralateral list).- Try to correct deformity - Is it locked? Or is the head held in a wry, painfree position.- Movement pattern: Most limited, L.F. towards side of pain >Rot. towards side of pain

>Extension, reproces local neck pain.- Pain eases immediately after movement (non irritable).- PPIVM's, PAIVM's - to confirm if it is locked and to localise the segment. Relaxation of

some muscle spasm in the NWB position.TreatmentIf locked, order of selection of technique:- ↔, initially in line of the deformity, progressively bringing the neck into the neutral position- LF away from the side of pain

- Rot. away from side of pain- Relaxation techniques at the segmental levels- Localized manipulative technique

If the joint was not locked or post "unlocking" technique:- Gentle unilateral glides over affected apophyseal joint- U.S. for inflammation and pain- Active movements in NWB position (eg on hot pack or ice pack if patient tolerates)- Disinhibit and activation of deep neck flexors and lower trapezius- Advice re rest for 24 hours

Day 2 Treatment

- Manual Therapy for residual joint pain- Ensure activation of all supporting muscles (if previous episodes, may need full active

stability rehabilitation program)- Active segmental exercises

"Discogenic" Wry NeckPrecise pathology in disc uunknown; care needs to be taken as these patients are vulnerable todevelopment of a disc, nerve root syndrome. High velocity manipulation is contra-indicated.History:- Often older person, 3rd or 4th decade- insidious onset, patient may "wake with" wry neck; can be a history of unaccustomed activity- deep ache, spreads, can feel pain adjacent the scapula- Often slightly irritable- Posture - laterally flexed, rotated and flexed away from side of pain- Try to correct; it is usually possible, but painful, limited by muscle spasmPhysical examination- Movement pattern: Most limited, extension > LF and Rot towards side of pain- Confirm level with manual examinationTreatment- Rotation away from side of pain- Posteroanterior glides with neck resting in a position of ease- if not successful, traction- Manipulation contra-indicated- Hot pack- Gentle active exercise in NWB position- Disinhibit and activation of deep neck flexors and lower trapezius- Advice re rest for 24 hours- + Collar- Often require analgesicsSubsequent treatment: Note these patients often have a slower response to treatment and maytake 2 weeks ± to subside.

Spasmodic torticollisDystonia – neurological disorder. It is often not overly painful but patient will often have a “tick”with neck moving into a wry position. Physiotherapy has not a major role to play. Referral to aneurologist is important.

Traumatic Wry NeckFor example following a whiplash injury or sporting injury.High velocity manipulation is contra-indicated as it is difficult to ensure that there is no underlyingpathology such as microfracture or other instabilities.

Bogduk, N., Engel, R. 1984. The menisci of the lumbar zygapophyseal joints: a review of theiranatomy and clinical significance. Spine 9:454-460

Bogduk, N., Marsland, A. 1988. The cervical zygapophysial joints as a source of neck pain. Spine13:610-7

Grieve, G. P. 1988. Common Vertebral Joint Problems Edinburgh: Churchill LivingstoneMercer, S., Bogduk, N. 1993. Intra-articular inclusions of the cervical synovial joints. British

Journal of Rheumatology 32:705-10

Mercer, S., Jull, G. 1996. Morphology of the cervical intervertebral disc: Implications for manualtherapy. Manual Therapy 1:76-81