PHTY 3120 Block 3 Lecture 4 TREATMENT OF ACUTE WRY NECK

Syndrome Categories: 1. "Locked" apophyseal joint 2. Discogenic Wry Neck 3. Spasmodic Torticollis 4. Traumatic Most 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 synovial fringe and reactive inflammation, swelling and muscle spasm. Most common segments are C1-2 or C2-3 (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. Treatment If 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 Neck Precise pathology in disc uunknown; care needs to be taken as these patients are vulnerable to development 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 spasm Physical examination Movement pattern: Most limited, extension > LF and Rot towards side of pain Confirm level with manual examination Treatment 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 analgesics Subsequent treatment: Note these patients often have a slower response to treatment and may take 2 weeks to subside. Spasmodic torticollis Dystonia 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 a neurologist is important. Traumatic Wry Neck For example following a whiplash injury or sporting injury. High velocity manipulation is contra-indicated as it is difficult to ensure that there is no underlying pathology such as microfracture or other instabilities. Bogduk, N., Engel, R. 1984. The menisci of the lumbar zygapophyseal joints: a review of their anatomy and clinical significance. Spine 9:454-460 Bogduk, N., Marsland, A. 1988. The cervical zygapophysial joints as a source of neck pain. Spine 13:610-7 Grieve, G. P. 1988. Common Vertebral Joint Problems Edinburgh: Churchill Livingstone Mercer, 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 manual therapy. Manual Therapy 1:76-81