Jessica is a new patient who presented this week with an acute case of myogenic torticollis (simple wryneck) which brings our grand total this summer to 11 cases! She claims there was no trauma to her neck during the past few days and that this was the first episode that she had ever experienced. She just "woke up with it" in the morning and was terrified because she couldn't move her head in rotation or lateral flexion to the right and was suffering extreme pain in the neck and upper back localized to the right side.
Simple acute idiopathic (without a known cause) torticollis will affect about 10% of the population during their lives and can be very scary for most. It is defined as "a form of dystonia (prolonged muscle contractions) in which the neck muscles, particularly the sternocleidomastoid and levator scapula muscle, contract involuntarily causing the head to turn. Torticollis may occur without known cause (idiopathic), be genetic (inherited), or be acquired secondary to damage to the nervous system or muscles.
Although a prolonged search of the literature will give you loads of data about virus induced, neurogenic (caused by a lesion in the brain), and congenital (born with it) types of torticollis there is very little to be found about what causes a simple, acute case in a relatively healthy individual. It is often cited that an "incorrect sleeping posture" is the principle factor and, although we agree with this, the preponderance of cases that appear suddenly as we head into the hot, humid, sticky months of summer in Mexico leads many therapists to believe that there may be something to the local "wives tale" beliefs that a constant breeze upon sweaty muscles can aggravate the situation.
In 8 years of private practice in the Riviera Maya I can confidently state that I see much more cases of torticollis in the summer months than winter. I too have suffered this condition and, although I know it is not serious and that eventually it will resolve without complication, it is at once scary, debilitating, and a terrible nuisance for at least three days. You can be sure that every masseuse, PT, chiro, and acupuncturist that owes me a favor will be getting a call from yours truly when I wake up with a "tweaked" neck.
Although I was hard pressed to find specific scientific studies as to exactly HOW a constant air flow hitting sweaty skin and underlying muscle tissue causes the muscle to go into uncontrollable spasm I did find several references to this precipitating factor.
Sanar Solution
Most of our patients (neck pain or no) have OVERLY TIGHT AND CHRONICALLY CONTRACTED MUSCLES IN THE UPPER BACK AND NECK. Specifically the upper trapezius, splenius capitus, levator scapula, and suboccipital muscles. Many also have tightened and shortened Sternocleidomastoid muscles (located in the FRONT of the neck, running from the clavicles up to the bony prominence behind the ear.) This is due in large part to the typical "shoulders rounded, head forward" posture of people who are working at computer stations, driving all day, or who just generally have a lazy posture. The farther forward the head is, the more extra work we give to these small muscles of the posterior neck. Making a conscious effort to hold your shoulders back and keep your chest "open" dramatically reduces the chronic tight bands and "knots" that we find in many patients. This, in turn, reduces the risk that the muscle will spontaneously go into spasm just because you sleep a little crooked. Obviously, learning how to STRETCH these tight muscles is one of your best defenses. EVERYBODY has bad posture and stress now and then. A good therapeutic stretch performed by the patient regularly is, in the opinion of many therapists, essential MAINTENANCE for the spine just as brushing and flossing is for the teeth!
Sleeping face down every night DEFINITELY puts you more at risk. This doesn´t need much explication. The natural curves of the spine are best preserved by sleeping in fetal, side lying position with the head supported by a small pillow keeping the neck in a straight line and even a pillow between the knees to keep the low back free of rotation. Alternately face UP with a pillow under the THIGHS to keep the low back flat and a small cervical roll under the neck. Face DOWN sleeping necessitates that the cervical spine is FORCED in rotation all night and also may aggravate low back pain in patients who already suffer from excess low back curvature (lordosis.)
Having a ceiling or pedestal fan on full power blowing on your sweaty skin all night is many times the "last straw" for these tight and tired muscles. I have found that I can protect my neck from torticollis by draping a very light "sarong" or "pareo" type material over my neck and upper body and I cannot recommend this practice enough if you just absolutely have to have your fan in "full-on-helicopter mode" to be able to sleep! If you are fortunate enough to have a good "mini-split" airconditioner try to just use that WITHOUT the fan and you may get through the summer without incident. Weak and "dying" airconditioners sometimes compound the problem because instead of helping to dry the air in your room they end up just re-circulating the humidity and putting a chill to it..a sure recipe for disaster.
If all of this does NOT work and you wake up one morning with a severe "kink" in your neck..don´t despair!! Between physical therapy, gentle chiropractic vertebral adjustments, therapeutic stretching and acupuncture we can get you feeling much better in no time! Most patients report 40-60 percent relief after the very first treatment and those who apply the therapeutic stretches that we teach plus using hot moist packs and some mild analgesic medicine at home tend to recover 100% after just 2-5 treatments. The key then is to PREVENT a recurrence which basically boils down to educating the patient and keeping their spine and muscular system in a balanced, relaxed and healthy state.
Home Rehab and Therapeutic Stretches
As has been explained to you already your headaches are often a result of poor posture while working with the "head forward" position and "rounded shoulders" putting incredible strains on muscles that were never designed for such loads. The chiropractic adjustments, muscle work, electrostiumlation and acupuncture that you receive in SANAR help us to "push the reset button" of your postural computer. However, current studies on posture indicate that it is a very complex interaction between physical muscle tension and an intangible "muscle memory." Effectively, changing the resting tone of any given muscle is like "teaching an old dog new tricks." We have found that one of the most difficult aspects of treatment is convincing the patient to DO THEIR PART by doing the therapeutic home stretching that we recommend EVERY DAY. Most times, the total stretching regimen you will be given can be done in a TOTAL of less than 15 minutes per day!! Yet still we find patients wasting more energy in INVENTING EXCUSES not to stretch than they would have spent stretching! Undoubtably the patients who get better faster are those who are COMMITTED to their recuperation and do their homework!!
Changes in daily life
5 minute forced break for every hour spent in front of the computer or driving. Stand up, move around, neck circles, auto-massage your trapezius muscles
. Make changes to your workstation following the IBM computer labor guidelines:
First line of text level with your eyes when correctly seated at the computer. Use old phone book to raise monitor height, put monitor DIRECTLY in front. Do NOT work with head turned to face monitor!! Do NOT cradle the phone between ear and head while working.
Knees bent at 90 degrees, butt touching the backrest of chair, feet flat on the floor, keyboard at height that leaves elbows bent at 90 degrees with wrists at SAME level or just below elbow height.
Use a glare shield on the computer screen to reduce eyestrain if office light is bad.
Do your best NOT to sleep face down. Always strive to keep the spinal column in a straight line either side lying or face up. When face up use a very thin pillow , a cervical specific pillow, or roll up a towel the size of your forearm and put under your neck to support the natural cervical curve (lordosis.)
d. Do NOT drive with the window open allowing strong cool breeze to hit your neck on the highway. Do NOT sleep with humid breeze hitting your neck NOR strong ceiling fans NOR directly in front of airconditioners. Always try to at least put a thin sarong type material over the neck and upper back if you must sleep in a wind current.
e. Do NOT spend more than one hour at a time with the head strongly inclined reading or doing other sewing or drawing type work. Watching TV laying on your back with the head propped up by several hours will ALWAYS make the situation worse.
Home massage and muscle retraining
Start with moist heat over the muscles. Use a humid towel heated in the microwave for 2 minutes if you don't have a hot pack or an electrical heating pad on top of a humid towel. Use the heat for 15 minutes only.
Any cream with menthol can be used if you want to have a more "slippery" massage and some creams sold in farmacies actually have some "anti inflammatories" inside them however their efficacy has yet to be proven.
Have your partner apply constant pressure to the " trigger points" that we have shown you for approximately 1 minute each point or, if alone, use a tennis ball against the wall to work deep knots between shoulder blades or two balls inside an old sock as you have been shown in the clinic.
When you feel pain your FIRST impulse should be to "open" your chest by turning your palms to face forwards. This externally rotates the shoulder joint and forces a light stretch on the pectoral muscles. To remind yourself how your posture should be, stand with feet and buttocks and shoulder blades against the wall and try to touch the back of your head on the wall at the same time. Do NOT incline the head back and look towards the ceiling to do this!! Instead, draw the chin backwards with the goal of bringing the ears over the shoulders (where they should be!)
Therapeutic stretches:
Seated or Standing Trapezius and Levator Scapula
Hanging rhomboid
Standing Pectoral
Chest opener using a Physio ball
Links
Anderson A, Boline P, Bronfort G, Kassak K, Nelson C, Spinal Manipulationvs. Amitriptyline for the Treatment of Chronic Tension-Type Headaches: ARandomized Clinical Trial Journal of Manipulative and PhysiolgicalTherapeutics 1995 ; 18(3): 148-54 Objective: To compare the effectivenessof spinal manipulation and pharmaceutical treatment (amitriptyline) for chronictension-type headache. Design: Randomized controlled trial using two parallelgroups. The study consisted of a 2-wk baseline period, a 6-wk treatment periodand a 4-wk posttreatement, follow-up period. Setting: Chiropractic collegeoutpatient clinic. Patients: One hundred and fifty patients between the agesof 18 and 70 with a diagnosis of tension-type headaches of at least 3 months'duration at a frequency of at least once per wk. Interventions: 6 wk of spinalmanipulative therapy provided by chiropractors or 6 wk of amitriptyline treatmentmanaged by a medical physician. Main Outcome Measures: Change in-patient-reporteddaily headache intensity, weekly headache frequency, over-the-counter medicationusage and functional health status (SF-36). Results: A total of 448 peopleresponded to the recruitment advertisements; 298 were excluded during thescreening process. Of the 150 patients who were enrolled in the study, 24(16%) dropped out: 5 (6.6%) from the spinal manipulative therapy and 19 (27.1%)from the amitriptyline therapy group. During the treatment period, both groupsimproved at very similar rates in all primary outcomes. In relation to baselinevalues at 4 wk after cessation of treatment, the spinal manipulation groupshowed reduction of 32% in headache intensity, 42% in headache frequency,30% in over-the-counter medication usage and an improvement of 16% in functionalhealth status. By comparison, the amitriptyline therapy group showed no improvementor a slight worsening from baseline values in the same four major outcomemeasures. Controlling for baseline differences, all group differences at4 wk after cessation of therapy were considered to be clinically importantand were statistically significant. Of the patients who finished the study,46 (82.1%) in the amitriptyline therapy group reported side effects thatincluded drowsiness, dry mouth and weight gain. Three patients (4.3%) inthe spinal manipulation group reported neck soreness and stiffness.
Conclusion: The results of this study show that spinal manipulative therapy is an effectivetreatment for tension headaches. Amitriptyline therapy was slightly moreeffective in reducing pain at the end of the treatment period but was associatedwith more side effects. Four weeks after cessation of treatment, however,the patients who received spinal manipulative therapy experienced a sustainedtherapeutic benefit in all major outcomes in contrast to the patients thatreceived amitriptyline therapy, who reverted to baseline values. The sustainedtherapeutic benefit associated with spinal manipulation seemed to resultin a decreased need for over-the-counter medication. There is a need to assessthe effectiveness of spinal manipulative therapy beyond four weeks and tocompare spinal manipulative therapy to an appropriate placebo such as shammanipulation in future clinical trials.
Cervicogenic Headache Model Gives Credence to Chiropractic Until recently, the medical understanding of headaches has not taken into account the chiropractic model. The concept that headache pain can emanate from cervical dysfunction is still completely foreign to most of the medical profession. Noted researcher Nikolai Bogduk , MD , PhD, professor of anatomy at Newcastle , Australia , commented:
"The people in control of the headache field seemingly have not, cannot, or will not, recognize this paradox ... that the model for cervicogenic headache is not only the best evolved of all headaches but is testable in vivo, in patients with headache complaints. No other form of headache has that facility."
Several years ago, a Canadian anesthesiologist, Peter Rothbart, MD, FRCPC, came to the same conclusions about cervicogenic headache. Dr. Rothbart made many observations in his own pain management practice, which subsequently led to an article in the Toronto Star, the most widely read newspaper in Canada . The Toronto Star article, "A Pain in the Neck," was subtitled: "Chiropractors were right. Many headaches are caused by damaged structures in the neck -- and scientific evidence proves it." The article explained that years ago, French medical professor Robert Maigne "came to believe that many headaches originated with a structural problem in the neck." He was "thought to be a lunatic," said Dr. Rothbart. But others took up Dr. Maigne's work, including Dr. Nik Bogduk. In 1995, a team of MDs at Syracuse University established neck problems as the cause of many headaches "with scientific, anatomical proof." Dr. Rothbart termed the Syracuse results "a minor miracle." In the Toronto Star article, Dr. Rothbart made several insightful comments:
"Some brilliant people have put their hearts, souls and minds to this (headache) problem and haven't come up with anything. All we've been able to do is treat people with an array of medicines, one after the other, and hope the side effects won't be too bad."
"We couldn't believe it at first. We've been able to put together a scientific explanation for how neck structure causes headaches -- not all headaches, but a significant number of them."
"It's true that chiropractors have been saying this for years. Unfortunately, many (medical) doctors tend to have a jaundiced view of chiropractors, but they were right about headaches."
Dr. Rothbart's clinical experience and findings have led him to become a founder and president of the North American Cervicogenic Headache Society (NACHS). The NACHS is dedicated to establishing the place of cervicogenic headache in the minds and practices of those health care provider who treat headaches. At the first North American Cervicogenic Headache Conference, held last year, Dr. Rothbart remarked:
"So far as the International Headache Society and the American Association for the Study of Headaches have defined this entity (cervicogenic headache) -- it simply doesn't exist. I'm pleased to say that thanks to the works of Drs. Merskey and Bogduk, cervicogenic headache is recognized in the IASP (International Association for the Study of Pain) taxonomy. This situation creates an enormous problem in addressing the diagnosis and treatment of headaches. Since most of the physicians and headachologists are unfamiliar with the IASP taxonomy, they are unaware of this entity, so diagnosis of cervicogenic headache is rarely made. Thus, there are a large number of chronic headache sufferers who go through life with the wrong diagnosis and hence the wrong treatment for their headache. It was the ongoing ignorance about this clinical entity that motivated the founders of this society to establish a formal organization. One of our goals is for this entity to be accepted into the general headache classification, and until this happens, large numbers of patients will continue to suffer unnecessarily."
The second North American Cervicogenic Headache Conference will be held in Las Vegas , March 22-23. Dr. Rothbart with be the conference moderator. Conference speakers include Dr. Bogduk and Howard Vernon, DC, associate dean of research at the Canadian Memorial Chiropractic College in Toronto . The conference is designed for MDs, DCs and all other providers who deal with headaches. One of the sessions will specifically address the use of "manipulative therapy" for cervicogenic headaches.
The development of the concept of cervicogenic headache has opened a new door for chiropractic. As this concept is developed and adopted, it is expected that a large percentage of headache sufferers will fall into this category. Chiropractic has much to offer as the first line care for cervicogenic headache. Dr. Rothbart notes the importance of this conference for DCs:
"This conference will demonstrate the anatomy and physiology of cervicogenic headache and will show the importance of manipulation as a method of treatment. This will be the first conference bringing together chiropractors and neurologists. It will help to validate chiropractic practice to some of the most skeptical medical practitioners and so benefit all practitioners involved in treatment of chronic headaches."
Editor's note: For information regarding the North American Cervicogenic Headache (NACH) Conference, please contact Bev Hann at 1-800-663-2858. The NACH fax number is: 1-905-882-8412.
Jessica is a new patient who presented this week with an acute case of myogenic torticollis (simple wryneck) which brings our grand total this summer to 11 cases! She claims there was no trauma to her neck during the past few days and that this was the first episode that she had ever experienced. She just "woke up with it" in the morning and was terrified because she couldn't move her head in rotation or lateral flexion to the right and was suffering extreme pain in the neck and upper back localized to the right side.
