Topics in pediatricsConservative Care of Pediatric Acquired Torticollis: A Report of 2 Cases
Introduction
Acquired torticollis is a painful condition that may be seen in chiropractic as well as in family and pediatric medical settings. Acquired torticollis differs from congenital torticollis in that the onset is after the first 2 months of life. It appears to be more common in the fall and winter months, with 60% to 70% of cases occurring during those 2 seasons.1, 2 Acquired torticollis is also common among adults, but is usually benign in this population, whereas it has a higher likelihood of representing serious underlying pathology in a pediatric population.3, 4
Acquired torticollis has been associated with serious pathologies, including brain and spinal cord tumors,5, 6 hemorrhage,7 meningitis,8 and encephalitis.9 Often the torticollis posture and pain on motion are the only presenting symptoms. Nonmuscular causes of torticollis in children may account for 18% of all torticollis admissions in a hospital setting.3, 10 Because torticollis may be a red flag for underlying serious and perhaps nonmusculoskeletal pathology, diagnosis and appropriate treatment should not be delayed.11, 12
History and physical examination can identify most pathologic etiologies, obviating the need for special imaging.1, 13 Regrettably, after significant pathology has been ruled out, the acquired torticollis of muscular origin is often left unaddressed, consigning the patient to a prolonged painful and limiting disorder, even though it eventually resolves.
There is a dearth of case reports on successful outcomes of manual therapy treatment of torticollis in the pediatric literature. One case describes successful resolution of an acquired torticollis that resulted in eye fixation.14 Another case discusses congenital torticollis rather than acquired torticollis.15 A recent large clinical trial16 that employed physiotherapy for pediatric torticollis included some similar treatment protocols and reported congruent findings, but included only patients with congenital torticollis and patients younger (2-5 months of age) than the 2 cases herein reported. This trial reported 90% successful outcomes in fewer than 10 visits, with rapid resolution of symptoms once the proper diagnosis is made and treatment initiated.
The few publications in the manual therapy literature on the diagnosis and treatment of acquired pediatric torticollis mostly report adverse events and missed diagnoses.4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 17, 18, 19, 20, 21 The only case series in the literature featuring chiropractic management concerns missed diagnoses of underlying pathologies.22 One case report of a child with congenital torticollis details how several providers missed diagnosing holocord astrocytoma resulting in quadriplegia.17 There have been reviews on the safety of chiropractic manipulation for pediatric patients that concluded that there is insufficient evidence to establish causation, but that adverse events are rare and may not exceed those of other interventions.23, 24, 25, 26 The literature is not reflective of the prevalence of the benign forms of acquired torticollis that approach 80% of cases, nor the successful outcomes of those in private practice.3 A consensus guideline on best practices for chiropractic care for children was published after the submission of the 2 cases herein reported and provides similar lines of reasoning on safety and treatment methods described in this report.27
The purpose of this case report is to describe the conservative management of two cases of musculoskeletal acquired torticollis in children under 3 years of age.
Section snippets
Case 1
A 26-month-old girl, crying on waking one morning, complained to her parents that her neck was hurting. The parents brought her to a chiropractic office and relayed her history and behavior to the doctor. The pain had begun after a day of playing in a bouncy house. She had no known previous accidents or injuries during play and had not complained of any pain the day prior. The pain was exacerbated when turning to the right. The parents noted that during the next several days, she flinched with
Discussion
The 2 cases are similar to each other and reflective of acquired torticollis of muscular origin. Practitioners may get a false sense of security from regularly treating adults with this condition who have very little risk of serious underlying pathologies. This is not necessarily true for the pediatric population, and practitioners may not always recognize the risk if they have not received extra training in pediatric musculoskeletal disorders. Both serious pathologies and benign presentations
Conclusions
This report described 2 cases of acquired torticollis that resolved under chiropractic care. The successful outcomes suggest that after performing a clinical examination that rules out significant underlying pathology, chiropractic care may be a useful treatment for this condition.
Funding Sources and Conflicts of Interest
No funding sources or conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): J.L.Y.
Design (planned the methods to generate the results): M.D.Y.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): M.D.Y.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): J.L.Y.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): M.D.Y.
Literature search (performed
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The safety of spinal manipulative therapy in children under 10 years: A rapid review
2020, Chiropractic and Manual Therapies