Upper Cervical Therapy
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Chronic Torticollis in Children

Our assumption is that the upper cervical asymmetry is a major contributing cause of chronic torticollis of the child: If the digastric muscle rearrangement was made, the torticollis is functionally eliminated. The physiological situation remains precarious, because the upper cervcical muscles hardly are enabled to maintain the symmetric muscle conduction and the old asymmetric state may - especially at the beginning of the therapy process - reappear easily. Therefore, it is important that parents learn to distinguish the symmetric from the asymmetric digastric muscle conduction and to establish the symmetric state.

We treated a girl (* 1999) on 1/30/09, who had a chronic, painful torticollis. An MRI had been done before and the following diagnostics had been established radiologically :

Chronically recurrent cervical syndrome with muscular deficit, constant hypermobility and blocking of C0/C1 on the right. Tendency to positional weakness (2 years ago there was a similar problem - X-raying then normal.). MRI Cervical Spine 28/11/08: stretching position with flat paradoxical kyphosis. In the atlantoaxial joint, rotation of the head to the left about 20 ° to 25 °, apparently deliberately in an effort to keep her head straight, whilst the lower cervical spine  is twisted to the right up to C2 (without malformation or destruction ). Infections and other diseases are not known. A lightweight lumbar pain since about 1 week is also reported.

The history of treatment recorded the following:

Two years ago, an accident with a fall down the hill -> torticollis -> X-ray of the cervical spine, after 2 weeks well again. Now, since the beginning of November 08, after horse riding, severe symptoms in the cervical spine - rotation significantly restricted to the right. In treatment with multiple trials chirotherapy, physiotherapy, analgesics.

The cervical syndrome had probably begun two years ago due to the above mentioned accident ("fall down the mountain") : There was a sprain / strain of the left posterior digastric muscle, thereby the latter passed more medially over the posterior arch of the atlas and, in the wake, caused a gradually increasing oblique position of the atlas against the axis. The lower cervical spine and ultimately increasing weakening / atrophy of the upper cervical muscles took place, which could no longer compensate a renewed head trauma ("after horse riding, severe symptoms").

Above: Atlas, below: Axis. on the left side (in the image on the right),the atlas is skewed against the Axis dorsally. In the atlantoaxial joint, a rotation of the head towards the left of approximately 20 ° prevails. This suggests that the strained left posterior digastric muscle continuously tears the left atlas transverse process backwards (dorsally).

The rotation values ​​reveal the course of therapy: At the beginning, the horizontal rotation is very limited  - especially to the right -, which is being dissolved and after massage symmetrical and extended head rotations are enabled. The pains, with which the child had come, did instantly fade away, which was confirmed by the written spontaneous utterance.

Top: angular measurements before and after upper cervical therapy: First column: horizontal rotation (L, R), second column: lateral flexion (SL, SR), third column: flexion / extension (B / S). First line: before digastric muscle rearrangement, second line: after digastric muscle rearrangement, third line: after vibratory massage. Below: Written spontaneous expression after treatment: "My throat does not hurt anymore."
Left: angular measurements in the second session on 03.09.09: First line: before massage, second line: after massage. Right: the child's head with compass goniometer, in which it turns upright almost at a right angle.
  • After treatment, rotation increases by 31.5%, rotation to the left only by 19%, however, rotation to the right with 34%. The L / R ratio is 1.45 before treatment (ie, heavy restriction of horizontal rotation to the right), after therapy 1.00 (absolute symmetrization of the same).
  • After therapy, lateral flexion increases by 16% totally, lateral flexion to the left by 9%, to the right by 20%. The SL / SR ratio is 0.71 before treatment (ie, heavy restriction of lateral flexion), after therapy 0.63 (reduction of lateral flexion asymmetry).
  • After therapy, flexion increases by 43%, extension by 23%.

Across all three parameters, there is a rotational angle extension of 27%. The rotational head movements developed from a one-sided rotation limitation towards absolute symmetry, the lateral flexion improves marginally. The development of the rotation angle values ​​clearly indicates the existing, deteriorated upper cervical asymmetry, which is eliminated in the course of digastric muscle rearrangement.

The head rotations two months later, on 09/03/09, are greatly enhanced: The rotation measurements showed an increase of the head rotations of 45% in total compared to the initial state, the horizontal rotation by 42.5%, lateral extension by 43.5%, and flexion / extension by 48%. The strongly increased rotation angles are striking even for a child and evidence that upper cervical muscles had been relatively atrophied and that, after some time, the full, painless range of motion was reached. Catamnestically, the following was found on 03/09/09:

No more complaints. When walking a little asymmetrical gait. Can do sports again.

Because of hypermobility, there is a risk that the left digastric muscle returns behind the left atlas extension again. But it is fortunately very easy to restore the physiologically favorable state. It is assumed that the upper cervical muscles gradually become stronger, and that, at a later stage, a spontaneous rearrangement of the digastric will hardly succeed.

Due to the spontaneous and immediate freedom of pain - the child had come with excruciating pains -, the symmetry and extension of all three rotational parameters, and the greatly enhanced mobility after two months, the rearrangement of the left posterior digastric muscle is to be considered as the causative treatment for the symptoms of this child. A generalization to other children with similar symptoms may be considered and should be checked. From upper-cervical therapeutic standpoint, the so-called atlanto-axial rotatory dislocation (see article: 'Der Schiefhals des Kindes, eine Bagatelle?'), is caused by upper cervical asymmetry and is to be treated by digastric muscle rearrangement. The 11-year old boy in the publication, after the operation of a lymph node in laryngeal area, suffered from anesthesia-related, worsened cervical asymmetry. The upper cervical muscles were relaxed during the general anesthesia, the head was passively moved against the lower body during the operation and the left posterior digastric muscle from thereon exerted a greater strain to the upper cervicals, which caused the extremely bended position of the head to the right with simultaneous rotation to the left (Cock-robin position), which corresponds to a whiplash injury. After surgery, in the area of the head and neck, one should regularly take heed of the symmetric conduction of the posterior digastric muscle.