Results

The factors that were reported by the patients to improve, or exacerbate, or have no effect on their torticollis are presented in the table, together with the percentage of the patients who noted each effect (better, unchanged, worse). The association between the direction or form of head deviation and the reported effect (better, unchanged, worse) was not significant for any of the factors considered.

Discussion

The present results are in general agreement with previous studies.4 10 11 In the present larger and more homogenous sample of patients with adult onset idiopathic torticollis, there is a greater consensus on the factors that exacerbate torticollis. Stress and self consciousness were reported as aggravating factors by more than 80% of the sample, whereas walking, fatigue, and carrying objects were noted as exacerbators by over 70% of the patients. For more than 40% of the sample, torticollis improved in the supine position, by relaxation, sleep, and lying on the side. However, the last four factors also worsened the head deviation in 16% to 25% of the patients. Use of a geste antagoniste to maintain the head in the body midline, was reported by 64 (88.9%) of the patients, which was still effective in correcting head position in 47%.

The effect of three factors on torticollis are of special interest: different phases of the menstrual cycle, alcohol, and morning relief. Menstrual phase related worsening of their disorder has been noted in female patients with Parkinson's disease,14 and dominantly inherited myoclonic dystonia.15 The greatest proportion of the premenopausal women in this sample reported no change in their torticollis during the different phases of the menstrual cycle, although worsening of torticollis in the premenstrual and menstrual phases of the cycle was respectively noted by 37.5% and 25%.

The present results on the effect of alcohol on torticollis are not consistent with the findings of Biary and Koller16 who reported improvement in head deviation in five of seven patients with torticollis (71%) after an intravenous injection of ethanol. In the present sample, alcohol was reported as an ameliorating factor only by 17.6%. In fact, alcohol aggravated the head deviation in 29.4% of the patients, and had no particular effect for most (52.9%). Differences in methodology may be partly responsible for the divergent results of the two studies.

A class of dystonia with marked diurnal variation characterised by freedom from dystonic movements and postures in the morning and worsening of dystonia in the afternoon and evening has been described by Segawa et al. 17 Improvement or relief from torticollis on awakening in the mornings was experienced by 31.5% of the present sample of patients with adult onset idiopathic torticollis. The relation of this to the subclass of dystonia with diurnal variation of Segawa et al 17 which is often coupled with features of parkinsonism and responsiveness to levodopa, bromocritpine, or anticholinergic drugs18 remains unclear.

The sensitivity of torticollis to social and emotional factors and motor and postural influences has in the past been regarded as evidence for the psychogenic origin of the disorder. We have previously provided evidence19-21 against a psychogenic aetiology in torticollis. Instead, we have suggested an alternative formulation that views the depression encountered in a proportion of the patients as a reaction to the disability and social embarrassment associated with the postural disfigurement.22-25 Similarly, with regard to factors that exacerbate or ameliorate torticollis, although the precise mechanisms are unknown, such influences are now subject to alternative and more plausible interpretations in biochemical or physiological terms. The exacerbation of torticollis in affect or stress inducing situations can be explained in terms of a possible link between extrapyramidal and affective disorders through overlapping changes in CNS catecholamine metabolism.26 Similarly, the worsening of torticollis with peripheral motor activity (walking, running, writing), or its improvement with changes in body posture (supine position), or with the geste antagoniste is best viewed in terms of alterations of peripheral proprioceptive feedback or central corollary discharge provoked by the motor output or command. Although feasible, these alternative interpretations are also speculative and require direct examination through further investigation.