IMMEDIATE EFFECT OF SCAPULAR REPOSITIONING

WITH ACTIVE CERVICAL ROTATION IN ACUTE

SPASMODIC TORTICOLLIS
Niyati A. Desai, BPTh, MPTh, a Subhash M. Khatri, PhD, b and Apeksha B. Agarwal, MPTh a

ABSTRACT

Objectives: The aim of this preliminary study was to investigate the immediate effects on pain and pressure pain
threshold (PPT) of a scapular repositioning technique in patients with acute spasmodic torticollis.
Methods: A randomized, single blind pilot study was conducted. The subjects were 23 individuals (age 20-40 years)
with a clinical diagnosis of spasmodic torticollis. Visual analog scale pain score, cervical active ranges of motion, and
PPT were assessed before and after the intervention. The comparison group was treated with only conventional
physiotherapy (microwave diathermy, submaximal isometrics, and ergonomic advice). The intervention group was
given scapular repositioning with active cervical rotation technique, in addition to conventional physiotherapy
treatment.
Results: There were significant improvements in intensity of pain (P b .01), cervical rotation to the ipsilateral side
(P b .01), cervical side flexion to the contralateral side (P b .01), and PPT (P b .01) immediately after the treatment of
the scapular repositioning and conventional therapy compared with the conventional therapy alone.
Conclusion: The present pilot study demonstrated that scapular repositioning may have an immediate hypoalgesic
effect on individuals with spasmodic torticollis in terms of pain severity, PPT, and cervical range of motion. Therefore,
further controlled trials are warranted. (J Manipulative Physiol Ther 2013;36:412-417)
Key Indexing Terms: Hypesthesia; Scapula; Dyskinesia; Torticollis

pasmodic torticollis is a relatively common condition upper cervical segments. Diskogenic torticollis has a gradual

S characterized by a sudden onset of sharp pain with

limitation of movement. It typically occurs with
unusual movements or prolonged abnormal postures before
onset of pain. Pain localized to the middle or, more usually,
on one side of the neck, restriction of movement (especially
same side rotation and opposite side flexion), and abnormal
position of neck are common complaints in spasmodic
torticollis. 1-3
Torticollis can manifest in various ways, out of which
apophyseal and diskogenic are most common. Apophyseal
torticollis occurs commonly in children and young adults and
is associated with sudden movement. It generally involves
a
Clinical Physical Therapist, Pravara Institute of Medical
Sciences, Loni, Maharashtra State, 413 736 India.
b
Principal, College of Physiotherapy, Pravara Institute of
Medical Sciences, Loni, Maharashtra State, 413 736, India.
Submit requests for reprints to: Niyat A. Desai, BPTh, MPTh,
Clinical Physical Therapist, Bungalow no 4, Sanket society, Vyas
Falia, Palsana, Surat (Dist), Gujarat, India (e-mail: niyati.1432@
gmail.com).
Paper submitted August 28, 2012; in revised form March 3,
2013; accepted March 25, 2013.
0161-4754/$36.00
Copyright © 2013 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2013.05.020
onset and occurs commonly on waking after a long sleep in
an awkward posture. It is common in older age group and
usually involves lower cervical or upper thoracic segments. 2
Conservative management of torticollis in the form of
heat, electroanalgesic modalities, manual therapy, cervical
traction, motor control exercises, and postural retraining is
widely recommended. 2 Orthopedic manual therapy and
therapeutic exercises are intriguing treatment options for
physiotherapist while treating cervical pain.
Studies have already found the altered activity of trapezius,
serratus anterior muscles, and scapular dysfunction in neck
and shoulder pain. 4-6 Several studies have documented how
changes in alignment in shoulder region have the potential to
alter the biomechanics of the cervical spine leading to cervical
pain. 7-9 Impairment in scapular alignment may alter cervi-
coscapular muscle length leading to increased compressive
load and shear force on the cervical spine during active neck
movements. 8,10,11 Prolonged excessive and repetitive stress
to the cervical structures possibly lead to cumulative trauma
causing neck pain and limited neck range of motion. 12,13
To date, few studies with modification of shoulder
alignment were performed in the clinical field to reduce
compressive stress on the cervical spine. 9,12,13 The efficacy
of shoulder alignment modification in neck pain patients
has been investigated, 8,12-14 but there is lack of similar

412
Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 7
evidence for the relative benefit of scapular repositioning in
the treatment of spasmodic torticollis. Hence, the present
pilot study was performed to investigate if there were any
immediate effects of a scapular repositioning technique in
patients with spasmodic torticollis on pain and pressure
pain threshold (PPT) and to guide future studies.
METHODS
Research Design
A randomized, controlled, single blind pilot study was
conducted to evaluate changes in intensity of pain, active
cervical range of motion, and PPT immediately after the
application of scapular repositioning technique in addition
to conventional physiotherapy for ipsilateral active cervical
rotation in acute spasmodic torticollis. Ethical clearance for
the study was granted by Institutional Ethical Committee of
College of Physiotherapy, Pravara Institute of Medical
Sciences, Loni, Maharashtra State, India. All subjects
received verbal and written information about the study
and signed a consent form.
Subjects
Subjects were recruited through a formal request to the
orthopedic department of Pravara Institute of Medical
Sciences, Loni, Maharastra, India. Subjects were screened
to find out their suitability to participate in the study if they
met the selection criteria. The inclusion criteria included
sudden onset of neck pain within 12 hours, torticollis due to
pain, subjects who felt sudden neck pain and restricted
movement when they got up from sleep, and subjects who
belong to 20 to 40 years of age. The subject population
enrolled in this study was 26 subjects (17 males and 9 female).
Only subjects with unilateral torticollis pain and stiffness that
altered by scapular repositioning were included in the present
study to evaluate the actual effectiveness of scapular
repositioning. The exclusion criteria included specific
known cervical pathologies, history of spinal surgeries and
known case of spondyloarthropathies, and subjects with red
flags 15 for manual therapy interventions. Three subjects were
excluded from the study because they did not respond to
scapular repositioning. A flow chart indicating flow of
subjects through each stage of the study is shown in Figure 1.
Interventions
Subjects were randomly assigned to 2 groups using a
table of random numbers created by using online software
www.randomization.com.
The conventional treatment group received physiother-
apy treatment in form of microwave diathermy, submax-
imal isometrics, and ergonomic advice. The study group
received conventional treatment and an additional inter-
vention in the form of scapular repositioning. For scapular
Desai et al 413
Scapular Repositioning in Spasmodic Torticollis
repositioning, the subject's position was sitting without any
arm or back rest. The therapist, standing behind the subject,
grasped both the scapulae with the fingers contacting the
acromioclavicular joints anteriorly and the palm and thenar
eminence contacting the spines of both the scapulae
posteriorly (Fig 2). Both forearms were angled obliquely
toward the inferior angles of each scapula for additional
support on the medial border. In this manner, the
examiner's hands and forearms applied a moderate force
to the scapulae to encourage scapular posterior tilting and
external rotation (inferior angle and medial border moved
anteriorly toward thorax) and to approximate both the
scapulae to a mid position on the thorax. 16 The subject was
then asked to do the offending cervical rotation movement.
Re-evaluation of the pain was done after every set of 10
repetitions. Total 3 sets of the above were given with a 30-
second rest interval between each application.
Outcome Measures
The main outcome measures used for this study were (1)
visual analog scale (VAS), (2) PPT, and (3) cervical active
ranges of motion (AROM), which were obtained before and
immediately after the intervention.
Visual Analog Scale
Subjects were asked to rate their level of neck pain on a
VAS by placing a mark on a 10-cm horizontally positioned
scale with the extremes labeled “least possible pain” and
“worst possible pain.” Visual analog scale is sufficiently
reliable to be used to assess spasmodic pain. 17
Pressure Pain Threshold
A pressure algometer was used to measure PPT.
Algometer was kept at the erb's point with the subject in
a sitting position (Fig 3). A skin marker was used to
highlight the measurement spot where the measurement
was done. A 1-cm rubber probe was placed perpendicular
over the tender spot by the assessor, and the pressure
stimulus was applied. Application of pressure stimulus was
under the subject's control as subjects were given the
information regarding the application. The measurement
was taken 3 times with 20-second interval, and mean value
was taken for the statistical analysis.
Cervical Active Range of Motion
The cervical AROM such as ipsilateral rotation and
contralateral side flexion, which were the movements that
created maximum discomfort in this condition, were
measured using universal goniometer.
414 Desai et al
Scapular Repositioning in Spasmodic Torticollis
Fig 1. Flow diagram for the study. AROM, active ranges of motion.
Subject Blinding
An assessor blinded to group allocation performed
outcome assessments for both groups before and immedi-
ately after the intervention. Subjects were instructed not to
divulge their group allocation and the type of intervention
they had received with the assessor. Security of the blinding
system was evaluated to ensure integrity.
Statistical Analysis
Preliminary analysis was done between groups for
baseline characteristics of age, sex, and body mass index
(BMI). Preintervention and postintervention VAS, cervi-
cal AROM, and PPT data were obtained. Postintervention
values of the same measurement were expressed as
percent change from preintervention measurements. The
Journal of Manipulative and Physiological Therapeutics
September 2013
Student t test was used to examine the effect difference
within and between 2 groups. GraphPad InStat software
(Trial version 3.03) was used for analysis with the α
value set at .05.
RESULTS
All 23 subjects completed the study. The baseline
characteristics between the groups in regard to age, height,
weight, and BMI was comparable (Table 1). Immediately
following the intervention, significant improvement was
found in both the study group and conventional treatment
group in terms of VAS score, PPT, cervical side flexion,
and rotation (Fig 4). The mean difference in VAS score
between the control and study group was 2.53 cm (control,
Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 7
Fig 2. Scapular repositioning with active cervical rotation.
Fig 3. Assessment of PPT using pressure algometer.
2.54 cm; study, 5.07 cm). The mean difference in PPT
between both the groups was 2.63 kg (control, 0.86 kg;
study, 3.49 kg). The mean difference between the cervical
rotation ranges in both the groups (same side of pain) was
12.4° (control, 8.3°; study, 20.7°) and between the cervical
side flexion range in both the groups (opposite side of pain)
was 12.6° (control, 5.3°; study, 17.9°).
Pain VAS Score
There was a marked decrease in VAS scores posttreat-
ment in the study group (65.4%). In between groups, there
was significant difference in VAS scores postintervention
(P b .01).
Desai et al 415
Scapular Repositioning in Spasmodic Torticollis
Table 1. Demographic profile of both groups (n = 23)
Scapular repositioning
Conventional and conventional
treatment group treatment group
Parameters (mean ± SD) (mean ± SD) t P
Age (y) 26.45 ± 4.89 27.25 ± 5.66 0.359 .72
Height (cm) 161.09 ± 6.99 159.5 ± 5.87 0.593 .56
Weight (kg) 63.45 ± 9.78 59.58 ± 8.67 1.006 .32
BMI (kg/m2) 24.4 ± 3.66 23.37 ± 2.85 0.802 .43
BMI, body mass index.
Pressure Pain Threshold
Pressure pain threshold increased by 34.3% following
the intervention in the study group. Unpaired t test
showed highly significant result in PPT between the 2
groups (P b .01).
Active Cervical Ranges of Motion
There was an increase in cervical rotation to the same
side by 82.1% and cervical side flexion to the opposite side
by 77.9%. Unpaired t test showed highly significant result
in between the 2 groups (P b .01).
DISCUSSION
The present pilot study showed an immediate effect on
cervical AROM (cervical rotation to the same side and side
flexion to the opposite side), pain score, and PPT following
scapular repositioning technique in addition to conventional
physiotherapy in subjects with acute spasmodic torticollis.
It is hypothesized that the intervention may not change the
natural course of the condition, but it may minimize the
discomfort received by the patient during this period.
There was an immediate 65.4% reduction in VAS score
and 34.3% increase in PPT score after the application of
scapular repositioning for the study group, which suggests
that scapular repositioning has a hypoalgesic effect on
spasmodic torticollis. The plausible mechanism behind the
hypoalgesic effect of scapular repositioning may be that it
allows the sensitized structures to become off-loaded and thus
enhancing normal functioning of the surrounding joints and
tissues. It has been already documented that incorrect patterns
of muscle activation lead to overloading of the cervical
structures, which upset the muscle functioning required for
correct joint stabilization. 18 Behrsin and Maguire 19 and
Mottram 20 identified a link between cervical pain syndromes
and the impairment in the axioscapular muscles.
This is in accordance with Tamlyn Guest 21 who
performed a single case study and reported the scapular
repositioning with manual therapy as a treatment of cervical
headache. In the present study, we found 65.4% pain
reduction immediate to intervention similar to that study
with 66.7% reduction following fourth treatment. He had
416 Desai et al
Scapular Repositioning in Spasmodic Torticollis
Improvement in Study Group
100
Change in Percentage
90 82.1
80
70 65.4
60
50
40 32.4 34.3 32.1
30
20 7.8
10
0 neck movement in individuals with spas-
VAS PPT C.Rot.
Outcome Measures
VAS: Visual Analogue Scale; PPT: Pressure Pain Threshold; C.Rot.: Cervical Rotation (Active);
C.SF: Cervical Side Flexion (Active)
Fig 4. Comparison of group outcomes: pain, PPT, and cervical
AROM. C.Rot., cervical rotation (active); C.SF, cervical side
flexion (active).
acknowledged the relationship of the shoulder girdle and
cervical region in scapular repositioning, which has been
introduced as a treatment option in spasmodic wryneck.
The present study showed an immediate effect on 82.1%
improvement in active cervical rotation to the same side and
77.9% improvement in side flexion to the opposite side.
This is in agreement with the findings of Tamlyn Guest 21
followed by scapular repositioning. The possible explana-
tion can be the reduction in pain and the change in length of
the cervicoscapular muscles followed by altered load on
sensitized structures. Furthermore, placebo or psychologi-
cal effects of the technique may minimize muscle guarding
directly or indirectly resulting in decrease in pain and
increase in range of motion.
LIMITATIONS
This study only measured the immediate effect of
scapular repositioning and did not measure long-term
outcomes. It is not clear if scapular repositioning alone
would have produced the same results as it was included in
addition to conventional physiotherapy treatment. It is
possible that there were additive effects. Future studies
should consider using a scapular repositioning treatment
alone as a treatment group. In addition to that, the present
study has insufficient sample sizes to provide definitive
conclusions, and the follow-up was limited considering the
natural prognosis of the condition. These issues should be
taken into consideration with larger clinical trials.
CONCLUSION
The present pilot study demonstrated that scapular
repositioning in addition to conventional physiotherapy
may have immediate hypoalgesic effect on individuals with
Journal of Manipulative and Physiological Therapeutics
September 2013
acute spasmodic torticollis as measured by pain score, PPT,
and cervical AROM.
77.9
Practical Applications
Control
22.6
Study • The present study showed immediate effects
of scapular repositioning along with active
C.SF
modic torticollis.
• Results have shown improvement in terms of
pain score, PPT, and cervical AROM.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
No funding sources or conflicts of interest were reported
for this study.
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