J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.485 on 1 June 1978. Downloaded from

Journal ofNeurology, Neurosurgery, andPsychiatry, 1978, 41, 485-492

Spasmodic : a combined clinical study

W. B. MATTHEWS, PATRICK BEASLEY', WILLIAM PARRY-JONES, AND G. GARLAND From the University Department of Clinical , Churchill Hospital, and the Department of Psychiatry, The Warneford Hospital, Oxford

SUM M AR Y The prognosis in 30 patients with spasmodic torticollis proved to be unexpectedly bad, only one patient making a full and sustained recovery. Investigation did not confirm previously reported reflex influences on the degree of spasm. Detailed otological investigation did not suggest that spasmodic torticollis originates in vestibular dysfunction. Psychological assessment of the patients showed no deviation from normal in premorbid personality but confirmed the severe adverse effects of the condition.

Spasmodic torticollis remains an essentially intrac- Methods table and disabling condition of unknown cause. Opinion is still divided on whether it is an organic A detailed medical history and examination were Protected by copyright. or psychogenic disease or whether two forms exist recorded. Investigations carried out on a propor- (Meares, 1971a). In this study particular attention tion of patients included radiographs of the skull has been paid to this aspect-to the natural history and cervical spine, and tests of thyroid function and relation to other forms of neurological dis- (protein-bound iodine (PBI) in 1971). In 1976 all order, the relevance of vestibular disease (Svien patients seen in the original survey were again and Cody, 1969), the relation to thyrotoxicosis followed up either by interview or postal enquiry. (Gilbert, 1971), and the effect of movement and The EMG was recorded either on an ink-writing other stimuli on the degree of spasm (Podivinsky, EEG machine from surface electrodes over the 1968). sternomastoid, trapezius, and deep cervical muscles, or from the sternomastoid muscles using Clinical material a two-channel Medelec electromyograph. The effects of eye closure, lifting a weight with either In 1971 an attempt was made to trace all patients hand, cutaneous stimulation on the neck and face, diagnosed as having spasmodic torticollis in the and of the patient's own "antagonistic gesture"

index of the Radcliffe Infirmary since 1954. Of were observed. http://jnnp.bmj.com/ these 37 patients seven could not be traced and Routine otological examination was carried out, two are known to have died. Eight patients either and, in addition, electronystagmography (ENG) did not wish to be seen or their general prac- was recorded from electrodes at the outer canthus titioners advised against further interest in their of each eye with a central reference electrode on complaint. Of these, four were known still to have the forehead. Spontaneous nystagmus was sought torticollis in 1971 and four claimed to have re- with the eyes open and closed, and with gaze covered. Data from these eight patients have not directed ahead and to either side. The effect of

been included in the survey, largely because of the passive neck torsion with the patient seated was on September 28, 2021 by guest. difficulty in assessing the real extent of recovery. also examined. Postural nystagmus was sought in Detailed study was limited to the 20 patients traced the supine, prone, and both lateral positions. from the diagnostic index and personally Caloric labyrinthine stimulation, either single examined, and to 10 further patients seen in temperature cold stimulation or bithermal stimu- clinical practice between 1971 and 1973. lation was carried out as follows: 1. left ear r at30°C 'Present address: Royal Devon and Exeter Hospital, Exeter. 2. right ear f t30 Address for reprint requests: Professor W. B. Matthews, University of Oxford, Department of Clinical Neurology, The Churchill Hospital, 3. left ear } at 440C Headington, Oxford OX3, 7LJ, England. 4. right ear f Accepted 26 January 1978 with the head raised 300 from the horizontal and 485 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.485 on 1 June 1978. Downloaded from

486 W. B. Matthews, Patrick Beasley, William Parry-Jones, and G. Garland the eyes closed. The number of beats of nystagmus There was a marked preponderance in the fourth in the period 60-90 seconds after the beginning of and fifth decades. In 12 patients the torticollis stimulation was recorded and counted, and used turned the chin to the right and in 15 to the left. in the calculation of preponderance (Hinchcliffe, One patient had retrocollis, and in two patients 1968). Labyrinthine preponderance (LP) was cal- who had sustained more than one episode the culated according to Jongkees' formula (Jongkees direction of turn had altered. and Philipszoon, 1963): In no patient was a history of epidemic encepha- litis obtained, and there was no evidence that LP= (1+3)-(2+4) X 100% 1+2±3+4 torticollis was drug-induced. No patient gave a For single temperature caloric tests the difference family history of torticollis or of any form of between the two sides was expressed as a per- organic nervous disease other than , with centage of the total response of the two sides. the exception of one patient who had a family Directional preponderance of nystagmus (DP) history of essential . was calculated from Jongkees' formula: In two of the 25 patients x-rayed, a congenital (1 +4)-(2+3) X anomaly of the cervical spine was seen; in one, DP=D= 1+2+3+4 100% spina bifida occulta of C6 and 7 vertebrae and in Values of less than 30% are not considered as the other, fusion of the bodies of C5 and 6 verte- significant deviations from normal. brae. Significant asymmetry of the skull was not Psychological and psychiatric investigation was detected in any of the 10 patients in whom satis- particularly directed towards the assessment, as far factory radiographs could be obtained. Thyroid as possible, of the premorbid state, the possible function (PBI) was normal in the nine patients relevance of stress to the onset of torticollis, and in whom this was examined. the psychological and social effects of the chronic Additional neurological signs were present in Protected by copyright. disorder. Particular attention was paid to the six patients. Two patients had dystonic movements possibility of detecting a psychogenic group with of one upper limb, probably developing at the a better prognosis than that of the presumed same time as the torticollis but without subsequent organic form of torticollis. Investigations com- progression. One patient had writer's cramp. One prised a structured clinical interview with the patient developed widespread torsion 24 patient and, whenever possible, with the spouse or years after the initial episode of torticollis. One closest other person. Special attention was focused patient had slight signs of Parkinson's disease when on social and marital adjustment, the psychiatric first seen with torticollis. One patient had both history, and the subject's life situation at the time hereditary and a mild infantile of the onset of the disorder. Specific investigations hemiparesis. In the remaining 24 patients torti- included the Eysenck Personality Inventory, form collis was the only neurological abnormality. No A, the Leyton Obsessional Inventory, and the association with any systemic disease was Hostility and Direction of Hostility questionnaire recognised. (HDHQ). Married subjects and their spouses com- OUTCOME

pleted the Ryle Marital Patterns Test and a simple http://jnnp.bmj.com/ marital adjustment rating scale. At the time of the survey in 1971-73 only one patient was entirely free of symptoms relevant to Results spasmodic torticollis. A further four patients were classified as having made a substantial recovery Of the 30 patients investigated, nine were male in that no torticollis was present, but these patients and 21 female. The age of onset is seen in Table 1. were still aware of some abnormality, and found that, under even mild stress, pain and tension would develop in the neck muscles in a manner Table 1 Age of onset recognisably related to their original symptoms. on September 28, 2021 by guest. remis- Age ofonset Number ofpatients Three patients gave a history of complete (yr) sion followed by relapse, although, as they were the period, it 0-10 0 not seen during symptom-free 11-20 3 is not known whether remission was indeed com- 21-30 3 plete. The details of the eight patients in whom 31-40 8 41-50 9 substantial or complete remission had occurred at 51-60 6 some stage are shown in Table 2. In general, re- 61-70 1 mission occurred relatively soon after the onset Total 30 but relapse might occur after many years of free- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.485 on 1 June 1978. Downloaded from

Spasmodic torticollis: a combined clinical study 487 Table 2 Cases with remission

Case Sex Age at Age at Duration of Age at Duration of Results Comments initial onset first attack relapse relapse survey (yr) (yr) (yr) (yr) 1971-73 1976 (yr) I F 56 41 4/12 - - Rc Rc 2 M 46 35 2 49 2/12 SRc SRc Relapse after initial survey with remission 3 F 26 18 1 - - SRc SRc 4 F 52 35 1 37 3/12 SRc SRc Relapse after initial survey with remission 54 4/12 5 F 57 52 1 61 2- SRc P Relapse after initial survey without remission 6 M 47 15 2 38 14+ P P Dystonia began with relapse 7 F 45 39 4 45 5 + P P Disabled after surgery 8 M 64 39 1 53 13 + P P Writer's cramp Rc recovery; SRc = substantial recovery; P = persistent torticollis dom. The caution exercised in distinguishing pain have been thought to be of prognostic signifi- "substantial" from "complete" recovery in the cance (Tibbetts, 1971; Mears, 1971 a). Of those original survey was justified by the further relapse who experienced a partial or complete remission of three of these four patients between 1971 and the onset was judged, in retrospect, to have been 1976, one being left with persistent torticollis. jerking in one, turning in six, and with a fixed At the time of the initial survey 22 patients had posture in one. In those with persistent torticollis had persistent torticollis from between a few the onset was jerking in six, turning in 14, and months to 40 years (Table 3). By 1976 three with a fixed posture in two. Pain was remembered patients had died of cardiac disease. Torticollis had as being present at the onset in 10 of the 22 with Protected by copyright. been present to the end in two of these patients persistent torticollis, and four of the eight in whom and probably in the third. No necropsy was ob- remission had occurred. tained. In 11 patients the torticollis had not changed but in six there had been significant im- ELECTROMYOGRAPHY provement, although in one of these Parkinson's This was carried out in 16 patients. The results disease had become increasingly disabling. No confirmed the widespread contraction of the neck patient had recovered. muscles even when the posture of the head sug- The type of movement present at the onset, gested relatively isolated corltraction of one sterno- whether jerking or turning, and the presence of mastoid muscle. The antagonistic gesture habitually used by each patient to restrain the torticollis was observed to inhibit muscular con- Table 3 Cases with persistent torticollis at the time of traction in five (Fig. I) and to have no effect in tile initial survey three, but in seven patients, under the condition of the test, spasm was enhanced (Fig. 2). Eye closure Case Sex Age at Age at 1976 Comments had no effect on the spasm in 13 patients, but suirvey onset Result http://jnnp.bmj.com/ (yr) (yr) regularly induced inhibition in one patient (Fig. 3). 9 F 48 28 Unchanged In another patient, however, eye opening was 10 M 48 47 Unchanged regularly followed by reduction of spasm. 11 F 67 52 Unchanged Dystonia of one arm on 12 M 57 52 Died 1974 The effect of lifting a weight with the hand 13 F 64 51 Died 1974 the same or opposite side to the direction of head 14 F 66 49 Improved turning was recorded, but no consistent results 15 M 46 43 Unchanged Dystonia of one arm 16 M 59 36 Unchanged were obtained. In six patients lifting a weight with 17 F 64 24 Unchanged

either hand increased the EMG activity recorded on September 28, 2021 by guest. 18 F 42 37 Improved Parkinson's disease 19 F 45 43 Unchanged Infantile hemiparesis from the neck (Fig. 4a, b), and in three no effect Essential tremor was observed. In three, using the ipsilateral hand 20 F 63 61 Improved 21 F 31 29 Improved increased spasm while use of the contralateral 22 F 44 43 Unchanged hand resulted in inhibition or had no effect, but in 23 M 49 48 Unchanged two these responses were reversed. In 24 F 37 36 Unchanged patients 25 F 37 35 Unchanged one patient using either hand inhibited spasm of 26 F 44 41 Improved the neck muscles (Fig. 5a, b). Light touch with 27 F 53 52 Improved 28 M 34 16 Unchanged cotton wool on the side of the neck and face had 29 F 34 31 Improved no recordable effect on spasm in the 10 patients in 30 F 76 65 Died 1974 whom this was examined. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.485 on 1 June 1978. Downloaded from

488 W. B. Matthews, Patrick Beasley, William Parry-Jones, and G. Garland

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: L .. , ::-a.. iJ. f'i:s . il JA ti i.Lru.ikrrkmwuuwuA.wqritJ i'irikLdL k.i. 1- ...? i""I'lillob" aiih liwgb "i-: .11 - -,.VIm "M. TiT01I F."T'F'T.-.-qm IVIIp 'IF r ?Mprwrjt"vmjplmw" Tript qlaw-Ir"71, W.' i f fi.TsNIFF' 4n f X Z r7 -E a s + Fig. 1 Surface recordings from right (below)tsi and sternomastoid muscles in case 22 with torticollis to the left. Arrows indicate beginning and ending of the patient's habitual antagonistic gesture of placing the hand on left side of chin.

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A is -. i 1 ,.1 -'V.0. t dv. .? '' i V%l M I,T:'v.wI "P Op-&..WI 4. vj. by#'*."

Fig. 2 Surface recordings from right sternomastoid (above), deep cervical muscles and trapezius (below) in case 6 with torticollis to left. Arrows indicate beginning and ending of antagonistic gesture. Protected by copyright. 4 ls 4,

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Fig. 3 Electrode placements as in Fig. 2 in case 13 showing the effect of eye closure and subsequent opening indicated by arrows. http://jnnp.bmj.com/ on September 28, 2021 by guest. Is

Fig. 4 Surface recordings from right (above) and left sternomastoids in case 27 showing enhancement of spasm after lifting a weight with the right (a) and left (b) hands. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.485 on 1 June 1978. Downloaded from

Spasmodic torticollis: a combined clinical study 489

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Fig. 5 Electrode placements as in Fig. I in case 22 showing inhibitory effect of lifting a weight with right (a) or left (b) hand. Protected by copyright. OTOLOGICAL EXAMINATION (PB) PSYCHOLOGICAL AND PSYCHIATRIC EXAMINATION Sixteen patients were examined, but not all (WLP-J AND GG) techniques were applied in every case (case num- Twenty-nine patients were examined, one being bers refer to Tables 2 and 3). excluded because of severe deafness due to oto- Case 3 had inactive right chronic suppurative sclerosis (this patient was not examined otologi- otitis media. Pure tone audiometry was normal in cally). Two patients had received psychiatric cases 28, 15, 7, and 10. There was symmetrical treatment at some time before the onset of presbyacusis in case 8 and 11, and case 19 had a torticollis, in both cases for depression. bilateral sensorineural deafness around 4 kHz with It was originally hoped to be able to compare an audiographic curve characteristic of minor a group of recovered patients with those with per- acoustic trauma. sistent torticollis for such features as neuroticism, Spontaneous nystagmus with eyes closed was obsessional manifestations, intropunitive hostility, recorded in five of the 15 patients in whom it was and marital disharmony, considered to be impor- sought (cases 4, 6, 7, 8, and 12). In each case tant factors in other studies (Meares, 1971a; was to nystagmus the right. Neck torsion nystag- Tibbetts, 1971) but the number of those in sub- http://jnnp.bmj.com/ mus was not elicited in any patient and positional stantial remission was small at the time of the nystagmus only in case 15 in whom it occurred to original surveys, and any comparison based on the left in the supine and left lateral positions. this grouping has since been invalidated by the Six patients were examined by single tempera- subsequent relapse of three of the patients ture caloric stimulation and nine by bithermal in this category. Evidence of neuroticism, ob- caloric tests. Assuming a level of significance of sessional symptoms and traits, and intropunitive 30%, only case 8 showed labyrinthine preponder- hostility in the group as a whole was, therefore,

ance at 44%, the left labyrinth being the pre- assessed by comparing the group with the normal on September 28, 2021 by guest. ponderant and the direction of turning being to population. the left. In the remaining 15 cases showing minor Group mean scores were as follows: EPI- degrees of labyrinthine preponderance the direc- N,9.93; Leyton Obsessional Inventory Symptom tion of torticollis was away from the preponderant 12.03 and Trait 7.20; HDHQ Hostility 10.60 and labyrinth in 11 cases and toward it in three. In no Direction of Hostility -0.5. Separate analyses patient was significant directional preponderance were done for males and females in the group for of nystagmus found, but in nine cases showing Leyton and HDHQ since these have separate minor degrees of such preponderance it was op- norms for males and females. There were no posite in direction to the torticollis in eight and in significant differences between this group and the same direction in one. the normal population. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.485 on 1 June 1978. Downloaded from

490 W. B. Matthews, Patrick Beasley, William Parry-Jones, and G. Garland Sixteen of the 29 patients described factors that supply, varying from section of one sternomastoid could have influenced the onset of torticollis or muscle to extensive anterior nerve root section. important environmental events coincident with Three patients had been treated by stereotactic the onset. These included, for example, exacerba- thalamotomy, but in each case treatment was tion of severe marital discord, stress from a change limited to making a lesion on the side contralateral to night shift work, an abortion, hysterectomy, to the direction of turn. The only patient who and a road traffic accident in which the neck was was regarded as being completely cured had re- possibly injured. The assessment of the significance ceived treatment by hypnosis and had recovered of such reported events often many years later is from severe torticollis within three months. One clearly difficult. other patient, as far as could be ascertained, had Of the 21 married subjects, 13 were women and been treated in this way with only limited and eight men. Marital adjustment measured on a temporary improvement. five-point scale indicated severe or moderately At the time of the second review some patients severe marital discord in nine subjects, a major had also received more recently developed forms factor being unsatisfactory sexual adjustment. of treatment including amantadine, levodopa, halo- All but six patients claimed adverse social effects peridol, and feedback from the neck muscles, but from torticollis at the time of examination. Four- the improvement noted in six patients was con- teen thought that, at the worst period in the course sidered to be spontaneous and not related to of their disorder, the disability had been severe treatment. and 11 moderately severe. Fear of ridicule and reluctance to leave the home were almost uni- Discussion versal. Two men and one woman were too dis- abled to work. Few neurologists believe spasmodic torticollis to Protected by copyright. be hysterical, and yet the evidence for organic TREATMENT disease remains problematical. Claims that dys- At the time of the original survey these patients tonic movements of the neck can be distinguished had been subjected to a great variety of different from hysterical spasm have been based on the treatments. A common pattern was that of referral widespread nature of the contractions, including by the general practitioner to a psychiatrist under antagonistic muscles (Herz and Glaser, 1949; Herz the impression that spasmodic torticollis was an and Hoefer, 1949) and the combination of sustained hysterical disorder. Eight patients had received and rhythmic activity. It is undeniable that the psychiatric inpatient treatment and a further six movement of spasmodic torticollis differs in many as outpatients. Two patients had been treated with respects from the normal action of turning the courses of electroconvulsive therapy. Another head, but it is also possible voluntarily to effect common sequence was referral from the general this movement in an abnormal manner accom- practitioner to an orthopaedic surgeon, perhaps panied by widespread fluctuating muscular con- because of some confusion with congenital torti- tractions. The inhibitory and enhancing effects of collis or because it was thought that there might different forms of movement and sensory stimula- be some abnormality of the cervical spine. Such tion reported by Podivinsky (1968) are of great http://jnnp.bmj.com/ referral commonly led to manipulation of the interest but are inconsistent. For example, we were neck, sometimes under anaesthesia, or immobilisa- unable to confirm his observations that slight tion in an elaborate plaster. Reference direct to touch on the side of the neck towards which the a neurologist did not lead to more successful chin is turned reduces the spasm while contra- treatment, varied forms of physiotherapy being the lateral stimulation causes enhancement. He also most popular. This ranged from local heat and reported that supporting a weight in the ipsilateral exercises directed against the direction of turn to hand aggravated the spasm in 87% of patients immobilisation in bed with sandbags and continu- while using the contralateral hand reduced spasm on September 28, 2021 by guest. ous traction. Injection of local anaesthetic into in 78%. We could find no consistent effect. The the motor point of the more accessible cervical antagonistic gesture, in which sometimes a very muscles was also practised. Drug therapy included light touch prevents the movement, has been inter- agents, phenothiazine derivatives, preted both as an indication of reflex inhibition antidepressants, barbiturates, and diazepam. This and of hysteria. In our test conditions spasm was last drug was frequently reported as affording more often enhanced than inhibited. some slight relief but was certainly not curative. In the only thorough neuropathological exam- Five patients had been treated by peripheral sur- ination of a patient with isolated spasmodic torti- gery to the muscles of the neck or their nerve collis, adequately investigated in life, no lesion was J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.485 on 1 June 1978. Downloaded from

Spasmodic torticollis: a combined clinical study 491 found (Tarlov, 1970). Attempts to detect a dis- the type of movement also afforded evidence of order of neurotransmitter mechanisms have also causation and prognosis. It is not easy to equate so far proved negative (Curzon, 1973). There is a their descriptive categories but both regarded strong association with other forms of involuntary sustained tonic spasm as evidence of a bad progno- movement, essential tremor (Couch, 1975), writer's sis. Tibbetts thought that those with mild spasm cramp (Meares, 1971c), and or with irregular movements were more likely to (Marsden and Harrison, 1974), all represented in recover while Meares emphasised the relatively the present series, but the anatomical basis of good prognosis where the onset had been "jerking" these conditions is also unknown. Patterson and or painful. Our original intention of comparing a Little (1943) reported motor abnormalities in no recovered with a persistent group was thwarted by less than 33% of their patients including 4% with the remarkably low rate of full recovery. In the . It is not easy to determine from whole group no evidence of pre-existing person- their account how much weight should be attached ality disorder or neuroticism beyond that of the to the 7% of patients who had a tremor of the normal population was discovered. Clearly this hands and the 6% with masked facies. Neverthe- method would not be capable of recognising one less the association with disorders of function or two patients in whom psychological factors either certainly or probably involving the basal were indeed important or even responsible for the ganglia is impressive. torticollis but our findings are further strong evi- The nature of any possible underlying structural dence against an hysterical cause in most patients. disease of the brain naturally remains obscure. It In those with relatively good prognosis, in that is now extremely improbable that substantial or complete remission occurred at some lethargica plays any part. Hassler and Dieckmann stage of the disease, there was no important (1970) suggested that brain damage in infancy difference in the mode of onset remembered by Protected by copyright. might be an important factor, basing this conten- the patient compared with the group with per- tion on asymmetry of the lateral ventricals seen on sistent torticollis. The exceedingly adverse effect pneumoencephalography, sometimes reflected in of spasmodic torticollis on the life and happiness the shape of the skull. One of our patients had a of many of the patients was, however, amply mild right infantile hemiparesis with torticollis to demonstrated. the right. No skull asymmetry was found in her The association between the onset of torticollis or in the other nine patients in whom satisfactory and some form of stress has been noted in other films could be obtained. series (Paterson, 1945; Meares, 1971a). It is Because of the close relationship of the ves- scarcely possible to exclude the natural tendency tibular system to posture of the head it has been of the patients to associate the onset of unpleasant natural to suspect that disturbance of this system symptoms with physical or mental trauma. The might be responsible for torticollis, but there has possibility that stress might distort the pattern of been no systematic investigation. Detailed neuro- neurotransmitter regulation in the central nervous otological examination in our patients produced system is attractive as a link between mutually "organic" and "psychogenic" disease, no evidence in support of this contention. exclusive http://jnnp.bmj.com/ The approach from the psychological aspect but remains unsubstantiated. Certainly the lack of presents similar difficulties. Paterson (1945) re- evidence of premorbid personality disturbance is ported successful results from psychotherapy, but most unlike what would be expected in a conven- those patients whom she regarded as hysterical tional psychogenic disorder. were not among those who recovered. Herz and The prognosis in our patients was unexpectedly Glaser (1949) considered that 50% of their poor, only one being thought to have made a com- patients had an abnormal personality pattern but plete and lasting recovery. The tendency to relapse quantitative assessment had not at that time been persisted even in those in whom spasm was re- on September 28, 2021 by guest. developed. This problem also arose with Tibbetts' garded as minimal at the time of the initial follow- (1971) recognition of an organic and a psycho- up examination. In general, our findings confirmed genic group. Cockburn (1971) using the Maudsley those of Meares (1971 b) who recognised three personality index and other indications of pre- stages: progression for five years, but with possi- morbid stability found no difference from control bility of remission; a static stage for the next five subjects. Meares (1971a) also distinguished two years; and a final stage during which slight im- categories. Those with greater evidence of pre- provement might occur. This pattern is, of course, existing neuroticism and psychosexual problems only an approximation to which many patients do had a much improved chance of recovery. Both not conform and, in particular, relapse may occur Tibbetts (1971) and Meares (1971a) thought that many years after the onset. Our study was not

B J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.485 on 1 June 1978. Downloaded from

492 W. B. Matthews, Patrick Beasley, William Parry-Jones, and G. Garland specifically concerned with treatment. In agree- torticollis. I: physiologic analysis of involuntary ment with Shaw et al. (1972), we did not find that motor activity. Archives of Neurology and Psy- medical treatment influenced symptoms signifi- chiatry (Chicago), 61, 129-136. Hinchcliffe, R. (1968). Nystagmus rate as an index of cantly, and surgery, which did not in our series caloric test response. Acta Otolaryngologica (Stock- include bilateral thalamotomy, was either ineffec- holm), 65, 311-315. tive or palliative. We found no indication of any Jongkees, L. B. W., and Philipszoon, A. J. (1963). The form of curative treatment and the outcome caloric test in Menieres disease. Acta Otolaryngo- appears to have changed little since Gowers (1893) logica Scandinavica, Supplement 92, 168-170. stated that "the prognosis must be grave in every Marsden, C. D., and Harrison, M. J. G. (1974). developed case." Idiopathic torsion dystonia (dystonia musculorum deformans). A review of forty-two patients. Brain, of 97, 793-810. PB would like to acknowledge the assistance Meares, R. (1971a). Features which distinguish groups Mrs M. MacDonald in performing electronystag- of spasmodic torticollis. Journal of Psychosomatic mography. Research, 15, 1-11. Meares, R. (1971b). Natural history of spasmodic torti- References collis and effect of surgery. Lancet, 2, 149-151. Meares, R. (1971c). An association of spasmodic torti- Cockburn, J. J. (1971). Spasmodic torticollis: a psy- collis and writer's cramp. British Journal of Psy- chogenic condition? Journal of Psychosomatic Re- chiatry, 119, 441-442. search, 15, 471-477. Paterson, M. T. (1945). Spasmodic torticollis: results Couch, J. R. (1975). The relationship between spas- of psychotherapy in 21 cases. Lancet, 2, 556-559. modic torticollis and essential tremor. Transactions Patterson, R. M., and Little, S. C. (1943). Spasmodic of the American Neurological Association, 100, 181- torticollis. Journal of Nervous and Mental Diseases, 183. 98, 571-599. Protected by copyright. Curzon, G. (1973). Involuntary movement other than Podivinsky, F. (1968). Torticollis. In Handbook of Parkinsonism. Proceedings of the Royal Society of Clinical Neurology, Vol. 6. Edited by P. J. Vinken Medicine, 66, 873-876. and G. W. Bruyn. North-Holland: Amsterdam. Gilbert, G. J. (1971). Spasmodic torticollis healed Shaw, K. M., Hunter, K. R., and Stem, G. M. (1972). effectively by medical means. New England Journal Medical treatment of spasmodic torticollis. Lancet, of Medicine, 284, 896-898. 1, 1399. Gowers, W.- R. (1893). A Manual of Diseases of the Svien, H. J., and Cody, D. T. R. (1969). Treatment of Nervous. System. Second edition, Vol. 2, p. 671. spasmodic torticollis by suppression of labyrinthine Hofner Pbblishing Company: Darien. activity: report of a case. Mayo Clinic Proceedings, Hassler, R., and Dieckmann, G. (1970). Stereotactic 44, 825-827. treatment of different kinds of torticollis. Confinia Tarlov, E. (1970). On the problem of the pathology Neurologica, 32, 135-143. of spasmodic torticollis in man. Journal of Herz, E., and Glaser, G. H. (1949). Spasmodic torti- Neurology, Neurosurgery, and Psychiatry, 33, 457- collis. II: clinical evaluation. Archives of Neurology 463. and Psychiatry (Chicago), 61, 227-239. Tibbetts, R. W. (1971). Spasmodic torticollis. Journal Herz, E., and Hoefer, P. F. A. (1949). Spasmodic of Psychosomatic Research, 15, 461-469. http://jnnp.bmj.com/ on September 28, 2021 by guest.