Spastic torticollis and pain in neck, shoulder, and upper limb and their impact on driving

Driving may be restricted in many patients by pain, deformity, difficult motion, loss of strength, dizziness, instability or abnormal movements that increase the risk of accidents if subjects are not adequately warned and advised.

In ill drivers, this situation is compounded by the associated anxiety and depression component, and also by the side effects caused by medication.

Spastic torticollis

This condition consists of neck muscle spasms causing lateral, anterior, or posterior head tilting or rotation, and may occur suddenly or, more commonly, gradually.

Spastic torticollis in adults is considered a focal dystonia in which several conditions are involved, including tardive dyskinesia, hyperthyroidism, central nervous system conditions, bone and soft tissue tumours, and in some cases heredity. Spastic torticollis is sometimes related to stress.

The condition occurs as unilateral, intermittent, or continuous spasms in the sternocleidomastoid, trapezius, and other neck muscles.

The disease may range from a mild disorder to cases very difficult to treat, and slowly progresses for 1-5 years, after which it becomes stabilised. In a low percentage of patients, spontaneous recovery occurs before five years have elapsed since the condition started.

In addition to orthopaedic treatment, the most commonly used drugs include anticholinergics and benzodiazepines, while muscle relaxants and tricyclic antidepressants are less commonly used.

Tips

• Spastic torticollis causing restricted motion and postural deformity prevents driving.
• Drugs used to treat torticollis have side effects interfering with driving, which should be warned to our patients.
• To be able to drive, the associated disease of the patient should be treated.
• If the patient is experiencing a period of anxiety or stress, all symptoms are exacerbated, thus decreasing vehicle control.
• Physicians should warn patients that even if symptoms have improved and they already able to drive, maintenance treatment may cause them significant and dangerous side effects that may delay driving resumption until doses are decreased or treatment is discontinued.
• Patients must not drive while they have symptoms.
• Pain and motion restriction may lead the physician to advise against driving.
• If surgical treatment is required, patients will not be authorised to drive until complete recovery has occurred, they have no symptoms, and the specialist physician has given his/her approval.

Pain in neck, shoulder, and lower limb

These are highly mobile areas continuously participating in movements often associated to weight bearing or use of a great strength.

Soft tissue is compressed and adjusted in its compartments, which increases susceptibility to stress.

Pain in these areas is frequent, and may be due to a single or several combined pathological conditions.

Among symptoms, particular mention should also be made of paraesthesia, muscle weakness, and decreased sensitivity and reflexes.

Inflammatory, degenerative, and mechanical stress conditions such as synovitis and neck, shoulder, and acromioclavicular arthritis are most commonly related to this symptomatic muscle dysfunction.

Other associated conditions include subacromial bursitis, tendinitis such as elbow epicondylitis or supraspinatus syndrome, capsulitis, fibromyalgia, and vascular disorders.

Neurological conditions arising in the spinal cord, nerve roots, or peripheral nerves, by a slipped cervical disk, cervical spondylosis, etc. are also possible causes.

Some chest and abdominal diseases may cause pain referred to those areas.

Cervical spine osteoarthritis occasionally causes functional compromise of vertebral arteries due to ostephytes, adding dizziness to the previous symptoms.

Tips

• Patients cannot drive while they are experiencing pain, loss of strength, and sensitivity changes.
• Joint stiffness impairs many movements required for driving, those preventing a rapid response when faced with an unexpected situation in the road.
• The vehicle should have a high, comfortable seat, with a straight back and a good neck rest.
• Both distance to the driving wheel and rearview mirrors should be adjusted to prevent forced shoulder and neck motion.
• Pain and neurological or motion restrictions may lead the physician to advise against driving.
• Patients with dizziness or vertigo must not drive.
• Drugs used for symptomatic treatment of these clinical conditions often have a sedative effect, e.g. benzodiazepines and major tranquillisers.
• Physicians should warn patients that even if symptoms have improved and they already able to drive, maintenance treatment may cause them significant and dangerous side effects that may delay driving resumption until doses are decreased or treatment is discontinued.
• Surgical decompression requires a subsequent period of functional recovery in which driving will not be allowed until a favourable report is issued by the specialist.
• Patients must not drive while they have symptoms.