Lec 25: Torticollis

Discussion of Literature Review of Torticollis (6)

1. "Conservative management" is widely accepted as treatment of choice in children < 1-2 years of age 2. Surgical rates have decreased significantly, no clear standard for when to have surgery 3. Evidence supports treatment by PT is more effective in achieving symmetrical movements than when parents do HEP alone 4. PT treatments have moved beyond just PROM to include positioning, active facilitation of symmetrical movement and motor skill progression 5. *Highly variable frequency and duration of PT: late age at referral, thicker SCM, lower birth weight all lead to longer treatment durations* 6. Evidence strongly supports earlier interventions PT result in the best outcomes and shorter episodes of care

Treatment: Soft Tissue Mobilization (2)

1. *Not strongly supported in research* 2. Clinically can be helpful tool - Tightness through upper traps/shoulder elevation - Fibromatosis colli

Discharge: CPG 2018 - Discharge goals (6)

1. *PROM within 5 degrees of nonaffected side* 2. Symmetrical active movement patterns 3. Age appropriate motor development 4. No visible head tilt 5. Parent/caregivers understand what to monitor as child grows 6. Follow up implications - Reassess infants *3-12 months after DC* direct services OR when child initiates walking

Assessment: Pain (3)

1. *Pain not typically associated with CMT, may be associated with passive stretching* 2. PT needs to differentiate actual pain response from behavioral reaction 3. Assess at rest and/or with PROM/AROM - CHIPPS - FLACC *recommended* - rFLACC

CMT Types and Severity (4)

1. *Postural CMT*: infant postural preference but no muscle/PROM restrictions; most mild 2. *Muscular CMT*: SCM tightness and PROM restrictions 3. *SCM mass CMT*: fibrotic thickening of the SCM and more significant PROM restrictions; most severe 4. *Acquired torticollis*: less common - Traumatic injury - Bony deformities - Neurological disease - Cancer

Treatment: TOT Collar (6)

1. *Use at 6 months of age or more* - Typically reserved for children who are older upon referral or have more severe torticollis 2. Need full PROM 3. Ability to actively hold head in midline posture 4. *Use only during waking hours* 5. Never during sleeping hours or in car seat 6. Supervision required at all times

Assessment: ROM Considerations (4)

1. Always do PROM and AROM 2. Consider infants emotional/behavioral state 3. Varies by position/posture 4. Be aware of substitutions/combinations

Assessment: Facial Asymmetries (5)

1. Anterior ear shift on weight bearing side 2. Eye squint 3. Decreased vertical facial height 4. Increased width (puffy cheek) 5. Jaw (suck/swallow asymmetry)

Assessment: ROM Tools and Landmarks (4)

1. Arthrodial protractor: most commonly referenced standardized measurement - Lack of research to support inter- rater reliability - Intra- rater reliable for lateral flexion - Recommended by clinical practice guideline 2. Goniometer - Intra- rater reliable for rotation 3. The "eye balling" it method 4. Body landmarks - Nipple line: 40-45 degrees - Axillary line: 70-80 degrees - Shoulder: 90 degrees - Ear position

Treatment: Parent/Caregiver Education (4)

1. Background information 2. Outcomes/expectations 3. Importance of home program 4. Ongoing communication

Assessment Components (10)

1. Background information 2. System review 3. Posture 4. Skull/facial asymmetries 5. Palpation/skin integrity 6. Visual skills 7. ROM 8. Muscle performance (strength, power, endurance) 9. Motor function (motor control, motor learning) 10. Neurodevelopmental status (fine/gross motor skills)

Treatment: Strengthening Precautions (3)

1. Be aware of functional coupling of movement 2. Strength must transfer into functional movement 3. Use functional self- initiated movement to gain strength

Fibromatosis Colli (2)

1. Benign proliferation of fibrous tissue found in SCM musculature (pseudo, tumor of infancy, SCM mass) 2. Self limiting and typically involves with time and PT

Significance of Torticollis Diagnosis (2)

1. CMT is a muscular balance - Skeletal changes - Postural dysfunction - Impaired movement patterns - Functional limitations - Limitations in participation 2. CMT occurs early before normal movement patterns can emerge

Assessment: Systems Review (7)

1. CV 2. Cognition 3. Communication 4. Integument 5. Musculoskeletal 6. Neurological 7. Pulmonary

Treatment: Equipment modification (4)

1. Car sear (safety ed) 2. Infant seat: bouncy seat/swings 3. High chair 4. Sippy cups

Treatment: Carrying and Feeding (2)

1. Carrying/picking up - Frequent reinforcement 2. Feeding - Nurse both sides? - Feeding in asymmetrical posture?

Treatment: AROM/Strengthening - Dynamic Activity (5)

1. Cervical rotation, lateral flexion in all postures 2. Trunk rotation, lateral flexion in all postures 3. Cervical (spinal) flexion/extension with midline alignment 4. Shoulder girdle, upper extremity 5. Pelvic girdle, lower extremity

Assessment: ROM Norms (2)

1. Cervical rotation: mean of 110 +/- 6 degrees - Clinical goal is 90 degrees 2. Cervical lateral flexion: mean of 70 +/0 2.2 degrees - Clinical goal 45-70 degrees

Treatment: Stretching/PROM (5)

1. Cervical, shoulder, trunk muscles 2. Slow, controlled movement 3. 3-5 sessions per day 4. *Start supine, but be prepared to move to alternate postures (ex: side- carry to get sustained stretch)* 5. For some patients- pelvis/spine

Prevention: PT's (4)

1. Continue educating other providers and referral sources 2. Assess broader scope of impairments 3. Full "ROM" is not only goal 4. Work hard to reduce persistence of secondary impairments (craniofacial asymmetry, postural asymmetry, developmental/functional asymmetry)

Assessment: Background Information (6)

1. Demographics - Patient age/gestational age - Birth weight/birth order 2. Head posture preferences, age of onset, any changes? 3. Face/head shape, age of onset, any changes? 4. Diagnosis, secondary diagnoses 5. Family history 6. Any treatment tried at home

Prevention of Torticollis (3)

1. Education of expectant parents and parents of newborns within 2 days of delivery - Importance supervised tummy time 3x/day - Full active movement through body - Prevention of postural preferences - Role of Pediatric PT 2. Assess Newborn Infants for Asymmetries/CMT within first 2 days of birth 3. Refer infants to physician and PT as soon as asymmetry is noted

Assessment: Background Information - Environmental, Social/Family, Caregiver (3)

1. Environmental factors - Sleeping position - Preferred head posture in various positions - Time spent in various positions, equipment 2. Social/family history - Feeding and sleeping habits - Care provided by parents/daycare/other 3. Caregivers goals/expectations

Treatment: Kinesiotape (5)

1. Facilitate desired posture, with muscle use or inhibition 2. Wear 2-3 days 3. Can get wet 4. Watch skin response 5. Start on paraspinal muscles, scapular stabilizers

Assessment: Skull/Facial Asymmetries - Plagiocephaly (4)

1. Flattening of occiput on one side 2. Frontal bossing, usually 3. Usually related to primary weight bearing posture in supine 4. Hint: visualize water balloon

Assessment: Visual Skills (2)

1. Focus - Monocular fixation- neonate - Central fixation- 1-2 months, first hand regard - Faces, toys, 3-4 months - Consistent fixation with convergence - 6 months 2. Tracking - Horizontal tracking - neonate-1 month - Vertical and circular tracking - 2 months - 180 degree range- 3 months - All directions with dissociation of head- 6 months

Associated Medical Conditions with CMT (5)

1. Hip dysplasia (DDH) 2. Club feet and metatarsus adductus 3. Brachial plexus injuries 4. Plagiocephaly 5. Reflux

Treatment: E-stim

1. Improve strength, endurance, sensory awareness of weak neck musculature 2. Contraindications: cardiac pacemaker, arrhythmias, h/o congestive heart failure 3. Precautions: excessive erythema >60 min, <6 months age 4. Placement: SCM, upper traps 5. Treatment: custom setting 5:5, 35 Hz, Wavelength 280-300, intensity to tolerance, 10-15 minute duration as tolerated

Environmental Factors for Increased Incidence fro CMT and Plagiocephaly (9)

1. Increased birth weights (males, firstborns) 2. Increased multiple births 3. In utero exposure to opioids 4. Breech presentation 5. Use of forceps during delivery 6. Premature birth environment 7. Back to Sleep Campaign (1992) 8. Increased use of infant positioning equipment 9. Decreased tummy time, lower activity level, slower attainment of gross motor milestones

Etiology of Positional Plagiocephaly (2)

1. Intrauterine positioning 2. More commonly positioning after birth

Muscle Function Scale (6)

1. MFS: a 5 point ordinal visual scale that interprets an infants righting response 2. Described infants muscle function in lateral neck flexors through ordered categorical scores of 5 levels from 0-4 3. Observe head position in relation to horizontal line 4. Infant must be held in position for 10 seconds to score at that level 5. Hold to prevent substitutions 6. Study led to *6 point scale*

Treatment in Supine (7)

1. Midline head 2. Active neck rotation 3. Arm movements, batting, reaching 4. Visual skills 5. Spine/trunk alignment 6. Pelvic alignment/stability 7. LE movement

Treatment in Prone (7)

1. Midline head 2. Active neck rotation 3. Symmetry of UE weight bearing 4. Symmetry of reaching ability 5. *Ability to rest cheek fully to surface* 6. Spinal/pelvic alignment 7. LE movement

Treatment in Supported Sitting/Independent Sitting (6)

1. Midline head/supine 2. Active neck rotation, lateral flexion 3. Symmetrical UE use 4. Pelvic/LE alignment, movement 5. *Ability to control weight shifts in multiple directions* 6. *UE loading/varied sitting positions*

Assessment: Gross Motor Skills (4)

1. Motor control/learning - Quality/rang/variety 2. Observe in *supine, prone, supported sit, supported stand* 3. Watch for asymmetries - Weight bearing - Extremity use - Transitions 4. Neurodevelopmental status: standardized testing - TIMP (1-4 months) - AIMS (1-18 months) - GM Peabody (1-72 months)

Assessment: UE Function (2)

1. Motor control/motor learning - Quality/range/variety/speed of motion 2. Neurodevelopmental status - Hand preference - Hands to midline - Transfer of objects - Toy grasp - Reaching - Weight bearing

Assessment: Palpation/Skin Integrity (4)

1. Neck musculature 2. Muscle tension 3. Nodules/mass 4. Skin creases

Assessment: Muscle Performance (3)

1. Neck/spine - Rotation - Lateral neck/trunk right reactions (emerging at 3 months of age, eyes should orient to environment with 45 degree body lateral tilt (eyes horizontal) - Pull to sit - Prone extension 2. Shoulder/arm - Upper extremity WB/reaching 3. Pelvis/leg - Kicking, lifting, bridging, rolling, crawling, standing

Prevention: Physician/Nurse Education (3)

1. Need early referral 2. Explain broader scope of our evaluations, treatment, and discharge goals. *Torticollis impacts much more than just ROM!* 3. Encourage *tummy time, parental follow through*

Treatment: Guidelines for Stretching (4)

1. Observe response of child closely (cry, color, respiration, facial expression) 2. Use caution with children with hypotonia 3. Explain end range/feel 4. Never force movement

Treatment: Surgical Intervention (4)

1. Outpatient procedure, use of laser to lengthen SCM 2. Not a typical course of action, but does occur for more severe cases 3. Many craniofacial surgeons will not do prior to 1 year of age 4. Need consistent therapy following procedure for best results

Prevention: Early Intervention (Petronio et al 2010) (3)

1. PT start <1 month age, 98% achieve near normal range in 1.5 months 2. PT starts >1 month age, prolongs intervention 6 months duration 3. PT start >6 months age, prolongs intervention 9-10 months duration with fewer infants reaching near normal range

Plagiocephaly (2)

1. Persistent molding of infants head caused by intrauterine or postnatal positioning 2. Can also be caused by unilateral closure of lambdoid or coronal suture (craniosynostosis)

Red Flags/Potential Refer to MD (8)

1. Poor visual tracking for age 2. Significant reflex symptoms 3. Abnormal lump on palpation not already noted by MD 4. Extramuscular masses 5. Abnormal muscle tone 6. Seizure- like activity 7. Atlanto- axial instability 8. Other asymmetries inconsistent with CMT

Assessment: Posture (5)

1. Preferred head-toe posture 2. Asymmetries 3. Base of support 4. COG 5. Dynamic vs Static

Assessment: Medical History (10)

1. Pregnancy history 2. Birth history/complications 3. Hospitalizations 4. Imaging 5. URI 6. GI dysfunction 7. Feeding difficulties 8. Visual impairments 9. Gross motor history 10. Meds/allergies

Prevention: Public Education (3)

1. Prenatal instructors 2. New parent class instructors 3. Brochure "Back to Sleep, Tummy to Play"

Developmental Activities (

1. Provide parent education regarding typical developmental skills, timelines 2. Monitor for symmetry of motor skills 3. Be aware of asymmetry of posture, extremity use, weight bearing, weight shifting, and transitions 4. *Prone skills often delayed* 5. Transitions frequently occur to dominant side only (rolling, sit to tummy, pull to stand) 6. Asymmetry in weight shift, weight bearing usually prevalent in multiple positions 7. Vestibular dysfunction may need to be addressed

Treatment: Frequency/Duration (2)

1. Recommend weekly appointments initially, decrease frequency as appropriate 2. Earlier you resolve issues, the less the impairment, shorter the therapy course

Treatment: Plagiocephaly - Cranial Orthotic (4)

1. Referral to cranial- facial specialist 2. Optimal results when initiated at *4-6 months* - Earlier referral, typically faster/better results - Need decent head control 3. Changes skull shape, less change to facial features or ear position 4. Usually wear for 3-4 months, 23 hours/day

Prevalence of Torticollis (2)

1. Reported rates 3.9-16% of newborns 2. Increase prevalence correlated with success of Back to Sleep Campaign

Treatment: Transitions (4)

1. Rolling 2. Sit to floor to sit 3. Sit to tommy/kneeling/4 point 4. Pull to stand

Anatomy of Torticollis (3)

1. SCM - Origin: clavicle and sternum - Insertion: mastoid process 2. Scalenes - Origin: transverse processes 3-6 cervical vertebrae - Insertion: first and second rib 3. Trapezius - Origin: occiput, cervical and thoracic spinous processes - Insertion: spine of scapula, lateral 1/3 of clavicle

Assessment: Muscle Performance - AROM/Functional Movement (4)

1. Strength 2. Power 3. Endurance 4. Position/Action Dependent

Treatment: Positioning Goals (3)

1. To prevent and conservatively treat deformational plagiocephaly 2. Correct postural preference leads to CMT/Plagiocephaly 3. Treat CMT if present Examples: - Reduce, eliminate asymmetry (car seat, infant seat, supine, sidelying) - Increase prone play time, modified if necessary - Use sustained postures to gain muscle length

Etiology of CMT (2)

1. Unsure of why CMT occurs 2. Theories: varying degrees of support from literature - Intrauterine positioning - Abnormal development of SCM in utero - Compartment syndrome correlating with delivery - Birth trauma - Hereditary factors - Newborn positioning preferences

Assessment: Ocular torticollis (4)

1. Usually manifests later than true CMT - Binocular vision development begins 4 months, peaks 2 years 2. Typically due to opthalmic conditions including: - Paralytic and restrictive disorders of ocular movement - Nystagmus - Defects of visual field 3. Difficult to assess clinically so if any visual concerns refer to opthalmologist for further testing 4. Differential diagnosis - Occlusion of one eye will cause head to straighten - Sit up test: head tilt observed in sitting resolves in supine

Congenital Muscular Torticollis (CMT)

A postural neck deformity involving the shortening of the SCM and other cervical muscles that presents shortly after birth. The head will typically tilt toward the *same side of the affected muscle and rotate away from the affected muscle* Ex: R torticollis = R head tilt and left rotation

Hemihypoplasia

Facial asymmetry caused by plagiocephaly - Flattened occiput - Ear shift - Vertical height - Width

Brachycephaly

Flattening of posterior head due to either permanent fusion of coronal sutures or external deformation (prolonged lying on back)

Craniosynostosis

Head deformation caused by premature closure of cranial sutures

Target Population Inclusions and Exclusions

Inclusions: - Infants with abnormal head positioning - Infants lacking full cervical spine mobility Exclusions: - Cervical spine instability - Acquired torticollis in older child - Plagiocephaly with absence of cervical dysfunction

Treatment in Standing and Gait

Standing: watch for asymmetry of body, involved side often retracted, externally rotated Gait: watch for asymmetrical step length, instability on one side in single limb stance

Treatment: Crawling/Creeping

Watch for asymmetry of weight shifts, weight bearing