Pediatrics → Congenital Muscular Torticollis (CMT):
When should a child demonstrate 5/5 strength bilaterally?
By 4 months of age
How do you measure active cervical range in an infant with CMT?
Cervical Rotation AROM: - Measured in supine → For ages < 3 Months - Measured in PT lap → For ages > 3 Months Lateral Flexion AROM: - Measured via function scale → For ages > 2 Months
Cranial Vault Asymmetry Index (CVAI) = 8.75-11.0:
Conservative treatment → Cranial remolding orthosis
What measure determines if a cranial deformation requires treatment?
Cranial Vault Asymmetry Index (CVAI)
Cranial Vault Asymmetry Index (CVAI) > 11.0:
Cranial remolding orthosis
Cephalic Index:
Determines the severity of cranial deformation by: 1) The number of deviations above the mean for Cephalic Index (CI) → CI = (Width/Length) x 100 2) Frontal involvement of the forehead and facial structures 3) CI is higher for infants who → Sleep supine and spend extended time in supine
CMT Severity Grade 1:
Early mild: 1) Infants between the ages of → 0-6 months 2) Presents with → Only postural preference or muscle tightness of <15° cervical rotation
CMT Severity Grade 2:
Early moderate: 1) Infants between 0-6 months of age 2) Presents with → Muscle tightness of 15°-30° of cervical rotation
CMT Severity Grade 3:
Early severe: 1) Infants between 0-6 months of age 2) Presents with → Muscle tightness of >30° cervical rotation or an SCM nodule
What is Sandifer Syndrome?
GI Abnormality → Combination of gastro-esophageal reflux disease with: 1) Spastic torticollis 2) Dystonic body movements → With or without hiatal hernia
CMT Severity Grade 7:
Late Extreme: 1) Infants > 7 months of age → Presenting with a SCOM nodule 2) Infants > 12 months of age → Presenting with muscle tightness of >30° cervical rotation
CMT Severity Grade 5:
Late Moderate: 1) Infants present between 10-12 months of age 2) Presents with → Only postural or muscle tightness of < 15° cervical rotation
CMT Severity Grade 4:
Late mild: 1) Infants between 7-9 months of age 2) Presents with → Only postural preference or muscle tightness of <15° cervical rotation
CMT Severity Grade 6:
Late severe: 1) Infants between 7-12 months of age 2) Presents with → Muscle tightness of >15° cervical rotation
What is an orthopedic sustained muscle contraction?
Poor postural alignment → Can lead to early onset of degenerative arthritis
Mildest form of CMT:
Postural CMT
CMT Etiology:
Prenatal: 1) Ischemic injury 2) Mal-positioning in utero 3) Muscle rupture Perinatal: 1) Birth trauma from breech position or assisted delivery Postnatal → Associated factors (Not causes): 1) Positional preference 2) Plagiocephaly 3) Hip dysplasia
Pain scale used in assessing a child:
QUEST Principles
What are the conservative first-choice interventions for CMT?
1) Caregiver Education 2) Environmental Adaptations 3) Cervical PROM 4) Neck and trunk AROM 5) Facilitation of symmetrical movement activities
What is Plagiocephaly strongly associated with?
1) Congenital muscular torticollis 2) Congenital hip dislocation 3) Congenital scoliosis
Scaphocephaly:
1) Cranial deformation 2) Long and narrow skull shape 3) Shape is common in babies who spend extended time in NICU or are positioned side-lying
CMT Differential Diagnosis:
1) CMT vs. Cervical Dystonia vs. Spasmodic torticollis 2) Ocular Disorders 3) Osseous Abnormalities 4) GI Abnormalities → Sandifer Syndrome 5) Brachial Plexus Injury 6) Benign Paroxysmal Torticollis
CMT Severity Grades:
- Grade 1 → Early Mild - Grade 2 → Early Moderate - Grade 3 → Early Severe - Grade 4 → Late Mild - Grade 5 → Late Moderate - Grade 6 → Late Severe - Grade 7 → Late Extreme - Grade 8 → Very Late:
What is Benign Paroxysmal Torticollis?
1) A rare paroxysmal dyskinesia 2) One of the childhood periodic syndromes 3) Presents with → Recurrent stereotypic episodes of torticollis 4) Usually accompanied with some of the non-headache features of migraine → Such as vomiting & ataxia
Perinatal CMT Etiology:
1) Birth trauma from breech position or assisted delivery
Plagiocephaly:
1) Cranial deformation 2) Unilateral occipital flattening 3) Anterior progression of the ear on the same side as the flattened occiput 4) Varying degrees of ipsilateral frontal and contralateral posterior parietal bossing → Parallelogram shape 5) Right occipital flattening more common than left occipital flattening → Ratio of 2:1 6) Severity is determined by the number of skull quadrants involved in the deformity → With or without the presence of facial and jaw asymmetry
Brachycephaly:
1) Cranial deformation 2) Wide skull with short length 3) Prominent or bossed forehead 4) Increased height of the cranial vault 5) Central occipital flattening
PT Discharge Criteria for CMT:
1) Full PROM of neck, trunk, and extremities → Within 5° of the non-affected side 2) Symmetrical movement patterns → Throughout passive range 3) Age-appropriate gross motor development → Including symmetrical movement patterns between the left and right sides (During static, dynamic, & reflexive movements) 4) Improved skull symmetry to Argenta Type I → Or referred for further management of CD 5) No visible head tilt 6) Parents/caregivers understand what to monitor as the child grows
What CMT grade is considered the mildest and what grade is considered the most severe?
1) Grade 1 → Mildest form of CMT 2) Grade 8 → Most severe form of CMT
What is CMT characterized by?
1) Ipsilateral lateral flexion 2) Contralateral rotation
Prenatal CMT Etiology:
1) Ischemic injury 2) Mal-positioning in utero 3) Muscle rupture
What is the Cranial Vault Asymmetry Index (CVAI)?
1) Measure that determines if a cranial deformation requires treatment 2) Measure in millimeters at 30° from center of nose → Outer edge of eyebrow 3) CVAI= |A-B|x100
Postural CMT:
1) Mildest form of CMT 2) Presents as a positional preference → Of the infant's head and neck 3) No limitations in PROM 4) No nodule/mass
Muscular CMT:
1) Moderate Form of CMT 2) Unilateral tightness of SCM 3) No nodular mass in muscle
SCOM Nodule CMT:
1) Most severe form of CMT 2) Palpable nodule in SCOM 3) Limitations in cervical rotation and/or lateral flexion
Treatment criteria of the Cranial Vault Asymmetry Index (CVAI):
1) No treatment required → < 3.5 2) Repositioning program → 3.5-6.25 3) Repositioning and cranial remolding orthosis → 6.25-8.75 4) Conservative treatment (Cranial remolding orthosis) → 8.75-11.0 5) Cranial remolding orthosis → >11.0
What is CMT?
1) Non-progressive unilateral shortening of sternocleidomastoid → Possible mass or nodule and/or tightening of upper trap 2) Asymmetrical posturing of the head and neck 3) Loss of AROM & PROM 4) Third most common congenital musculoskeletal condition → After hip dislocation and clubfoot
What orthopedic condition is commonly associated with CMT?
1) Orthopedic sustained muscle contraction → Poor postural alignment can lead to early onset of degenerative arthritis 2) Developmental Dysplasia of the Hip (DDH)
Types of Cranial Deformity:
1) Plagiocephaly 2) Brachycephaly 3) Scaphocephaly
CMT Red Flags:
1) Poor vision tracking 2) Abnormal muscle tone 3) Extra-Muscular mass 4) Other asymmetries atypical of CMT
Which types of CMT do not have a nodule/mass present?
1) Postural CMT 2) Muscular CMT
Types of CMT:
1) Postural → Mildest Form 2) Muscular → Moderate Form 3) SCOM Nodule → Most Severe Form
What areas of the CMT Examination are important to address?
1) Posture 2) PROM 3) AROM 4) Pain 5) Palpation 6) Integumentary 7) Craniofacial assessment 8) Activity & Developmental Status → OMs
How do you determine the severity of cranial deformations?
1) The number of deviations above the mean for Cephalic Index (CI) → CI = (Width/Length) x 100 2) Frontal involvement of the forehead and facial structures 3) CI is higher for infants who → Sleep supine and spend extended time in supine
What scale do you use to classify cranial deformation?
Argenta Classification Scale
Postnatal CMT Etiology:
Associated factors → Not causes: 1) Positional preference 2) Plagiocephaly 3) Hip dysplasia
Pain scale used in assessing infants:
FLACC
Cranial Vault Asymmetry Index (CVAI) < 3.5:
No treatment required
How do you measure strength in an infant with CMT?
Muscle Function Scale (MFS) → Used to assess active cervical range & strength
What is Cervical Dystonia?
Painful condition in which your neck muscles contract involuntarily
Cranial Vault Asymmetry Index (CVAI) = 6.25-8.75:
Repositioning and cranial remolding orthosis
Cranial Vault Asymmetry Index (CVAI) = 3.5-6.25:
Repositioning program
Most severe form of CMT:
SCOM Nodule CMT
Which types of CMT have a nodule/mass present?
SCOM Nodule CMT
CMT is the ___(#)___ most common congenital MSK condition.
Third most common MSK condition → After hip dislocation and clubfoot
Muscle Function Scale (MFS) → Grading System:
Used to assess active cervical range & strength: - Grade 5/5 → Holding the head very high above the horizontal line (Almost vertical position) - Grade 4/5 → Holding head high above the horizontal line and > 45° - Grade 3/5 → Holding the head high over the horizontal line (Below 45°) - Grade 2/5 → Holding the head slightly over the horizontal line - Grade 1/5 → Holding the head on the horizontal line - Grade 0/5 → Holding the head below the horizontal line Child should demonstrate 5/5 strength bilaterally → By 4 months of age
CMT Severity Grade 8:
Very Late: 1) Infants and children > 12 months of age 2) Presents with any asymmetry → Including: - Postural preference - Any difference between sides in passive cervical rotation - A SCOM mass