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