Congenital Muscular Torticollis

what to do w/ torticollis patients

Stretching (should be frequent throughout the day, every day) Orthoses Taping? Medical management

some think that __________ __________ begins in utero, and causes torticollis secondarily other thoughts?

cranial deformation Intrauterine crowding Soft tissue compression leading to compartment syndrome Muscle trauma Congenital abnormalities of the soft tissue of SCM

severity of CMT is determined by...?

difference in L and R measurements of cervical lateral flexion and rotation (2-10 months)

8-20% of those w/ torticollis have associated

hip dysplasia

strongest association with outcome tied to the

severity classification (Argentina classification system)

Torticollis is the_________ most common congenital musculoskeletal impairment

third

Hip assessment should be done at...? Includes...?

three-months Symmetry of folds Barlow: Bar-fad - Flexion, adduction Ortolani: extension and abduction to check for relocation

Prognosis of full resolution of CMT prior to ____?_____ months is 100% and 75% if treatment is started after ____?____ months of age

3, 3

Provide a follow up screening of the infants _______-_______ months post discharge

3-12

Not known if last ____-_____ degrees resolves on their own or remains as a mild limitation

5-10

tummy time for _____ a day is important

1 hour

developmental delays w/ CMT seen as early as

2 months, tummy time important to decrease these delays

how are cognitive deficits of babies w/ CMT thought to develop

2/2 motor deficits, which leads to limited or asymmetrical exploration

passive range of motion measuring tool other than goni

Anthrodial

FLACC

Areas to look at in regards to pain: Face, Legs, Activity, Crying, and Consolability

common findings

Asymmetry of craniofacial skeletal structures Asymmetry of muscles of mastication and tongue Underdevelopment of ipsilateral jaw Inferior and posterior ipsilateral ear Asymmetry of eyes with ipsilateral eye smaller Deviation of nasal tip

red flags

Atypical presentation Skull/facial asymmetry Visual abnormalities Abnormal tone Suspected hip dysplasia History of acute onset Late-onset torticollis

Considerations for refer if not progressing

If after 6 months there is a lack of progress If older than 7 months on initial exam and tight SCM mass If a child begins after 1 year and presents with facial asymmetry and/or a 10-15 degree difference Asymmetries of head, neck, and trunk not resolving after 4-6 weeks of initial intense treatment

Invasive procedures Botox or Surgery

If after 6 months with conservative treatment lack of progress After 1 year of age significant restriction and/or SCM mass

Clinical characteristics of "stuck" baby:

Ipsilateral side Eye smaller Cupped ear Flattened lower jawline Elevated shoulder Contralateral side Flattened ear Mild frontal flattening Tilted mandible

duration of treatment

Mildest forms: 2-3 months More severe forms: up to 5-6 months

Modification or avoiding tests w/ what 3 disorders

Osteogenesis Imperfecta Congenital Hemivertebra Down Syndrome (if not cleared for cervical instability)

subgroups of CMT

Palpable swelling pseudotumor SCM (sternocleidomastoid) tightness without tumor Muscular torticollis without SCM muscle tightness or tumor

Types

Sternomastoid tumor Muscular torticollis Postural torticollis Postnatal

Argenta classification system (type I - V)

Type I Deformity restricted to back of the head Type II Deformity includes malposition of ipsilateral ear and posterior flattening Type III Includes frontal asymmetry deformity, malposition of ipsilateral ear, and posterior flattening Type IV Includes ipsilateral facial deformity, ipsilateral fronal asymmetry, and ipsilateral ear deformity Type V Decompression of brain vertically or temporally as well as all above with temporal bulging or abnormal vertical growth of posterior skull

First choice physical therapy intervention for CMT

neck prom neck and trunk arom development of symmetrical movement environmental adaptations integrate Tummy time or prone play (van Vlimmeren,2006; Ohman, 2009; Monson, 2003; Davis, 1998; Kennedy, 2009) Positioning and handling to encourage symmetry (van Vlimmeren, 2006; Stellwagen, 2004; Ohman, 2011; Gray, 2009; van Vlimmeren, 2008) Minimize time in bouncy seats and carrier as risk factor to plagiocephaly (Boere-Boonekamp, 2001; Stellwagen, 2004;Laughlin, 2011) Alternate feeding to each side (Losee, 2007)

Torticollis associated with _____________ __________: a growing epidemic.

positional plagiocephaly (80-90% of cases)

active_____________ and passive __________ correlates with a high of resolution CMT

positioning, stretching