Congenital Muscular Torticollis

what can you tell from a soft spot?

Dehydration, any issues, swelling

when can the head no longer be shaped?

cut off is 5 years old

what age has the highest incidence of cranial deformation?

birth

Gastrointestinal

causes such as Sandifer syndrome—dystonia of the neck/shoulders with gastroesphogeal reflux or a hiatal hernia · tilts away from the GI system ·

Neurological (2)

causes such as brachial plexus injury, CNS lesions àCNS lesions can cause CMT or head tilt.

One skin fold on the mid thigh can indicate what?

hip dysplasia sometime seen with CMT kids

how would left torticollis present?

left lateral side bend and rotation towards the right

what do you do if you find an SCM tumor ?

refer out for the infant to get an ultrasound dont give homework such as massage or cross friction. the parents can do ROM

what would you do if a 3 year came in with CMT and they dont have a prior history of it?

refer out--> rule out tumor in the brain

you are treating a baby that presents in prone with limited movement into left lateral SB,full ROM towards left rotation. which side has the torticollis?

right side torticollis

what side torticollis is seen with reflux babies?

see a lot R torticollis

what position do babies with reflux prefer?

tilted at 45 degrees

Upper Trapezius (3)

unilaterally side bends to the same side and rotates to opposite side, elevates scapula -they like to hike up to rest

§ Sternocleidomastoid muscle (SCM) - action unilaterally bilaterally

unilaterally: side bends to same side and rotates to opposite side · bilaterally: flexes neck symmetrically · Two palpable bands: medial and lateral

what other muscles can be involved?

upper trapezius and scalenes

what should happen around 4 months?

4 months developmental habits--> should be symmetrical

Pull to sit (2)

· Note head lag · Note if head is turned to R or L

Skeletal abnormalities (4)

(short, webbed neck, fused cervical vertebrae, Extra rib) -->can alter the skull and SCM

Scalenes

- flexes neck and rotates to opposite side * Scalene are hard to palpate--> seen in significant cases

Deformational Plagiocephaly

-Flattened occiput is typically contralateral to the tight SCM · Example: Left CMT with a shortened left SCM is associated with right DP occipital flattening. -Flattening on the right--> rotated towards the right -Left SCM is usually tight -Typically easier for them to rotate towards that side

baby with R CMT, what limitations do they present with?

-Limitation see it on the right rotation -Limited in left SB

name the 3 subtypes of CMT

-Sternomastoid Tumor(Fibromatosis colli) - Muscular Torticollis -Postural Torticollis

Physical Assessment/Tests and Measures (3)

-palpation -strength -extremities

o Evaluation: Clinical Observations (3)

-pull to sit -head righting -trunk righting

Physical Assessment/Tests and Measures: (5)

-visual tracking -craniofacial argentas -cervical region and back -observe trunk position -motor development

when does the skull fuse?

12 months

Postural Torticollis (4)

Mildest form § No SCM muscle tightness § No palpable mass § Normal x-rays Rule out visual system See this when they sit and they can really maintain Limited in range but not really tight Curvature within posture causing this lateral head tilt to happen

which subtype did hayden have?

SCM tumor

SCM tumor: what is it? x-rays? common? Fibrous tumor is usually ____ cm in diameter in SCM muscle when does it become noticeable? does it go away? infants are unable to what?

Severe form § Discrete mass palpable within the SCM muscle § X-rays are normal § Most common type § Fibrous tumor is usually 1-3 cm in diameter in SCM muscle § Tumor becomes noticeable 14-21 days after birth; sometimes as late as 3 months § Tumor disappears by 4-8 months § Infant is unable to maintain a vertical head against gravity in static postures or during transitional movement Fibrous tumor (begin)--> pops up when severely contracted They range in size

why would you want to rule out the hip?

Want to rule out same side hip Right SCM contracted (right CMT)--> rule out hip dysplasia maybe positioning or avascular development(come in when they are developing) Check both sides

kinesotape

Want to shut down the side over lengthen Right side is shorten the other side is over lengthen Kinesotape two bands--> shorten it --> correct to midline over time

should you put your baby in a bumbo sit?

no Can cause severe postural instability--> can promote lateral head tilt

increased or decreased to referrals to craniofacial clinics due to postnata positioning?

o Increased referrals to craniofacial clinics due to postnatal positioning since 1992 "Back to Sleep" campaign.

· Observe trunk position:

o Note if trunk is laterally flexed in resting positions

· Cervical region and back (4)

o Observe neck position in: supine sitting prone standing

· Acquired non-traumatic torticollis caused by: (5)

o Ocular imbalance o Dystonic syndromes o Arnold-Chiari malformation—herniation of cerebellar through the foramen magnum o Syringomyelia—cyst or cavity in the spinal cord o Posterior fossa tumors

Craniofacial-Argenta's Scale

o Skin assessment should note the presence of redness or creasing of skin at the neck.

how should babies sleep?

o They should sleep on their back (overnight) § Cause of head neck/control and don't want any issues with not being able to breath properly o Bring them to the side as long as they are supervising (tiny naps) § Reflux they have to be prone

· Risk factors for CMT and CD prognosis (5)

o poor adherence--> parents not doing stretches or not wearing the helmet o Initiating intervention after 3 months of age o Persistence of CMT after 6 months o Developmental delay o Severity of initial CD

· Palpation

oSternocleidomastoid muscle (SCM) o Upper Trapezius muscle o Scalenes muscles o takes a lot of practice (deep ones can be hard)

o Nonconservative Interventions for CMT (3)

operative -z plasty -surgical release -botox

Head righting

§ · Righting to midline or beyond · Note restrictions R compared to L · Note if speed of righting is altered R compared to L

· Neuromuscular o Neurological Screen- Evaluate for the following: (4)

§ A predominant ATNR (should be integrated by 4-5 months) § Presence of sustained clonus § Abnormal muscle tone § Pain assessment should be completed using an age appropriate pain scale. o Immediate recommendation for referral to Neurology made to referring care physician if any of the above are present and considered to be atypical.**

how do you evaluate ROM with an infant?

§ Arthrodial goniometer

· Extremities Secondary to increased incidence of hip dysplasia in children with torticollis, evaluate the following: (5)

§ Asymmetry of thigh folds One thigh fold is a little raised compared to the other. Usually their rolls are symmretircal. Check the hips and arm rolls(no sublux) § Asymmetry of hip abduction (≥ 5 degrees difference) § Apparent leg length difference in supine with knees bent § Clunking with passive ROM of hip with § These are red flags!! · Immediate recommendation for referral to Orthopedics made to referring care physician if any of the above are present. **

Classified rating scales for CD

§ Based on clinical observation § Argenta's Clinical Classification Scale · 5 types of DP · 3 types of DB

Incidence of CMT § Congenital Muscular Torticollis (CMT) is the ______most common congenital musculoskeletal anomaly. § Reports of incidence vary from __% to __% in newborns § Infants born with CMT may have what? § Infants born with CMT without CD are at risk for ?

§ Congenital Muscular Torticollis (CMT) is the 3rd most common congenital musculoskeletal anomaly. § Reports of incidence vary from .3% to 16% in newborns § Infants born with CMT may have Cranial Deformation(CD). § Infants born with CMT without CD are at risk for developing cranial deformation secondary to asymmetrical positioning.

Congenital Muscular Torticollis Definition Characterized by

§ Definition: Unilateral shortening of the sternocleidomastoid muscle (SCM);named for the side of the involved SCM · Characterized by lateral head tilt toward and chin rotation away from involved side.

Screening/Differential Diagnosis: -Up to ___% of children presenting with a torticollis posture has a non-muscular etiology. purpose of screening is to rule out conditions that what?

§ Differential Diagnosis -Up to 18% of children presenting with a torticollis posture has a non-muscular etiology. -Purpose of screening is to rule-out conditions that mimic CMT

o Cranial Deformation: what is it?

§ Distortion of the shape of the skull resulting from forces that occur pre- or postnatally.

Anatomy of the skull

§ Frontanelles and cranial suture lines and junctions § Open sutures give the infant's cranium flexibility to pass through the birth canal and to expand during infant brain development/growth.

CMT and CD Prognosis § Full resolution of CMT is _____ for infants <3 months of age · If referred early and caregivers carryover with intervention · __% for infants referred 3-6 months of age · __% for 6-18 months of age § Full resolution of CD is ____% after parent education in repositioning and __%-__% after cranial remolding therapy

§ Full resolution of CMT is 100% for infants <3 months of age · If referred early and caregivers carryover with intervention · 75% for infants referred 3-6 months of age · 30% for 6-18 months of ageà established bad habits its hard to break them but it is possible § Full resolution of CD is 77% after parent education in repositioning and 94%-96% after cranial remolding therapy

o Physical Therapy Examination: Evaluation (9)

§ History/Systems Review: · Age at initial visit · Age of onset of symptoms · Pregnancy history · Birth History · Assistance during delivery · Head posture/preference · Family history · Other medical conditions · Developmental History · Refer to Campbell, Pg. 192: Nine Health history factors*

head righting reaction

§ In head righting reaction (neck-righting reaction), the stimulation of proprioceptors in the neck as the child's head is turned actively or passively to one side causes the body to following one complete unit, without rotation within the vertebral column. (starts at 4 months of age) · The neck-righting reaction gradually diminishes over time as another reaction, the body-righting reaction acting on the body, evolves.

o Typical Activity Limitations (7)

§ Inability to have symmetric movement of the head due to neck muscle contracture or neck muscle strength imbalances § Reinforcement of an asymmetric postural preference; lack of midline control; motor milestones may develop atypically and asymmetrically § May neglect ipsilateral hand § Decreased awareness of ipsilateral visual field § Interference of symmetric development of head and neck righting reactions § Limited vestibular, proprioceptive, and sensorimotor development § Persistent asymmetries can lead to postural deformities

Etiology of Cranial Deformation (4) Risk factors(5)

§ Interauterine deformation that worsens postnatally, postnatal positioning and cervical muscular imbalance (CMT). § Risk factors include: · Male gender · Firstborn · Forceps or vacuum extractor · Exposure to supine position · Neck problems-->not CMT related

Motor Development: (8)

· Look for symmetry in postures and movements: o Prone, supine, sidelying, sitting, standing, etc o Rolling - note direction preferred o Pull to sit o Head and trunk righting (emerging at 4 months)

botox

· Neurotoxin that is injected into SCM to relax tight muscle by inhibiting acetylcholine release or causes muscle atrophy that allows for easier stretching Relaxes it

o Physical Therapy Intervention § Intervention directed toward _____ PROM and AROM towards elongation ___ asymmetric extension what type of exercises? care giver instructions

§ Intervention directed toward activity limitations § Passive and active ROM (including gentle stretching) to increase lateral flexion to contralateral side and rotation to the ipsilateral side § Elongation ipsilateral rotation and contralateral lateral flexion § Contralateral asymmetric extension § Strengthening and postural control exercises § Caregiver instruction in stretching, positioning, carrying, etc

o Evidence-based Supplemental Interventions (7)

§ Kinesiotaping--> very effective § Microcurrent--> e-stim § Myokinetic stretching § Tscharnuter Akademie for Motor Organization (TAMO) or Perception/Action approach Perceive the info--> work off the perception § Cervical collars--> TOT collar for older kids § Cranial remolding/helmet § Positioning devices

Risk Factors of CMT (9)

§ Large birth weight Don't have a lot of room to change their position. § Breech position § Multiple birth couple of babies in there § Primiparous mother—first birth for the mother --> mom is smaller with the first baby, nothing hasn't expanded and organs haven't dropped and moved out of the way § Difficult labor and delivery § Forceps assist à -brachial trauma, they try to avoid, they use suction if the baby is stuck in the canal § Nuchal cord—umbilical cord around the neck --> wrapped around 3-4 times § Maternal uterine abnormalities § Male gender They tend to be a lot bigger and they don't move around as much

Congenital Muscular Torticollis left

§ Left CMT: Left sternocleidomastoid tightness with: · Left lateral tilt · Rotation to right

o Function (Impairments) neck ROM (2) not able to what (4)

§ Neck ROM is decreased for ipsilateral rotation and contralateral lateral flexion § Infant is not able to maintain a midline alignment of the head with the torso in static postures or during movement secondary to neck muscle imbalance and muscle contracture § Persistent ATNR § Scoliosis or skull/facial asymmetry § Associated with developmental dysplasia of the hip à could be related § Windswept hips (abd on face side, add on skull side)

o Other Causes of Abnormal Neck Position (To be assessed by physician) (9)

§ Ophthalmologic Dysfunction § Superior Oblique M. Weakness (Inability to elevate eye) § Lateral Rectus M. Paresis (Inability to abduct eye) § Duane's Syndrome (Inability to abduct/adduct eye) § Brown's Syndrome (Inability to elevate and adduct eye) § Congenital Nystagmus (Involuntary movement of eyes) § Hemiplegia § Abnormal vertebral structure/alignment § Klippel-Feil Syndrome

o Physical Therapy Examination: Evaluation Positioning devices used - and how often/how long? (4)

§ Positioning devices used - and how often/how long? · swing · umbrella stroller · bouncy seat · car seat

o Congenital Muscular Torticollis Right

§ Right CMT: Right sternocleidomastoid tightness with: · Right lateral tilt · Rotation to left

body-righting reaction

§ The body-righting reaction acting on the body is a predominant factor in movement by 6 months of age. · When the head is rotated to one side, the body reacts to the proprioceptive stimulus to the neck by following in the direction of the head turning, thus rolling toward that side. This results in segmental vertebral column movement. This rotation within the body axis is referred to as intra-axial rotation and is facilitated by the body-righting reaction acting on the body, permitting the infant to roll from prone to supine and supine to prone.

positional device: tortle

§ Tortle § bulge to help with midline placement § Depending on the side they like to roll towards § Works okay

Muscular Torticollis

§ Unilateral tightness, but no palpable mass within the SCM muscle § Normal X-rays pic left to right left torticollis and right torticollis

Cranial Deformation: · A coexisting impairment in up to ___% of infants with CMT. · Increases the risk of what? · Prevalence of CD is age dependent and ranges: o __ to __% at birth o __% to __% from 1.5 months to 4 months, o __% the first year o __% at 2 years ___% at 12-17 years

· A coexisting impairment in up to 90.1% of infants with CMT. · Increases the risk of facial, ear and mandibular asymmetry. · Prevalence of CD is age dependent and ranges: o 6% to 61% at birth o 16% to 46.6% from 1.5 months to 4 months, o 6.8% the first year o 3.3% at 2 years 2% at 12-17 years

Causes of postural torticollis may be (3)

· Benign paroxysmal torticollis (unknown cause)- recurrent episodes of torticollic posturing of the head · Congenital absence of one or more cervical muscles or of the transverse ligament · Contracture of other neck muscles

Feeding

· Breast fed · Bottle fed -Do they switch sides? Do they bottle prop? · Reflux?

Deformational Brachycephaly

· Central occipital flattening · Associated with prolonged supine position They love supine Don't exhibit tummy time throughout the day

§ Arthrodial goniometer cervical rot lateral flex cervical flex capital flex cerivcal ext UE LE what happens when you feel a bony end feel

· Cervical Rotation (80 degrees* or chin should touch shoulder) · Lateral Flexion (40 degrees* or ear should touch shoulder) · Cervical Flexion (chin nearly touching chest wall*) · Capital Flexion (10 degrees) · Cervical Extension (45 degrees*) · Upper extremity - clinical observations · Lower extremity - clinical observations · The most accurate ROM measurements are obtained when the child is relaxed. · Consider end feel when assessing range of motion. Bony end feel -> recommend Orthopedic consult**

Tumor is characterized by (3)

· Deposition of collagen and fibroblasts around the individual muscle fibers with an absence of normal striated muscle · Healthy myoblasts degenerate · Remaining fibroblasts produce excess collagen, resulting in a scar-like band and muscle contracture

CMT Most widely accepted theories of cause are the following: (3)

· Ischemia- secondary to abnormal vascular patterns · Birth trauma- direct injury to the muscle · Intrauterine malposition- perinatal compartment syndrome Positioning inside the womb Mom is small framed --> baby gets comfortable in the womb

§ Deformational Dolichocephaly, known as Scaphocephaly.

· Long and narrow skull Associated with premature birth-->brain size(skull hasn't developed)

o Goals of Intervention for CMT/CD § First-Choice Interventions (6)

· Parent/caregiver education-->intense HEP · Environmental adaptations · Passive neck ROM exercises · Neck and trunk AROM · Facilitation of symmetrical movement · Cranial remolding if severe after 4 months of age

Trunk righting

· Righting to midline or beyond · Note restrictions R compared to L · Note if speed of righting is altered R compared to L

Therefore you must rule out: (4)

· Skeletal abnormalities · Neurological · Gastrointestinal -Acquired non-traumatic torticollis

Surgical release of the SCM is required more frequently when: (2)

· Surgical release of the SCM is required more frequently when: o Children have a history of SCM tumor or o Deficits of ≥ 30° in cervical rotation at the time of diagnosis · Younger children at presentation and initiation of physical therapy are less likely to require surgery.

visual tracking

· Visual tracking: Immediate recommendation for referral to Ophthalmology made to referring physician if visual dysfunction is observed.** ·

how long do the babies wear the helmet?

· Worn 23 hours a day--> 1 hour break (bathing ) · After 3 months of age --> increase head and neck control · New born wait it out 3-4 months correct it in time so they don't need helmet · Check head for any red marks or blistering · Cranial modeling helmet be shave down restructure · You have to perform all of the measurements § Inside thick foam (dense foam) § Space on side to give for a skull § Side burns--> ear cut out § Foam indicate shifting--> build up on one side § You cant wash it with soap § No alcohol § Only wipe with water § If its indicated for the child they go their scans done

z-plasty

· Z-plasty lengthening of sternocleidomastoid may be required if torticollis persists releases the SCM to help it gain some range