Torticollis+and+Plagiocephaly

= Congenital Muscular Torticollis: What is it? =

Congenital Muscular Troticollis (CMT) is a unilateral shortening of the sternocleidomastoid muscle with ipsilateral cervical flexion and contralateral cervical rotation.




 * In layman's terms
 * Tightness of the neck muscles on one side result in:
 * head tilting towards the affected side and head rotating away from the affected side
 * range of motion in both rotation and lateral flexion are limited
 * muscle imbalance or weakness present around the neck; head righting on the opposite side is weekend compared to the affected side
 * generally presents at 4-8 weeks of age
 * [[image:kumc-ptrs-ebp/torti_pic.jpg]]
 * Subgroups
 * Infants with a fibrous mass or contraction of the sternocleidomastoid (at 1-4 weeks after birth a sternomastoid tumor may be found); approximately 50-70% of SCM tumors resolve spontaneously during the first year of life.
 * [[image:http://www.bostream.nu/torticollis/bilder/knolsoftx.htm.jpg width="310" height="229" caption="SCM Tumor"]]
 * Muscular torticollis
 * Positional torticollis: same clinical features as CMT but without muscle tightness
 * What causes it?
 * The birth history of children with CMT often experience difficulties during labor (30-60%)
 * breech delivery
 * first born children are predominant
 * carrying multiples
 * a high rate of hip dysplasia coexists with CMT
 * incidence of torticollis is relatively high at 1 out of 250 live births
 * males have a slightly higher incidence than females
 * right side slightly higher involvement than left side
 * Your evaluation should consist of an accurate history, physical exam, and possible diagnostic testing. The history obtained should consist of onset, pregnancy and birth history. Physical exam will include palpation over the SCM for fibrotic mass, range of motion and strengthen assessment, and other associated problems (gross motor delays, cranial asymmetries). Diagnostic testing is not generally done early on in the treatment process, diagnostic testing is most often performed if improvements are not seen in ROM or strength or if the problem gets worse. Diagnostic testing performed includes X-rays (cervical spine pathology), ultrasound (muscle pathology), MRI (soft tissue pathology) or CT.

= What to expect during the Physical Therapy Examination for CMT =

After a complete history is obtained the examination process with consist of 5 primary objectives; palpation of the SCM for mass or tumor, ROM in cervical lateral flexion and rotation with the use of an arthrodial protractor, muscle function in the lateral flexor muscles of the neck using the Muscle Function Scale (MFS) or head righting reactions and finally and observance of cranial and facial asymmetries (plagiocephaly).

**1. Range of motion for torticollis is most effectively measure with the use of an arthrodial protractor**


Emery Golden et al ||= 110 100-120 90 ||= 85-90 || Beckung ||= 110 ||= 70 ||
 * Normal or Excellent ROM in Neck Rotation and Lateral Flexion for Infants (as stated by various authors)**
 * = **Author** ||= **Normal/Excellent**
 * Rotation** ||= **Normal/Excellent Lateral**
 * Flexion** ||
 * = Bartlett ||= 100-120 ||= 85-90 ||
 * = Cheng et al
 * = Taylor et al ||= >75 ||= >40 ||
 * = Ohman &
 * There is also evidence present by Ohman & Beckung that indicates ROM measurements at 2 months of age were 5 degrees less than the measurements at 4, 6, and 10 months of age.

**2. Muscle Strength and Endurance**
For many children with CMT there is also an imbalance in muscle function around the neck, primarily on the non-affected side, and sometimes excessive muscle strength on the affected side. This presents as the lateral head righting reaction on the opposite side as weaker compared to the affected side. The muscle function scale (MFS) was developed by a Swedish children's hospital to specifically assess lateral head righting in infants. The following tool provides the therapist with a baseline for cervical muscle strength and endurance. By holding the infant horizontally around the trunk without support for the head, lateral head righting reaction is estimated. ====The infant has to hold the head for at least five seconds on one level to achieve the score for that level otherwise it would be scored at the level below. ====



**3. The following examination items are recommended for differential diagnosis (rule in/out other diagnosis)**

 * 1) Visual Field Tracking (ocular/opthalmologic causes)
 * 2) Response to Sound (auditory causes)
 * 3) Reflux or GI complications (Sandifer's Syndrome); a number of infants who experience reflux will often hold their head tilted to one side as a position of comfort
 * 4) Neurologic Examination
 * There are a number of condition associated with CMT to be aware of:**
 * 1) Scoliosis
 * 2) Hip dysplasia (10-20%)
 * 3) Metatarsus adductus
 * 4) Plagiocephaly
 * 5) Cranial asymmetry
 * 6) Brachial plexus injury
 * 7) Delay and asymmetrical motor development
 * 8) Visual field deficits
 * 9) Asymmetrical reflexes
 * 10) Decreased propioceptive input

**4. Observe for cranial and facial asymmetry**
Infants who have torticollis and also sleep on there back are said to be at a greater risk of developing **deformational plagiocephaly** this may also be referred to as **positional plagiocephaly, non-synostotic plagiocephaly or flat head syndrome**. It generally describes a an asymmetrical condition of the head arising from extrinsic molding of the occipital skull. Depending on the severity of the condition, the asymmetrical flattening of the occipital skull may also involve varying degrees of ipsilateral frontal bone protrusion __(frontal bossing)__, asymmetry of the ear position __(anterior shift)__ and facial asymmetry __(noticed at the jaw/cheek and eye position)__. = = = Plagiocephaly and What is it? = In 1992, the American Academy of Pediatrics recommended that healthy infants be positioned on the back or side when the child is put down to sleep. The **"Back to Sleep"** campaign resulted in a significant decrease in the incidence of SIDS. However, the prevalence of **deformational plagiocephaly** at 4 months was recently estimated at 19.7%.

There are 2 primary subgroups of Plagiocephaly:
 * **Posterior Deformational Plagiocephaly**




 * **Deformational Brachycephaly:** The head flattens uniformly, causing a wider and shorter shape, and can also cause increased head height.


 * Deformational plagiocephaly** results from either intrauterine forces or postnatal positioning. Unilateral **deformational plagiocephaly** occurs more often on the right side (54-71%) than the left side.
 * Risk Include: maternal age >35, breech position, prolonged labor and assisted vaginal delivery, oligohydramnios, and male sex. The risk in twins or multiples is much higher than in singletons, with asymmetry found in 56% (Peitsch et al., 2002).
 * Etiology: occurs secondary to CMT, begins in utero and worsens during infancy, inherently soft or pliable cranium, and/or increased supine positioning.
 * Most commonly, deformational plagiocephaly occurs postnatally and is associated with CMT, vertebral anomaly, neurologic impairment or forced sleeping positions. There are few reports that documents any late effects of plagiocephaly other than potential cosmetic concerns and the potential for strabismus, especially involving vertical eye movements (Miller et al., 2000).
 * Deformational plagiocephaly becomes worse in the first weeks of life due to holding the head in a fixed position; then the head shape begins to improve with normal developmental progression involving head control and a full range of neck motion (Miller et al., 2000)
 * In approximately 10% of affected infants with plagiocephaly, there will be a permanent deformity with a mild to moderate cosmetic effect.
 * Research indicates that deformational plagiocephaly does not always correct spontaneously.

= What to expect during the evaluation process: =
 * **Anthropomorphic measurements are obtained using calipers to measure standard cranial diameters**
 * [[image:kumc-ptrs-ebp/calipers.jpg align="right"]]
 * Cranial vault asymmetry (CVA): measurement from the eyebrow to the opposite occiput region
 * Moss proposed defining a severe deformity of a CVA measurement >12mm
 * Diagonal difference
 * Trans cranial vault asymmetry
 * Cranial (or Cephalic) Index is calculated by taking the cranial width divided by the cranial length x 100
 * Several researchers have noted a poor correlation between anthropomorphic measurements and appearance
 * Facial asymmetry


 * **Differential Diagnosis**
 * deformation caused by birthing process generally resolves by 6 weeks of age
 * **deformational plagiocephaly** caused by external molding forces
 * **dolichocephaly** most often seen in premature infants that results in flattening of both sides of the skull
 * **synostotic placiocephaly**is caused by premature fusion of the cranial sutures
 * the prevalence of a true lambdoid synostosis with premature fusion of the suture is estimated at 3 in 100,000 live births
 * a CT will be conducted to rule out synostosis
 * There is reportedly no increased risk of neurologic disability in children with plagiocephaly without synostosis. There are few reports documenting any late effects of plagiocephaly. The only late effects discussed in the literature consist of visual disturbances, orthodontic/oral surgical issues, cosmetic concerns and psycho-social issues (Rekate, 1997).
 * **Brain volume and shape in infants with deformational plagiocephaly (Collett et al., 2012)**
 * A study was conducted utilizing MRI's to examine brain volume and shape in infants with and without plagiocephaly.
 * The study concluded that cases exhibited greater asymmetry and flattening of the posterior brain (p >.001) and cerebellar vermis (p = .035)
 * Shortening of the corpus callosum (p = .012)
 * Differences in the orientation of the corpus callosum (p = .005)
 * Asymmetry and flattening of brain structures were also associated with worse developmental outcomes on the Bayley Scales of Infant and Toddler Development-III (but was not significant)




 * ==**Terminology you may see in a report or hear the therapist discuss with you:**==
 * Cranial vault asymmetry: this is the asymmetry present between the 2 diagonal measurements taken
 * Frontal bossing: protrusion of the forehead on the flattened side
 * Anterior ear shift: it is a frequent occurrence that the ear will shift forward on the flattened side
 * Facial asymmetry: the eye may be offset slightly, one may be squinted more, or one cheek may be fuller than the opposite side
 * Shoulder elevation: especially when torticollis is involved; one shoulder may sit higher than the opposite, this usually occurs on the affected side

= Treatment Recommendation for Torticollis and Plagiocephaly =

>
 * == Treatment options and outcomes for torticollis supported by research :==
 * Manual stretching of the neck muscles are performed primarily for lateral bending/flexion, rotation and flexion/extension
 * Most common stretches performed:
 * http://www.orthoseek.com/articles/ifs-right.html
 * http://www.thebarrow.org/stellent/groups/public/@xinternet_con_bni/documents/webcontent/207044.pdf
 * New studies are showing that a more frequent/intensive PT program with therapist performing stretches versus a home program and parent stretching is more effective at resolving torticollis in a shorter time period.
 * PT performs stretches 3x/week
 * Stretches for rotation and lateral flexion are held 10-30 seconds depending on the infants tolerance with the session lasting approximately 15 minutes, along with a home program for prone positioning during awake time and carrying techniques (Ohman et al., 2010).
 * Stretches performed three sets of 15 stretches, holding the stretch for 1 second, with a 10 second rest in between for 3 days per week, with additional home activities carried out by parents consisting of positioning (Do, 2006) (Cheng et al., 2001).
 * **Duration of treatment in the above studies of those infants with CMT had a mean time frame of 0.9 months to 3.7 months (with PT only stretching and at home positioning)**
 * In the study done by Ohman et al. there was also parent group that performed the stretches (not the PT) 7 days a week along with the same instructions for home program This group also achieved good outcomes with full ROM but with a mean time frame of 3.0 months versus the 0.9 months.
 * Do, T. Congenital muscular torticollis: current concepts and review of treatment. Current Opinion in Pediatrics 2006, 18: 26-29
 * Cheng, J., Wong, M., Tang, S., Chen, T., Shum, S., Wong, E. Clinical Determinant of the Outcome of Manual Stretching in the Treatment of Congenital Muscular Torticollis in Infants. Journal of Bone and Joint Surgery, May 2001; 83: 679-687.
 * Ohman, A., Nilsson, S., Beckung, E. Stretching Treatment for Infants with Congenital Muscular Torticollis: Physiotherapist or Parents? A Randomized Pilot Study. Physical Medicine and Rehabilitation, December 2010, Vol 2: 1073-1079
 * Petronic, I., Brdar, R., Cirovic, D., Nikolic, D., Lukac, M., Janic, D., Pavicevic, P., Golubovic, Z., Knezevic, T. Congenital muscular torticollis in children: distribution, treatment duration and outcome. European Journal of Physical and Rehabilitation Medicine. 2010: 45: 153-158.
 * This study indicated that earlier treatment was indicated; specifically by 3 months of age. Their rationale for this was that younger children have a higher elasticity and less voluntary resistance.
 * There was also a statistical significance on the number of children with torticollis at their first check-up
 * Another reason for early treatment was that children begin developing head control around 3 months of age which would result in head tilting.
 * The study also points out that the older the children are, the duration of treatment significantly rises.
 * Other treatment options:
 * Surgical muscle lengthening is only indicated after therapeutic measures have been ineffective and deformity still persists
 * 12-18 months of age
 * Botox injections have also been used as a fairly new approach to treating CMT.
 * there is limited long term evidence on this technique
 * Joyce et al. published an article in 2004 that reported high satisfaction in a series of 14 patients with Botox injections but there have been no long term studies conducted at this time.
 * Tot Collars
 * Kinesiotape


 * == Treatment options and outcomes of Plagiocephaly supported by research: ==
 * Deformational plagiocephaly can be minimized by providing the infant with a minimum of 30 minutes of "tummy time" while the child is awake each day. Due to the increased risk of plagiocephaly and other delays the American Academy of Pediatrics modified its initial recommendations about "Back to Sleep" to " a certain amount of tummy time while the infant is awake and observed is recommended for developmental reasons."
 * Prior to 3-4 months of age a child can be repositioned, but after this age the effectiveness of this therapy is reduced due to the infant's ability to regulate its own position
 * Children's Healthcare of Atlanta developed a wonderful handout that can be accessed online or distributed through clinics on repositioning and carrying techniques to assist with cranial molding and improving ROM for infants with CMT.
 * http://www.orthomerica.com/pdf/tummytimetools.pdf
 * In approximately 10% of infants with plagiocephaly, there will be permanent deformity with a mild to severe cosmetic deformity. Patients with moderate to severe asymmetry will often be referred for consideration of a cranial orthosis (Miller et al. 2000).
 * For infants who fail to improve with repositioning by 6 months of age and continue to have severe deformity (>12mm), many pediatric neurosurgeons and plastic surgeons recommend treatment with a cranial orthosis.
 * Headbands, helmets, orthoic devices
 * An individual mold or topographic scan is taken of the infant's head and a corresponding helmet is made
 * Passive helmets allow room for growth in the flattened areas while minimal pressure is applied to the areas of bossing
 * Here are some various sites that discuss the different orthotic devices, measuring techniques, and wear time (generally 23 hours/day for 3 months).
 * www.cranialtech.com/index.php?option=com_content...id..
 * www.starbandkids.com/
 * http://www.bostonbrace.com/Content/Boston_Band_for_Plagiocephaly.asp
 * Cranial surgery is almost never indicated for plagiocephaly without synostosis unless the presentation is very severe.

References Robinson, S., & Proctor, M. Diagnosis and management of deformational plagiocephaly. Journal of Neurosurgery: Pediatrics, 2009: 3: 284-295. http://thejns.org.proxy.kumc.edu:2048/doi/pdf/10.3171/2009.1.PEDS08330

Ohman, A., Nilsson, S. & Beckung, E. Stretching Treatment for Infants with Congenital Muscular Torticollis: Physiotherapist or Parents? A Randomized Pilot Study. Physical Medicine and Rehabilitation, December 2010, Vol 2: 1073-1079. []

Do, T. Congenital muscular torticollis: current concepts and review of treatment. Current Opinion in Pediatrics 2006, 18: 26-29

Cheng, J., Wong, M., Tang, S., Chen, T., Shum, S., Wong, E. Clinical Determinant of the Outcome of Manual Stretching in the Treatment of Congenital Muscular Torticollis in Infants. Journal of Bone and Joint Surgery, May 2001; 83: 679-687.

Petronic, I., Brdar, R., Cirovic, D., Nikolic, D., Lukac, M., Janic, D., Pavicevic, P., Golubovic, Z., Knezevic, T. Congenital muscular torticollis in children: distribution, treatment duration and outcome. European Journal of Physical and Rehabilitation Medicine. 2010: 45: 153-158.

Collett, B, Aylward, E., Berg, J., Davidoff, C., Norden, J., Cunningham, M., Speltz, M. Brain volume and shape in infants with deformational plagiocephaly.

Miller, R., & Clarren, S. Long-term Developmental Outcomes in Patients with Deformational Plagiocephaly. Pediatrics. 2000: 105; e26

Pollack, I., Wolfgang, H., Fasick, L., & Fasick, P., Diagnosis and Management of Posterior Plagiocephaly. Pediatrics. 1997: 99;180.

Joyce, M., & DeChalain, T. Treatment of recalcitrant idiopathic muscular torticollis in infants with botirlinum toxin type A. Journal of Craniofacial Surgery. 2004; 16: 321-327.

Peitsch, W., Keefer, C., LaBrie, R., & Mulliken, J. Incidence of cranial asymmetry in healthy newborns. Pediatrics. 2002; 110: 1-8.

Rekate, H. Occipital Plagiocephaly: a critcal review of the literature. Journal of Neurosurgery. 1998; 89: 24-30.

[] [] [] [|www.cranialtech.com/index.php?option=com_content...id..] [|www.starbandkids.com/] []