Congenital Muscle Torticollis

Question 1

Etiology of Torticollis

Answer 1

• Ischemia
• Birth Trauma
• Intrauterine Malposition
• Injury to muscle
• Ischemic injury based on abnormal vascular patterns
• Rupture of the muscle
• Infective Myotosis
• Neurogenic Injury
• Hereditary factors
• Intrauterine compartments syndrome

Question 2

What leads to the development of a prerinetal compartment syndrome?

Answer 2

Head position in utero that selectively injures the SCM muscle
-Explains upper extremity weakness on the same side as the involved SCM muscle

Question 3

Position of the head and neck in utero or during labor and delivery of forward flexion, lateral bending, and rotation may cause a compression injury of the…

Answer 3

Ipsilateral SCM muscle and brachial plexus, resulting in ischemia, reperfusion, edema and neurologic injuries

Question 4

Muscular Torticollis

Answer 4

• 3rd most common congenital musculoskeletal anomaly after dislocated hip and clubfoot (incidence ranges from 0.3% to 1.9% of newborns)
• Associated with ipsilateral mandibular symmetry, ear displacement, plagiocephaly, scoliosis, pelvic asymmetry, congenital dislocated hip, and foot deformity

Question 5

Plagiocephaly (flat head syndrome)

Answer 5

• May identify neurocognitive differences or delay disorders among patients who may have appeared normal before the change in sleep position
• Incidence increased since it was recommended infants sleep on their backs to prevent sudden infant death syndrome (1 in 60 births)

Question 6

Torticollis

Answer 6

• Most newborns exhibit mild or moderate craniofacial asymmetries
• Possible to detect early in life
• Identified by measuring neck rotation and neck lateral flexion and by comparing left and right side neck mobility
• > 15% difference when comparing the two sides

Question 7

Infants born with Torticollis are at risk for developing…

Answer 7

Plagiocephaly (risk may be reduced by early intervention)

-Coexisting impairment in 80-90.1% of cases

Question 8

Risk Factors for Muscular Torticollis and Plagiocephaly

Answer 8

• Large birth weight
• Male gender
• Breech position
• Multiple birth
• Primiparous mother
• Difficult labor and delivery
• Use of vacuum or forceps assist
• Nuchal cord (wrapped around neck)
• Maternal uterine abnormalities

Question 9

Appearance of a fibrous tumor in Torticollis

Answer 9

• Usually 1 to 3cm in diamater and spindle shaped in the SCM btw 14-21 days after birth
• First appearance can be as late as 3 months
• Tumor disappears by the time the patient is 4 to 8 months old
• Pseudotumor of Infancy: diagnosis made within 2 to 6 weeks after birth
• Tumor is characterized by deposition of collagen and fibroblasts around individual muscle fibers with an absence of normal striated muscle

Question 10

Associated head tilt with Torticollis may be due to…

Answer 10

(1) The healthy myoblasts degenerate
(2) The remaining fibroblasts produce excess collagen, which results in a scar like band and muscle contracture
(3) The infant is unable to maintain a vertical head against gravity in static posture or during transitional movement

Question 11

Non-Muscular Causes for Torticollis

Answer 11

• Skeletal abnormalities (Klippel-Feil syndrome)

- Neurologic Causes (brachial plexus injury)

Question 12

Acquired Nontraumatic Torticollis

Answer 12

May be caused by ocular lesions

• Sandifer syndrome
• Benign Paroxysmal Torticollis
• Dystonic Syndromes
• Posterior fossa pathology
• Postencephalitis syndromes
• Arnold Chiari malformation
• Syringomyelia

Question 13

Typical Activity Limitations in CMT

Answer 13

-Unable to have purposeful symmetric movements of the head because of the neck muscle contracture and neck muscle strength imbalances
-Impaired mobility that leads to persistent asymmetry of early reflexes and reinforcement of an asymmetric postural preference
-Secondary Impairement: Neglect. of ipsilateral hand, decreased visual awareness of ipsilateral field, interference of symmetric development of head and neck righting reactions
-Delayed propping and rolling over to the side
-Limited vestibular, proprioceptive, and sensorimotor development
-

Question 14

Early Activity Limitations in CMT can lead to…

Answer 14

-Asymmetrical weight bearing in sitting, crawling, walking, and transitional movement skills and incomplete development of automatic postural reactions

Question 15

What happens if activity limitations in CMT are not addressed?

Answer 15

• May cause postural asymmetries causing structural deformities such as pelvic obliquity and scoliosis
• Inability to rotate the head and neck results in the child rotating the body to compensate
• Inability to recruit lateral neck flexion with automatic reactions cause the child to compensate with overuse of the trunk muscles
• The child with CMT may clinically present as a child with hemiplegic cerebral palsy

Question 16

Systems contributing to Activity Limitations

Answer 16

-Musculoskeletal system: Limited cervical range of motion and muscle strength
-Sensory Systems of vision, vestibular function, and somatosensation needed to regulate posture
(systems also influence adaptive and anticipatory responses to help control head position and anticipate postural adjustments by adapting head positions during weight shifts and active exploration)

Question 17

The infant with CMT responds to imposed restrictions with…

Answer 17

• Self-initated movements that include a pattern of head tilting to the ipsilateral side and rotation to the contralateral side of the SCM muscle involvement
• Then unable to adapt appropriately to the supporting surface and has limited kinesthetic feedback (affects the development of the sensorimotor systems, postural organization, orientation, and body schema)

Question 18

The infant may demonstrate difficulty participating in activities toward the involved SCM muscle side while developing appropriate…

Answer 18

postural, motor, and visual control of the uninvolved side. The infant may not exhibit organized midline behavior as a result of the foregoing asymmetries.

Question 19

Motor milestones may develop atypically in CMT because…

Answer 19

The various subsystems (visual, vestibular, somatosensory, and musculoskeletal) are developing asymmetrically and the infant is not experiencing normal interactions of each system as growth and development occur.

Question 20

CMT Intervention

Answer 20

• Directed toward resolving each impairment or activity limitation identified during the therapy assessment.
• Currently, most authors advocate conservative, nonoperative treatment for CMT. -Conservative intervention typically consists of passive neck ROM exercise
• Equally important to include is active assistive ROM, strengthening, and postural control exercises.
• Caregivers are instructed in how to carry and position the infant to promote elongation of the involved SCM as well as how to promote active contraction of the contralateral SCM.
• Caregivers are also instructed in developmental exercises and how to reposition the child to prevent progression of deformational plagiocephaly