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Topics in Peds > Congenital Muscular Torticollis > Flashcards

Congenital Muscular Torticollis Flashcards

1
Q

What is congenital muscular torticollis?

A

shortening of the SCM which causes the neck to laterally flex to the affected side and rotate to the opposite side

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2
Q

3 types of congenital muscular torticollis

A
  1. SCM Mass CMT: fibrotic thickening of SCM with PROM limitations
  2. Muscular CMT: SCM tightness and PROM limitations
  3. Postural CMT: Without muscle or ROM restrictions
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3
Q

SCM Mass CMT

A
  • Characterized by head tilt to one side (lateral neck flexion) with neck rotated to opposite side
  • Postural deformity present at birth
  • Palpable mass located in SCM
  • Can be called fibromatosis colli
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4
Q

Etiology of SCM Mass CMT

A
  • unknown
  • trauma to SCM during labor
  • hereditary
  • tar/bleeding of SCM
  • in-utero positioning –> compartment syndrome
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5
Q

SCM Mass CMT

A
  • incidence
  • may be associated with hip dysplasia, BPI, cranial deformity and distal extremity deformity
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6
Q

Muscular CMT

A
  • Asymmetrical position of the head/neck observed at birth may be related to intrauterine position
  • SCM is tight and PROM limitations are present
  • Most common presentation is lateral flexion with contralateral rotation; can also see tilt and turn to the same side
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7
Q

Incidence of muscular CMT

A

3:2 male to female

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8
Q

postural CMT

A
  • Infant presents without muscle or PROM restrictions
  • Places head to “preferred” side
  • Mildest presentation
  • Early identification and early referral key –usually have shorter treatment lengths and needs
  • Associated with deformational plagiocephaly
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9
Q

Container baby syndrome

A

Infant’s mobility and postural alignment is altered due to spending excessive amount of time in “containers” or baby equipment that limits freedom of movement. Results in DP and asymmetries.

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10
Q

Differential diagnosis

A

Brachial Plexus Injuries
Ocular Torticollis
Sandifers
Congenital anomaly/Klippel-Feil
Spinal tumor
Other Diagnoses

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11
Q

Brachial Plexus injuries

A
  • May induce a torticollis due to the infant’s preference to rotate head to the more functional or stronger UE
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12
Q

Ocular Torticollis

A
  • Abnormal head posture utilized to compensate for visual field deficit
  • Common diagnoses related to ocular torticollis include: Duane syndrome, congenital fibrosis of extraocular muscles, congenital nystagmus, visual field defects.
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13
Q

Sandifers

A
  • Rare pediatric manifestation characterized by abnormal and dystonic movements of the head, neck, eyes and trunk; strong association w/ GERD
  • Referral to neurologist is necessary
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14
Q

Congenital anomalies

A
  • Infantile Congenital Scoliosis- present at birth
  • Infantile Idiopathic Scoliosis- considered early onset before age of 3
  • Klippel-Feil Syndrome: Abnormal fusion of two or more bones in the cervical spine
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15
Q

Spinal Tumors

A

CNS tumors: posterior fossa, spinal cord and brainstem ***Acquired torticollis may be first sign of presence of tumor

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16
Q

Benign Paroxysmal Torticollis

A
  • Cervical dystonia of unknown cause
  • changes from side to side
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17
Q

craniosynostosis

A
  • premature fusion of one of the cranial sutures
  • ref flag: refer back to physician –> surgical needs required
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18
Q

hemi vertebrae

A

side bending is limited
hard end feel

19
Q

children who have CMT may also have

A
  • deformational plagiocephaly
  • craniofacial asymmetry
  • hemihypoplasia
  • scoliosis
  • hip dysplasia
  • foot deformities
  • internal tibial torsion
  • BPI
20
Q

Deformational Plagiocephaly

A

▪ Also termed, positional plagiocephaly. Results in cranial flattening and asymmetry.
▪ Side of rotational preference- posterior flattening with opposite bossing of skull and possible forward ear advancement

21
Q

Factors increasing risk of deformational plagiocephaly

A
  • male
  • first born
  • limited neck PROM at birth
  • bottle feeding only
  • tummy time < 3 times a day
  • sleeping with head to the same side/positional preference
22
Q

Management of deformation plagiocephaly

A
  • watch and wait
  • repositioning and PT
  • molding therapy
23
Q

Potential long term effects

A
  • Musculoskeletal deformities –especially rotational
    problems.
  • Visual problems- eyes not working together as expected
  • Proprioceptive problem- poor understanding of body schema and movement in space due to asymmetry of
    development
24
Q

APTA Guidelines of PT role in CMT

A

Educate
Identify
Screening
Referral
Examination
Intervention
Discharge
Follow up

25
Q

education

A

expectant & new parents to prevent asymmetries/CMT

26
Q

screening

A

neurological
MSK
integumentary
vision
GI

27
Q

red flags

A
  • hip dysplasia, skull/facial asymmetry, abnormal tone, plagiocephaly, late-onset torticollis (6 months or older), no improvement after 4-6 weeks of intense PT
28
Q

Pt Exam

A
  • birth and family history
  • red flags and non muscular causes
  • postural alignment
  • strength
  • A/PROM cervical range
29
Q

How to assess strength

A

spontaneous lateral neck flexion and rotation of the head and neck with imposed transitions, note with and against gravity

30
Q

Normal neck rotation

A

110 degrees +/- 6.2

31
Q

normal range of neck lateral flexion

A

70 degrees +/- 2.4

32
Q

chin to nipple on involved side

A

40 degrees

33
Q

chin between nipple and shoulder on involved side

A

70 degrees

34
Q

chin over shoulder of involved side

A

90 degrees

35
Q

chin past shoulder of involved side

A

100 degrees

36
Q

Muscle function Scale for righting reactions

A

0=head below horizontal
1=head in the horizontal 2=head slightly over the horizontal
3=head high over horizontal, <45
4=head high (45-75) over horizontal
5=head very high >75 over horizontal

37
Q

review severity scale

A

slide 41

38
Q

home program

A
  • Parent follow through on home programming is paramount
  • Passive range of motion/ stretching
  • Active range of motion
  • Positioning with environmental adaptations
  • Development and strengthening of symmetrical postures
39
Q

Develop symmetrical patterns

A

● Observe caregiver handling and adjust to promote symmetry of movement
● Discuss daily activities- diaper changes, feeding and dressing- how can they be adjusted to improve alignment and symmetrical strength
● Look at play and teach family set up to promote symmetrical
movement

40
Q

education to families

A

-Offer ways to incorporate in daily routines via holding, playing, carrying and feeding
-Removes pressure from back of the head
-Improve core strength
-Optimizes typical developmental trajectory
-Goal is 50% of awake time in alignment
- need equal frequency of movement pattern between
involved and uninvolved sides

41
Q

more education

A
  • limit time in bouncy chairs
  • look at posture in seating chairs and optimize
  • limit exersaucers and containers
  • no walkers - unsafe
  • minimize car seat time
42
Q

additional possible treatments

A
  • micro current - older child
  • myokinetic stretching
  • kinesiotape
  • TOT collar
43
Q

medical treatment

A
  • Botox
  • surgery
44
Q

discharge and follow up

A

1.Demonstrate full passive neck ROM within 5 degrees
of unaffected side 2.Symmetrical strength, postural alignment and
movement
3.Age appropriate development
4.No visible head tilt
5.Parents able to monitor and continue to incorporate
home program activities in daily routines
*Provide Follow-up: Provide 3-12 month follow up or
when child initiates walking

Topics in Peds (15 decks)

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