Congenital Muscular Torticollis Flashcards
definition:
postural deformity evident shortly after birth
typically presenting as side bending of the neck to one side and head or chin rotation to the opposite side
due to shortening of sternocleidomastoid muscle on one side of the neck
may be accompanied by other msk or neurological conditions
named by:
side of the tight muscle
torticollis R sided =
nose/face rotates to L
R ear tilts to R shoulder
tight R SCM muscle
incidence:
1 in 6 newborns (16%)
more prevalent in males - 3:2
15% of babies with CMT also have hip dysplasia
CMT frequently is accompanied with cranial deformation = distortion of shape of skull due to mechanical force occurring prenatally and postnatally
types of CMT
postural
muscular
SCM mass
postural CMT
most mild form
infant exhibits postural preference without muscle tightness or restriction to PROM
muscular CMT
characterized by tightness of SCM muscle and limitation of PROM
SCM mass CMT
most severe form
presents with thickening of SCM muscle and restricted PROm
etiology:
prenatal factors
perinatal factors
postnatal factors
prenatal factors:
longer body length
intrauterine crowding
perinatal factors:
birth trauma
postnatal factors:
positional preference
containers
gastrointestinal reflux
identification - who?
physicians
nurse
midwives
obstetrical nurses
nurse practitioners
lactation specialists
PTs
any clinician or family member
identification - what?
refer infants to their primary physician and a PT with expertise in infants
identification - when?
earlier the better if they notice:
postural preference
reduced cervical ROM
SCM mass
craniofacial asymmetry
prognosis:
referral before 1 month
98% of infants achieve near normal range within 1.5 months
prognosis:
referral between 1-6 months
prolongs interventions to about 6 months
prognosis:
referral after 6 months
requires 9+ months of intervention with fewer infants achieving near normal range
possible complications if untreated:
1) trouble bringing their hands to midline
2) delayed visual development and visual tracking
3) problems with motor planning
4) decreased or limited protective responses on affected side
5) asymmetrical motor skills and transitional movements
6) cranial deformation
**they are always lying on that side
shortening of the ____ shortly after birth
sternocleidomastoid
named by ____
side of tight muscle
frequently accompanied with ____
cranial deformation
can lead to delays in ____ and ____
motor
visual development
_______ and ______ is key
early diagnosis
treatment
Examination:
document infant history
routines
exam body structures
strength and mobility
Family Interview - History
Age at initial visit (chronological and corrected age)
Age of onset of symptoms
Pregnancy history including maternal sense of whether the baby was “stuck” in one position during the final 6 weeks of pregnancy
Delivery history including birth presentation (cephalic or breech); use of assistance during delivery such as forceps or vacuum suction
Head posture/preference and changes in the head/face
Family history of torticollis or any other congenital or developmental conditions
Other known or suspected medical conditions
Developmental milestones appropriate for age
Family Interview - Routines
feeding
sleeping
tummy time
time in equipment/devices
daycare/sitter
Posture and Positioning
Observe the infant in all positions, documenting alignment, preferred positioning, posturing, and tolerance
supine
prone
supported upright positions
sidelying
supine =
Document the side of torticollis, asymmetrical hip, trunk, and extremity positions, facial and skull asymmetries, restricted AROM
prone =
Document asymmetry of the spine, the head on the trunk, asymmetrical use of the extremities, and the infant’s tolerance
supported upright positions =
Document asymmetrical preferential postures and compensations in the shoulders, trunk, and hip
side lying =
Document asymmetries, trunk flexion or extension, head lifting, leg position
Bilateral AROM – Cervical Rotation and Lateral Flexion
Assess in supine and supported upright if age appropriate
Asymmetrical and compensatory movements can indicate muscle tightness, restrictions or weakness
Treatment to improve AROM consistent with goals of early intervention
Bilateral PROM – Cervical Rotation and Lateral Flexion
Severity of CMT determined by difference between left and right PROM measures of cervical rotation
Normal value passive cervical rotation for child
< 12 months:
110 ± 6 degrees
Normal value passive lateral flexion for child
< 12 months:
70 ± 2.4 degrees
Bilateral AROM/PROM – Upper and Lower Extremities
Document infant’s natural movements
Passively move arms and legs through all available range at each joint
Passively move ribs and spine
Bilateral AROM/PROM – Upper and Lower Extremities
rule out:
Developmental dysplasia of hip (DDH): observe for symmetry and stability of hip, leg length symmetry, gluteal skin folds, hip scour test, Barlow and Ortolani Maneuvers
Brachial plexus injuries or clavicle fractures
Neurological impairments
Hypermobility
CNS lesions
Scoliosis
Document any behaviors reflective of ____ reactions in the infant and child during the examination process
discomfort, or pain
Pain or Discomfort =
Pain is not typically associated with the initial presentation of CMT
The FLACC is recommended to document baseline status
The PT should work with the parents and caregivers to differentiate actual pain responses from discomfort or behavioral reactions to stretching, anxiety, or the stress of an unusual environment.
Skin Integrity =
Document skin integrity
Symmetry of neck and hip skin folds
Presence and location of SCM mass
Size, shape and elasticity of SCM muscle and secondary muscles
Up to 90% of infants with CMT will also have ___
craniofacial asymmetry
Craniofacial Asymmetries and Head/Skull Shape:
Document cranial deformities, including plagiocephaly, brachycephaly, and dolichocephaly
Craniofacial asymmetries on the side of the torticollis may include:
smaller and elevated eye with changes in the orbit
recession of the ipsilateral ear
a reduced jaw height with malocclusion
possible gum line asymmetry
Cranial Deformations =
Plagiocephaly
Brachycephaly
Dolichocephaly
Plagiocephaly –
most common type of infant flat head syndrome. Generally, the back of the baby’s head is flat on one side
Brachycephaly –
second most common type of flat head syndrome. The back of the head is flattened instead of curved
Dolichocephaly –
less common type of flat head syndrome
The head is flattened on both sides
Severity Ratings: Plagiocephaly
Cranial Vault Asymmetry Index (CVAI):
Mild: 3.7
Moderate: 5.2
Severe: 7
Severity Ratings: Brachycephaly
Cephalic Ratio (CR):
Mild: 81-86
Moderate: 87-92
Severe: 92
Craniosynostosis vs Plagiocephaly
affect the shape of an infant’s skull
Premature closure of one or more cranial sutures
Prevalence ranges from 0.4% to 0.07%
Requires referral to neurosurgery
Plagiocephaly =
ipsilateral frontal bossing
ispilateral displaced anteriorly
ipsilateral occipitoparietal flattening
contralateral occipital bossing
Craniosynostosis =
contralateral frontal bossing
ispilateral displaced posteriorly
ipsilateral occipitomastoic flattening
ipsilateral occipital bossing
contralateral bossing
Gross Motor Function
Test of Infant Motor Performance (TIMP)
Alberta Infant Motor Scale (AIMS)
Peabody Developmental Motor Scales (PDMS-2)
Test of Infant Motor Performance (TIMP):
0-4 months
Alberta Infant Motor Scale (AIMS):
0-18 months
Peabody Developmental Motor Scales (PDMS-2):
0-5 years
*Gross Motor Subtests
Muscle Function Scale (MFS):
- head very high above horizontal line - almost vertical position
- head high above horizontal line and more than 45 degrees
- head high above horizontal line but below 45 degrees
- head slightly above horizontal line
- head on horizontal line
- head below horizontal line
Severity Level Classification
grade 1: early mild
grade 2: early moderate
grade 3: early severe
grade 4: later mild
grade 5: later moderate
grade 6: later severe
grade 7: later extreme
grade 8: very late
grade 1: early mild
0-6 mo: postural preference OR passive cervical rotation difference < 15°
grade 2: early moderate
0-6 mo: passive cervical rotation difference between sides 15-30°
grade 3: early severe
0-6 mo: SCM mass OR passive cervical rotation difference between sides > 30°
grade 4: later mild
7-9 mo: postural preference OR passive cervical rotation difference < 15°
grade 5: later moderate
10-12 mo: postural preference OR passive cervical rotation difference < 15°
grade 6: later severe
7-9 mo: passive cervical rotation difference > 15°
10-12 mo: passive cervical rotation difference 15-30°
grade 7: later extreme
7-12 mo: SCM mass
10-12 mo: passive cervical rotation difference > 30°
grade 8: very late
12+ mo: SCM mass, any asymmetry, OR any passive cervical rotation difference
Treatment – First Choice
Neck PROM
Neck & Trunk AROM
Symmetrical Movement Development
Environmental Adaptations
Parent/Caregiver Education
Neck PROM –
Gentle stretching
Should not be painful to baby and stopped if infant resists or parent perceives changes in breathing or circulation
Each cheek on caregiver’s chest or floor.
Neck & Trunk AROM –
Exciting things to the non-preferred side. Tummy time, short spurts, total > 1hr/day.
Symmetrical Movement Development –
Both sides, both ways.
Sidelying, rolling, reaching.
Want bend and twist, not arching.
Environmental Adaptations–
Carry baby vs keeping them in holders, use towel rolls inside of swing or holder
Parent/Caregiver Education–
Alternate sides for holding, feeding and changing diaper
Discharge Criteria:
PROM within 5 degrees of the non-affected side
Symmetrical active movement patterns
Age-appropriate motor development
No visible head tilt
Parents/caregivers understand what to monitor as the child grows
Re-Assess:
3-12 months following discharge from PT intervention OR when the child initiates walking
Re-evaluation should include:
Positional preference
Symmetry of movement
Developmental milestones
Consult Primary Care:
- When asymmetries of the head, neck, and trunk are not starting to resolve after 4-6 weeks of comprehensive intervention.
- After 6 months of treatment with a plateau in resolution.
Cranial Reshaping Helmet?
Head shaping not improving with positioning
4-10 months old
Length depends on severity
Examination includes:
infant history, routines, body structures/posture, strength and mobility
Use ___ to classify severity level
decision tree
Follow ___ interventions
first choice
Use discharge criteria for ___ and ___
developing goals
plan of care
