Congenital Muscular Torticollis

Question 1

What is Congenital Muscular Torticollis (CMT), and what is its hallmark feature?

Answer 1

Congenital Muscular Torticollis (CMT), also called ‘wry neck’ or ‘twisted neck,’ is characterized by unilateral shortening of the sternocleidomastoid (SCM) muscle, causing lateral flexion (head tilt) to the same side and rotation to the opposite side.

Question 2

What are the three main classifications of cranial deformation associated with CMT?

Answer 2

1. Plagiocephaly: Flattening on one side of the skull, causing ear and facial asymmetry.
2. Brachycephaly: Symmetrical flattening at the back of the head.
3. Dolichocephaly/Scaphocephaly: Elongated skull, often seen in preterm infants.

Question 3

What are common associated conditions with CMT?

Answer 3

Associated conditions include deformational plagiocephaly, facial asymmetry, scoliosis, brachial plexus injury, congenital hip dysplasia, and foot deformities.

Question 4

What are the potential prenatal causes of CMT?

Answer 4

Prenatal causes include intrauterine positioning and ischemic injury leading to compartment syndrome.

Question 5

List potential perinatal and postnatal factors contributing to CMT.

Answer 5

Perinatal factors: Breech presentation, forceps or vacuum-assisted delivery, and birth trauma.
Postnatal factors: Positional preference, plagiocephaly, and reflux.

Question 6

What grading system is used to assess the severity of CMT?

Answer 6

The APTA Clinical Practice Guideline (2018) grades severity from 1-8 based on age at recognition, age at PT evaluation, degree of cervical ROM limitations, and presence of an SCM mass.

Question 7

Differentiate between left and right torticollis in terms of head tilt and rotation.

Answer 7

Left torticollis: Right head rotation and left lateral flexion.
Right torticollis: Left head rotation and right lateral flexion.

Question 8

What is plagiocephaly, and what percentage of infants with CMT also have this condition?

Answer 8

Plagiocephaly is a cranial deformation caused by mechanical forces leading to asymmetry of the skull. Approximately 90% of infants with CMT also have plagiocephaly.

Question 9

What are the differential diagnoses for CMT?

Answer 9

Differential diagnoses include atlantoaxial rotary instability, hemivertebrae, cervical subluxation, posterior fossa tumors, cerebral palsy (CP), Chiari malformation, ocular/vestibular anomalies, and GI disorders.

Question 10

What is the prevalence of CMT in newborns?

Answer 10

The prevalence of CMT in newborns ranges from 0.3% to 16%.

Question 11

What is the typical clinical finding on the SCM in CMT?

Answer 11

A palpable mass or fibrotic pseudotumor may be found on the SCM.

Question 12

What is the role of the Argenta’s clinical classification system in CMT?

Answer 12

Argenta’s clinical classification is used to evaluate the severity of plagiocephaly by assessing craniofacial asymmetry and skull deformation.

Question 13

How does CMT affect muscle function beyond the SCM?

Answer 13

Other muscles involved in CMT include the scalenes, levator scapulae, and upper trapezius, which may contribute to additional asymmetry.

Question 14

What is the significance of birth trauma in the development of CMT?

Answer 14

Birth trauma, such as from forceps or vacuum-assisted delivery, can cause damage to the SCM or lead to positional constraints, increasing the risk of CMT.

Question 15

What GI disorder is associated with postnatal factors contributing to CMT?

Answer 15

Reflux is a postnatal factor that can influence positioning and contribute to CMT development.

Question 16

What is the typical head posture observed in CMT?

Answer 16

In CMT, the head is laterally flexed (tilted) to the side of the affected SCM and rotated to the opposite side.

Question 17

What are the common craniofacial asymmetries associated with CMT?

Answer 17

Craniofacial asymmetries include facial flattening, ear asymmetry, and mandibular deviation due to mechanical forces on the skull.

Question 18

What are the key postures to assess during a physical therapy examination for CMT?

Answer 18

Key postures include supine, prone, sitting, and standing to evaluate head positioning, weight bearing, and symmetry.

Question 19

What are the seven body functions and structures recommended for examination in CMT by the 2018 CPG?

Answer 19

1. Infant posture in multiple positions.
2. Bilateral active cervical rotation, lateral flexion, and diagonal movements.
3. PROM/AROM of extremities.
4. Screening for hip dysplasia.
5. Bilateral passive cervical rotation and lateral flexion.
6. Pain using the FLACC scale.
7. Integumentary evaluation.

Question 20

How is the FLACC scale used in the examination of CMT?

Answer 20

The FLACC scale evaluates pain in infants based on five criteria: Face, Legs, Activity, Cry, and Consolability, providing a score from 0 to 10.

Question 21

What postural asymmetries might be observed in a supine infant with CMT?

Answer 21

Supine asymmetries include a resting head position tilted to one side, limited hands-to-midline movements, and ATNR (asymmetric tonic neck reflex).

Question 22

What are the key developmental milestones to assess in CMT?

Answer 22

Key milestones include tolerance of prone positioning, rolling, pull-to-sit, sitting, crawling, and symmetrical weight-bearing in standing.

Question 23

How is AROM of cervical rotation assessed in infants with CMT?

Answer 23

AROM of cervical rotation is assessed in supine, sitting, and prone positions, often using visual tracking with a toy or object.

Question 24

What is the purpose of the Muscle Function Scale in the examination of CMT?

Answer 24

The Muscle Function Scale measures active head righting in infants, providing an assessment of SCM muscle strength and functional alignment.

Question 25

What integumentary findings are important in the examination of CMT?

Answer 25

Important findings include skin integrity, redness, symmetry of skin folds (e.g., thigh and gluteal), and the presence of an SCM nodule or fibrous band.

Question 26

What additional craniofacial assessments are recommended in CMT?

Answer 26

Assessments include evaluation of ear alignment, mandibular symmetry, and overall head shape to identify deformational plagiocephaly or asymmetry.

Question 27

How does asymmetrical weight-bearing in prone positioning present in infants with CMT?

Answer 27

Infants with CMT may show a preference for weight-bearing on one upper extremity, with difficulty maintaining midline alignment during prone play.

Question 28

What findings might indicate the presence of hip dysplasia in infants with CMT?

Answer 28

Findings include asymmetrical thigh or gluteal folds, limited hip abduction, and instability during passive hip assessments.

Question 29

What visual tracking assessments are recommended for infants with CMT?

Answer 29

Visual tracking is assessed using toys or objects to encourage active cervical rotation and lateral flexion in all planes of motion.

Question 30

What ROM limitations are typically observed in infants with CMT?

Answer 30

Typical ROM limitations include decreased cervical rotation to the side opposite the affected SCM and limited lateral flexion toward the unaffected side.

Question 31

What are the key components of conservative PT management for CMT?

Answer 31

Conservative PT management includes cervical PROM/stretching, active cervical and trunk strengthening, visual tracking, head righting, midline control, prone play, symmetrical developmental skills, and parent education.

Question 32

What is the purpose of prone positioning in CMT management?

Answer 32

Prone positioning encourages head and neck extension, promotes symmetrical upper extremity weight-bearing, and strengthens the cervical and trunk muscles.

Question 33

What is the recommended frequency for cervical stretching in infants with CMT?

Answer 33

Cervical stretching should be performed daily, focusing on improving cervical rotation and lateral flexion toward the restricted sides.

Question 34

How is visual tracking used in CMT management?

Answer 34

Visual tracking involves using toys or objects to encourage active cervical rotation and lateral flexion, improving range of motion and muscle function.

Question 35

What role does parent education play in managing CMT?

Answer 35

Parent education focuses on proper positioning, tummy time, carrying techniques, and incorporating stretching and strengthening exercises into daily routines.

Question 36

What positioning strategies are recommended for infants with CMT?

Answer 36

Recommended strategies include side-lying, midline head positioning in the car seat and crib, and minimizing prolonged use of devices like swings or bouncers.

Question 37

What is the role of kinesiotaping in CMT management?

Answer 37

Kinesiotaping supports weakened muscles, facilitates proper alignment, and improves proprioception in the cervical and trunk regions.

Question 38

At what age is referral for cranial orthoses typically recommended in cases of plagiocephaly?

Answer 38

Referral for cranial orthoses is typically recommended at 4-5 months of age if conservative management does not improve cranial asymmetry.

Question 39

What are the names of common cranial orthoses used in CMT and plagiocephaly management?

Answer 39

Common cranial orthoses include the DOC Band (Dynamic Orthotic Cranioplasty) and STAR Band (Symmetry Through Active Remolding).

Question 40

What are the medical interventions for severe CMT cases?

Answer 40

Medical interventions include Botox injections, surgical release of the distal SCM, splinting post-op, and vision screening for superior oblique palsy.

Question 41

What criteria indicate the need for surgical intervention in CMT?

Answer 41

Surgical intervention is indicated for persistent SCM tightness, poor response to PT, or the presence of a fibrotic mass that limits cervical motion.

Question 42

What is the purpose of a TOT collar in CMT management?

Answer 42

A TOT (Tubular Orthosis for Torticollis) collar provides support for head alignment and encourages active cervical rotation and strengthening.

Question 43

What developmental skills are targeted during PT for CMT?

Answer 43

Targeted skills include symmetrical rolling, transitions, crawling, creeping, and pull-to-sit with equal weight-bearing through the extremities.

Question 44

Why is early intervention critical in the treatment of CMT?

Answer 44

Early intervention prevents secondary complications such as craniofacial asymmetry, delays in developmental milestones, and permanent range of motion limitations.

Question 45

What specific post-op care is required after surgical intervention for CMT?

Answer 45

Post-op care includes stretching exercises, splinting, pain management, and progressive strengthening to maintain cervical ROM and alignment.

Question 46

A 2-month-old infant presents with left lateral head tilt and right cervical rotation. A small nodule is palpable in the left SCM. What is the likely diagnosis and appropriate initial treatment?

Answer 46

The likely diagnosis is left-sided Congenital Muscular Torticollis (CMT) with a fibrotic SCM mass. Initial treatment includes daily cervical stretching, active strengthening, prone positioning, and parent education.

Question 47

During a PT evaluation, a 4-month-old infant is noted to have a flattened posterior skull on the right side and facial asymmetry. What condition is likely associated with CMT, and what intervention is indicated?

Answer 47

The infant likely has plagiocephaly. Recommended interventions include repositioning strategies, increased tummy time, and referral for cranial orthoses if asymmetry persists beyond 5 months.

Question 48

A parent reports their infant prefers turning their head to the left during feeding and play. Examination reveals limited cervical rotation to the right. What condition should the therapist assess for, and what strategies should be implemented?

Answer 48

The therapist should assess for right-sided CMT. Strategies include right cervical stretching, visual tracking exercises to the right, and positioning to encourage right cervical rotation.

Question 49

An 8-month-old infant presents with persistent SCM tightness despite conservative PT. What medical intervention might be considered, and why?

Answer 49

Surgical release of the SCM may be considered to address persistent tightness and restore cervical range of motion.

Question 50

A 6-month-old infant shows significant asymmetry in cervical ROM, with no improvement despite parent adherence to the home program. What is the next step in management?

Answer 50

The next step includes reassessment of the treatment plan, possible referral for cranial orthoses, and consideration of additional medical interventions like Botox or surgical evaluation.

Question 51

An infant with CMT is unable to maintain midline alignment during prone play. What PT interventions can address this issue?

Answer 51

Interventions include prone positioning to strengthen the cervical and trunk extensors, active midline head control exercises, and parent-guided symmetrical play activities.

Question 52

A 3-month-old infant diagnosed with CMT is noted to have asymmetrical thigh and gluteal folds. What condition should also be screened, and how?

Answer 52

The infant should be screened for developmental hip dysplasia using physical examination techniques like Ortolani and Barlow maneuvers.

Question 53

A parent asks how to reduce their infant’s positional preference for one side during sleep. What recommendations should the therapist provide?

Answer 53

Recommendations include alternating the infant’s sleep position, using a side-lying position during supervised awake times, and incorporating midline positioning during play.

Question 54

A parent is concerned about the visible flattening of their infant’s head despite increased tummy time. What additional interventions might be necessary?

Answer 54

If flattening persists despite repositioning and tummy time, referral for cranial orthoses may be necessary to correct the asymmetry.

Question 55

During a reassessment, an infant shows improved cervical ROM but continues to exhibit slight craniofacial asymmetry. What is the next step in the treatment plan?

Answer 55

Continue ROM and strengthening exercises while monitoring cranial symmetry. If asymmetry persists, refer for cranial orthoses to address residual deformity.