Congenital Muscular Torticollis + Cranial Abnormalities Flashcards
1
Q
Congenital Muscular Torticollis (CMT) Defined
A
- Asymmetrical posturing of the head and neck resulting in a variable degree of lateral head tilt + rotation
- “Wry neck”
2
Q
Associated impairments/findings w/ CMT
A
- Hip dysplasia→ incd risk w/ incd severity of torticollis (bc in-utero pos’ing)
- Brachial Plexus injury (BPI), distal extremity deforms (Metatarsus Adductus, club foot), dev. delays, face/skull asymm, TMJ dysf
3
Q
Primary issue resulting in CMT
A
Fibrosis of SCM
SCM→ IPSILAT flexion c/s, CONTRALAT rotation c/s
4
Q
Fibrosis of ________=== primary issue in CMT
A
SCM
5
Q
How is Torticollis named?
A
Named for side of HEAD TILT****
6
Q
CMT Clinical Presentation:
A
- Head tilt to IPSILAT (same) side, rotation to CONTRALAT (opp) side
-
NAMED FOR SIDE OF HEAD TILT***
- Ex. Right torticollis
- Right head tilt, left cervical rotation
- Ex. Right torticollis
7
Q
Causes of CMT
A
- True cause→ unknown
-
Risk factors→
- Packaging issues/fetal crowding== MOST COMMON (esp first-born)
- multiple births (twin A impacted most), tumor on SCM, breech pos (butt first), prolonged labor, LGA >8.5lbs, poor post-natal pos’ing
8
Q
Breech===
A
Butt first
9
Q
Differential Dx for CMT
A
- Klippl-Fell Syndrome, bony abnorms, Neuro syndromes, Brachial plexus injury, ocular defects, auditory defects, GERD
10
Q
Differential Dx for CMT
Klippl-Fell Syndrome
A
Rare dis. w/ congenital fusion of 2/7 cervical spine vertebrae
11
Q
Differential Dx for CMT
Bony abnorms
A
Hemivertebra
bloc vertebra
12
Q
Differential Dx for CMT
Neuro Syndromes: Benign Paroxysmal Positional Torticollis (BPPT)
A
Torticollis switches sides*
Self-limiting and resolves w/out intervention
13
Q
Differential Dx for CMT
BPI
A
Can be w/ or w/out clavicular fx
14
Q
Differential Dx for CMT
Auditory defects
A
Chronic ear infxs
15
Q
Differential Dx for CMT
GERD
A
Baby tries to arch head/neck AWAY from sensation==> Torticollis
16
Q
Tests/Imaging for Torticollis
A
US, Xrays,
Severe cases→ CT/MRI
17
Q
Torticollis Prognosis
2 Key Things:
A
- Earlier referral=== better/faster resolution of sx’s
- MOST have full resolution of sx’s when RX started prior to age 1
18
Q
Better outcomes for torticollis when?
A
EARLIER THE BETTER
If RX started prior to age 1
19
Q
Torticollis prognosis
A
- Earlier referral===better/faster resolution sx’s
- prevents 2* impairs
- MOST have full resolution when RX started prior to age 1
- Residual head tilt may be present
-
May see re-emergence of head tilt posture when acquiring new motor skills
- bc forget about it while learning/focusing on new skills***
20
Q
We should see AND observe CMT by when for best outcomes?
A
3 months
21
Q
Torticollis Exam:
The Hx
A
- Age @ initial visit (we want <3mos), age of onset sx’s,
-
Pregnancy hx:
- baby “stuck” in one pos, # of pregnancy
-
Delivery info:
- Vag or C-section
- cephalic or breech
- forceps? suction?
- how long did mom push (2nd stage labor)
22
Q
Additional Subjective Info for CMT Exam:
A
- Family hx?→ if yes==poor post-natal pos’ing
- Head posture/preference, face changes
- Dev. milestones not approp for age
- med cond’s
-
pos’ing t/o day:
- jumpers, car seats, strollers, swings, bouncers
- Prone tolerance**→ poor in children w/ CMT
23
Q
Screening Systems
MSK
A
- Facial features/symmetry, posture in supine/upright, skull shape bc flat head, entire spine, shoulder, hips,
- *palpation of entire length of mm belly for fibrosis or mass→ SCM
24
Q
Screening Systems
Neuro
A
- r/o more serious causes, look for abnorm tone, age approp reflexes, CN integrity,
- Look for appearance of BPI→ abnorm mvmt/low mm tone of one UE
25
Screening Systems
## Footnote
**Vision screen**
* Tracking ability, nystagmus, perceptual deficit→ **posture in supine vs upright**
* **Visual torticollis→** abnorm posture _resolves in supine_ and _returns in upright_ due to **lack of horizon in supine**
26
Screening systems
**Auditory screen**
* Assess response to name, sound, music toys
* Does child suffer from chronic ear infxs?
27
Screening Systems
## Footnote
**Integumentary**
* Skin fold asymm→ **neck and glutes**
* Color, cond of neck fold skin **on side of torticollis bc head tilt compressing skin**
* **maybe open/foul odor**
28
Screening Systems
## Footnote
**Cardiorespiratory**
* rib expansion, B/L clavicular mvmts, resp distress or accessory breath sounds i.e. **wheezing**
29
Screening Systems
**GI**
Torticollis + _______ **go hand and hand\*\*\*\***
Torticollis and reflux \*\*\*\*\*\*
30
Screening Systems
## Footnote
**GI**
* Hx via parent report
* **constipation or reflux→ _Reflux and torticollis go hand and hand_\*\*\*\***
* preferential feeding one breast or side
* arching behaviors
31
Torticollis **Red Flags**
## Footnote
**\*if hx or screening indicate any of the following a referral back to primary MD indicated**
* Suspected hip dysplasia
* Plagiocephaly/skull deform and facial asymm.
* **Atypical presentation→** Tilt/Turn to SAME side OR plagiocephaly and torticollis SAME side\*\*\*
* Abnorm tone
* **Late onset \>6mos**→ maybe neuro impair
* Visual abnorms→ gaze aversion, inconsist tracking
* Hx of acute onset usually == trauma or acute illness
32
Musculoskeletal Exam:
* **Document→** posture + B/L CS AROM/PROM into **rotation, LF, ext**
* likely resting head tilt w/ or w/out rotation, ipsilat shoulder elevation, anterior CS tight limits CS ext=poor prone skills, ROM/posture of entire length of spine bc trunk component present in severe cases
* A/PROM all 4 extremities
* **Palpation of SCM + assoc'd structures**
* Tightness→ upper traps, levator scap, scalenes, hyoids
33
Assessing **PROM** in infant w/ CMT
* Research says use→ **arthrodial protractor**
* Goni/angle finder OK too
* PROM/AROM **cervical rotation**
* **Position→** Supine
* **Stationary arm→** neutral
* **Moving arm→** follows child as they rotate in line w/ nose
* Look down onto cranium from supine
* PROM/AROM **lateral flexion**
* **Pos→** Supine
* **Stationary arm→** pointing towards belly button
* axis @ chin
* **Moving arm→** middle of cranium
34
MSK Exam for CMT cont'd
## Footnote
**Strength assessment:**
* Assess ability to **laterally flex (**should be 4mos) against gravity OR right their head to horizon→ **Muscle Function Scale (MFS)**
* Time ability to hold pos.→ **mm endurance**
35
MSK Exam for CMT
## Footnote
**Developmental Assessment:**
* Look for:
* asymm in skills, delay in milestones,
* **Rolling (typ to see rolling to _contralateral side first)_**
* Delay in prone skills, SLOW to crawl/creep
* Most w/ CMT enjoy standing sooner bc **less stress on CS**
36
MSK Exam for CMT
## Footnote
**Approp. standardized assessments to use:**
TIMP, AIMS, PDMS-2
37
Muscle Function Scale
Assesses **ability to lateral flex against gravity** OR **right head to horizon**
38
In general, CMT **should NOT be painful**
## Footnote
**T/F????**
TRUE!!!!!!!
39
MSK EXAM CMT
## Footnote
**Pain**
* Assess discomfort @ rest→ **FLACC scale should be used\*\*\*\***
* **CMT should NOT be painful!!!**
40
MSK Exam CMT
## Footnote
**Cranial Anthropometrics:**
* Facial asymmetries
* Skull deforms:
* **plagiocephaly**
* **brachiocephaly**
* **Combination\*\*\***
41
Tx of CMT
* Principle**→ STRETCH** **tight side**, **STRENGTHEN** **weak side**
* **CPG 3 categories:**
* “First Choice”→ **most evidence\***
* “Supplemental”→ not as strong evidence
* Interventions not supported by any
42
First Choice Interventions basic principle:
**Strengthen** weak side
**Stretch** tight side
43
First Choice Interventions listed:
* Neck/Trunk PROM and AROM
* Developmental skills w/ emphasis on symmetrical mvmt
* Parent/caregiver edu.
44
First Choice Interventions:
## Footnote
**Neck/Trunk PROM**
Positioning or manual maneuvers
Should be **comfortable** → NO _fighting_ stretch\*\*\* (remember example of older PTs doing this----BAD!)
45
FIRST CHOICE INTERVENTIONS
## Footnote
**Neck and Trunk AROM**
Rotation, LF, mvmt into upper quadrants
46
First Choice Interventions:
**Developmental skills→** emphasis on _symmetrical mvmt_
**What is _VERY EFFECTIVE_ for this?**
TUMMY TIME!!!
47
First Choice Interventions:
**Developmental skills→** emphasis on _symmetrical mvmt_
* **Strengthen→** rotators, extensors, LFs
* **TUMMY TIME\*\*\***
* **Devices→** theraball, swings, wobble boards, wedges, boppy pillows
**NOTE:** LF emerges **4mos\*\*\***
48
First Choice Interventions:
Parent/Caregiver Edu.
* **Environmental adaptations:**
* positioning, stretching/strengthening,
* tips for carrying, feeding, room set up
* **Stress importance of daily HEP**
* \*Routine-based activities **into what they are _already_ doing!!!**
* try to implement into routine so its not new and adherence will be higher!
49
Interventions for Stretching\*\*\*
* Stretching/positioning
* **AVOID** pressure to **jaw, ear, cheek**
* **\*stabilize shoulder to prevent _compensations_**
50
Interventions: **Strengthening**
see pics
51
Supplemental Interventions
## Footnote
**\*lower lvls of _evidence_ to support use**
* Microcurrent e-stim, custom fabricated cervical orthoses, K-taping to **contralat. neck to _facilitate_ _lateral righting rxns_,**
* **Tubular Orthosis for Torticollis (TOT collar)**
52
Additional Interventions W/OUT Supporting Evidence
\***Documented and widely used in tx of CMT→ insuff. evidence to support use and further research indicated**
STM
Cranial sacral techniques
Total Motion Release (TMR)
53
Lapses in Improvement…..**Why?**
Illness, constipation, poor night's sleep, teething, **growth spurts\*,** gaining new skills (and forget about torticollis ex's)
54
When to **Refer Back to PCP**
* **Child NOT progressing after:**
* 4-6wks intense PT
* 6mos of PT w/ **only mod resolution**
* Infant \>12 months @ IE **and a 10-15\* diff persists**
* Mass present in infants **\>7mos**
* may be more serious cond.
* **MAY be Indicated for Botox to tight SCM OR sx release of SCM\*\*\***
55
When to D/C
We want them to be doing what???
**_WALKING_ W/OUT HEAD TILT\*\*\***
56
WHEN TO D/C
* When **ROM is w/in 5\*** of uninvolved side\*\*\*
* On target for motor skills and **no asymm of motor skills present**
* **NO** visible **head tilt**
* Parents IND w/ HEP
* **\*CPG recommends f/u screen _3-12mos after D/C_**
**WANT THEM WALKING W/OUT HEAD TILT\*\*\***
57
Infants w/ postional head deforms are more likely to reach motor milestones ________ vs other babies
LATER!!!
58
Positional Plagiocephaly/Skull Deformity
* Infants w/ pos'l head deforms likely to reach motor milestones **LATER** vs other babies
* **3 Categories Skull Abnorms:**
* Plagiocephaly
* Brachiocephaly
* Scaphocephaly
59
3 categories skull abnorms
Plagio, Brachio, Scaphocephaly
60
This skull abnorm. is **usually associated w/ Torticollis**
Plagiocephaly
61
Plagiocephaly cranial abnorm is usually associated w/…
Torticollis
62
**Plagiocephaly**
**Describe findings:**
**Ipsilateral ear shift**
**Ipsilateral frontal bossing (popping up)**
**Ear shift _forward_ on _ipsilateral side_**
Think “**Paralellogram head”\*\*\***
63
Positional Plagiocephaly
## Footnote
**“Parallelogram Head”**
see pics
64
This cranial abnorm **IS NOT ASSOCIATED W/ CMT**
Brachycephaly
\***developmentally delayed→ _supine too much_**
65
Brachycephaly
## Footnote
**Findings:**
* **B**rachycephaly→ **Bi**lateral forehead bossing, incd posterior vault, **bi**lateral protrusion of parietal bone above ears
* CI of \>81%
* **dev. delayed→ supine too much, NOT assocd w/ CMT\*\*\***
66
Scaphocephaly (AKA- Dolichocephaly)
## Footnote
**Findings:**
* Sc**A**phocephaly→ long, n**A**rrow skull shape
* **NOT assocd w/ CMT\*\*\***
67
Facial Asymmetry
Ex.
see pics
68
Craniosynostosis
## Footnote
**Defined**
Abnormal **premature closure** of skull sutures; **does not allow brain growth**
* **\*Typical→** babys skull fuses @ **8mos**, full closure of sutures @ **2 yrs**
69
Craniosynostosis
## Footnote
**Findings:**
* **Typ. presents w/** palpable ridge on suture lines, **contralateral bossing** and **posterior shift of IPsilateral ear**
* Helmets DO NOT improve head shape→ **likely reqs sx**
70
How to tell difference bw:
## Footnote
**Plagiocephaly vs Craniosynostosis**
* ****_P_**lagio→ “**_P_**arallelogram head”**
* Contralat occ. bossing
* Ipsilat ear displaced ANT.
* Ipsilat frontal bossing
* **Craniosynostosis→ “Trapezoid head”**
* Ipsilat occ bossing
* Ipsilat ear displaced POST
* Contralat parietal bossing
71
Plagiocephaly vs Craniosynostosis
## Footnote
**Shapes drawn out**
Plagio→ Parallelogram head
Cranio→ Trapezoid head
72
Positioning Programs for **Plagiocephaly/Skull Deforms**
* Parent edu, **STRESS TUMMY TIME+alleviating stress on back of head _while awake_,**
* **_Still have child sleep on back_\*\*\***
* Bumbos, devices to relieve/prevent posturing→ Tortle, work closely w/ MD
73
How to determine course of Rx for **Cranial Deformity**
* Monitor head shape
* → **measurement of cranial anthropometrics:** Calipers and tape measures
* **No tools+ mod-severe==\>** refer to orthotist for head scan
74
Measurement/Important Landmarks
## Footnote
**ALL**
* **Glabella (g):** most prom. point bw **supraorbital ridges (bw eyebrows)\***
* **Opisthocranion (op):** most prom point of **occiput**
* **Eurion (eu):** most lateral point **either side of head**
* **Frontotemporale (ft):** most med. point of **temporal crest (**palpate, typ. @ lateral point of eyebrow)
* **Lambdoideal point (ld):** junction bw **occiptal and parietal bones**
75
Glabella
most prom. point bw **supraorbital ridges (bw eyebrows)\***
76
Opisthocranion
most prom point of **occiput**
77
Eurion
Most lateral point on either side of head
78
Frontotemporale
Most medial point on temporal crest (palpate, typ @ lateral point of eyebrow)
79
Lambdoideal point
Junction bw occipital and parietal bones
80
Head Length
Glabella→ Opisthocranion
81
Head Width
Eurion→ Eurion
82
Head Circumference
Encircle tape measure around head covering glabella and opisthocranion
83
Obliques:
Left frontotemporale to Right lambdoideal
Right frontotemporale to Left lambdoideal
84
Cranial Vault Asymmetry Index
## Footnote
**CVAI**
CVAI== (A-B)x100/A or B (whichever larger)
## Footnote
**A and B are obliques**
85
Cranial Index aka Cranial Ratio
## Footnote
**CI or CR**
CI==M/L/A/P x 100
86
5 Levels of Severity
## Footnote
**\*Things to _KNOW_!**
* Lvl 3: **mod-severe==** recommend orthotist
* **Severity dictates recommendation for _helmet_\*\*\***
* **BEST TIME bw _4-8_mos**
87
Best time for helmet
Bw **4-8mos**
88
Argenta Scale
rec'd by CPG- easy/no equip
## Footnote
**Via observation of skull shape**
89
Helmets
## Footnote
**2 main types:**
1. Star Band -→ “fixin my flat”
2. Doc Band
90
Helmets best to rx bw\_\_\_\_ and ______ and WHY?
4 and 8mos of age\*\*\*\*\*
\***CAN HOLD HEAD UP!!!**
91
HELMETS
* **Best to rx b/w _4 and 8mos of age_**
* Best window for improve.
* **can hold head up\*\*\***
* **Duration→** 23/24 hrs/day, **length depends on severity**
* Night only once improve. obtained\*\*\*
92
Name that Torticollis!
RIGHT
93
Name that Torticollis!
LEFT
94
Name that Torticollis!
LEFT
95
Name that Torticollis!
RIGHT
96
Name that Torticollis!
LEFT
97
Name that Torticollis!
TOUGH ONE
**Remember _named for lateral tilt_**
**SCM-- ipsilat LF, contralat ROT.**
RIGHT
98
Name that Head Shape!
Parietal **Plagiocephaly**
99
Name that Head Shape!
R. Anterior **Plagiocephaly**
100
Name that Head Shape!
Scaphocephaly
Long, nArrow skull
101
Name that Head Shape!
R. Parietal **Plagiocephaly**
102
Name that Head Shape!
Brachiocephaly
\*easy to remember, supine too much→ flat in back
103
Name that Head Shape!
Craniosynostosis
104
Name that Head Shape!
R. Parietal **Plagiocephaly**
