Lecture 11: Torticollis and Plagiocephaly Flashcards
What is a fontanelle?
Soft spot
When does the anterior fontanelle close?
12-18 months
When does the psoterior fontanelle close?
2-3 months
this is a big one. This is where you can see the kid breathing through that soft spot
KNOW: once everything closes you can’t change the head shape. However before that you can
When doing the intial examinination:
* Look at craniofacial symmetry
Eye position and tracking
Facial muscular symmetry
Etiolog and pathophysiology of cranial deformation
Etiology:
* Intrauterine deformation that worsens post-natally - can be in a position that puts pressure on it
* Postnatal positioning - think lying on one side of head (not getting tummy time)
* cervical muscular imbalance
About 75% of infants wht cranial deformation have SCM imbalance of or congenital msucular torticollis
Incidence of cranial deformation
* Increases until roughly 4 months of age, when infants independently can maintain their head upright - so think, if they’re lying it all day its going to get worse. That prone on elbows 90 degrees of head contorl = 4 months
* decreasing incidence by 2 beacuas someone should’ve found it and corrected it
What is plagiocephaly and what pathology / condition causes it?
Comes w/ torticollis
Posterior flatenning on one side, and anterior bossing (head comes out) on the opposite side
* so if it has flattening on R posterior, than theres bossing on L anterior side
What is brachycephaly?
When head is shortened and out wider
Thinking more some kind of genetic syndrome
* when tis more symmetrical we start thinking some genetic syndrome
What is Dolichocephaly / Scaphocephaly
ears closer head longer
Thinking some kind of genetic syndrome caused
* when its more symmetrical is when we start thinking more genetic syndromes
Plagiocephaly
Clinical Presentations:
* Parallelogram shape of the skill
* Ipsilatearl occipital flattening
* Contraltaeral occipital bossing or bulging
* Facial abnormaltities including uneven - think one eye / ears higher. cheekbones, eye sockets, or lower jaw - we don’t measure this as PT’s
* Commonly ssociated w/ Congential msucular torticollis
* Flattened occiput is typically contraltaeral to the tight SCM
So if its a left tight SCM the right side is flattened
pt has plagiocephaly. You observe an flattened occiput on the R side. What is likely going on?
L SCM tightness
Flattened occiput is typically contralateral to the tight SCM
* because it does contraltaeral rotation
Explain what the cranial vault asymmetry index is and how it’s used
* If its uneven what pathology is likely?
Checks for facial symmetry
Measure in millimeters at 30 degrees from center of nose (outer edge of eyebrow)
Will not need to know formula
Draw that X and see if those lines are equal and make an X. If not equal were thinking the have plagiocephaly (because the other 2 are symmetrical due to having gentic origins)
Cranial vault assymetry idnex
If the index is <3.5 everythings within normal limits
Cranial remolding orthosis = helmit
Probs dont memorize
NOTE: when using the cephalic index to measure head size it should be pretty much the same from medial lateral and anterior posterior
What would someones cephalic index look like who has brachycephalic?
Would be much longer anterior posterior than medial latearl (remember, the should both be even)
How is Brachycephalic treated?
Cranial remolding orthosis
Bracycephalic presentation
* Bilatearl forehead bossing or flattening?
* Bilatearl posterior bossing or flattening?
Bilatearl forehead bossing (makes sense their head is longer)
Posterior flattening (so since their forehead protrudes it needs to compensate in the back)
NOTE: Bilatearl protrusion of parietal bone above ears
What is a cranial remodeling orthosis?
A non-invasive device used to correct the symmetry of an infants skull
High temperature thermoplastic matearials
Lined w/ high-density, hypoallergenic medical grade foam
The FDA requires fitting of the cranial remodeling orthosis within how many days of the initial scan?
14
How many hours per day should the cranial remodeling orthosis be worn?
* how often are they adjusted?
* HOw long does treatment last?
23.5
off for bathing and cleaning
Adjusted every 1-2 weeks
Typical treatment time = 2-6 months
You put the helmit on and the head grows into anywhere there is open space
What is Craniosynostosis?
The sutures in the head fuse to early
* it makes the helmit not worth wearing unless they go and do surgery to open the sutures back up
* This is a contraidination/precaution
Can a baby get a cranial remodeling helmit if they have hydrocephaly?
No, this is a red flag
Must be cleared by doctor
makes sense there is swelling on brain
can do a brain shunt to get rid of fluid and cleared by doctor they can get this
Cranial remodeling is contraindicated under _ months old?
under 3 months old = don’t do cranial remodeling
* all more conservative internvetions
At what age can the child no longer get cranial remodeling and why?
Can no longer get it over 24 months old becuase the skull is fully fused and no longer pliable
NOTE: skin breakdown / lack of sensation are also precautions / contraidincaitions for cranial remodeling
notice how the skull will grow toward the direction there is still space
Found that the best choice for these kids if there is significant head deformity is the helmit w/ PT
If you can’t do that than changing their position alone will still help. Meaning that they won’t be lying on one side of their head all day.
Helmits coereved when they are determined medically necessairy
A 2-month trial of conservative therapy consisting of re-positioning the child’s head such that the child lies opposite to the preferred position, has failed to improve the deformity and is judhed to be unlikely to do so, and CVAI or CR moderate to severe
* so have to not be getting better
If only cosmetic it is not covered
Medically necessary for infants to correct continued assymmetry following surgery
* if their ears are not symmetrical they can’t wear glasses = medically necessairy
For Medicaid specifically to cover head shit
remodeling must start between 4-12 months to be covered
Prognosis following for fucked up head shape
Full resolution of CD
* 77% after parent education in repositioning (for mild cases)
* 94-96% after cranial remolding therapy (moderate to severe)
Risk factors poor prognosis:
* Poor adherence to positioning schedule
* Poor adherence to therapy program (home or clinic)
* Initiating positioning/therapy intervention after 3 months of age
* Persistence of CMT beyond 6 months of age
* Developmental delay
* Abnormality of tone
* Severity of inital CD
* Poor adherence with helmet wear
* Initiating remodeling intervention after 6 months
Associated changes w/ cranial deformation:
* An apparent change in the atlas and axis
* Progressive anatomical cahnges affecting the upper cervical vertebrae-develop. Around 8 months become more evident in older children
* Rotational and bending deformitites most likely - think driving ability
* Changes decreased gardually until C7, which appeared to be normal in most
* Affects mainly the superior articular facet, the lamina, and the body
* Long-standing, untreated congenital muscular torticollis (CMT) can lead to permanent craniofacial deformitites and asymmetry
Congenital muscular torticollis = twisted neck
Congenital or Acquired characterized by lateral inclination of the head to shoulder and torsion of the neck and deviation of face
Right SCM is tight. How is someone w/ torticollis lying
Rotation = left
Ipsilatearl flexion to right
So they would have difficly w/ right rotation, and difficulty w/ contralateral left flexion
NOTE: Torticollis is named for the side that the SCM is tight on. So this would be defined as right torticollis
Causes of torticollis: - undefined origin
Multiple Hypothesis:
* Brith trauma/difficult delivery - often impacting first born babies for obvious reasons
* Venous compression
* Myopathy of the SCM
* Fetal Malpositioning
* Intrauterine Crowding
* Prematurity
* Breech - head down curled up
Much more common in vaginal deliveries than C sections
However, they really don’t know why it happens
Differential Diagnosis for general msucular Torticollis:
* GERD: Sandifer’s Syndrome - turn their head when they swallow because it hurts to eat. Ask if the baby spits up loads etc… to rule this out.
* Malformation Atlas - fractures here can cause that head position
* Inflammitory conditions
* Cervical/Clavicular fractures
* Ocular Disorders - if baby is not visually tracking - that torticollis can be because they’re turning their head to see something ebcause their eyes don’t move great
* C1/C2 Rotatory Subluxation - would cause that rotary issue sideways
Risk factors:
* First born x 6
* Multiple Births
* Forceps and birth trauma
* Long body length
* Breech
* Hip dislocation - if they have torticollis were gonna check this out as well
SCM:
Origin: Manubrium and medial portion of the clavicle
Insertion: Mastoid proess of the temporal bone, superior nuchal line
Clinical Practice Guideline for CMT
Congenital muscular torticollis is a postural deformity evident shortly after birth, typically characterized by latearl flexion/side bending of the head to one side and cervical rotation/head turning to the opposite side due to unilatearl shortening of the SCM
Clinical present of CMT
Head tilt to one side
* Latearl flexion: head tilt to ear close to shoulder
Neck rotation:
* Face rotated toward opposite side
ROM deficit
Age diagnosed
* Birth - 12 months
CMT is the third most common pediatric diagnosis in infancy
* Up to 16% of neonates
Early PT is an effective and non-invasive treatment
Were getting increased torticollis
Hypothesis of why this is true is due to back to sleep campaign
* They’re missing out on that tummy time
Torticollis Impact on Motor Contorl
If you don’t have symmetrical movement pattern, you’re not going to have symmetry down the spine.
You need symmetry in order to have stability
Infants need prone time to help avoid this condition (not just back to sleep)
* Infants learns from experience and practice to content w/ grabity
* Practice increases strength and contorl
* Consistent sensory input face and oral motor area
* Sensory input, practice, experience and environment circumstances lead to the progression of icnreased motor contorl and delicate balance between flexors and extensors
* Critical for upright development and postural control
so incooportating that tummy time in within everydayactivities. nobody has 2 hours to spend just playing with the baby
8 Examine body structure:
CPG torticollis
* Faster we start the less PT needed
* More severe = means it takes longer to fix
* #1 thing is to educate on positioning - should happen within 2 days of birth (prone play) - doesnt happen because there are a lot of other things going on
* Refer infants with asymmetries in CMT to PT
* Document the history of development (think age, age of onset symptoms etc…)
* Screen infants for non-muscular causes of asymmetry and conditions associated w/ CMT (think screening for vision, Gi hx, postural preference, structural / movement symmetry) - anything that could be causing that baby to go into that position that isnt actually that tight SCM (because that stuff is treated very differently) - remember reflexes should be symmetrical
* Refer infants from PT to physician if indicated by screen (think poor visual tracking, abnormal muscle tone, extra muscular masses, cranial deformation, asymmetry non-consistent w/ CMT, over 7 months of age and SCM mass present)
* Requies images and reports (arent great imaging for this)
- cervical PROM/AROM (Arthoridal Protactor)
- Active PROM UE/LE
- Palpation of SCM (fibrotic mass present, tissue mobility, skin integrity)
- Pain
- Craniofacial asymmetries
- Muscle strength/Function (muscle function scale)
- Bilatearl Hip Assessment (barlow / ortalani manuver)
- Resting head posture (prone, supine, sitting, standing - if it goes all the way down their spine its proably not torticollis
Prone:
* Asymmetry of spine/presence of scoliosis
* Head and trunk
* Use of asymmetrical patterns
* Tolerance to position
Sitting
* Supported/unsupported
* Compensations in shoulders, trunk, and hip
Line up w/ chink and nose
Very specific to torticollis
you’re going to let go of their head (SLOWLY) and see what happens
always check bilatearlly
0 = worst. Won’t be able to have contraltaerral head flexion because its held down by the tight SCM
What is 0 on the muscle function scale?
Head below horizonral line
What is 1 on the muscle function scale?
Head on horizontal line
what is a 2 on the muscle function scale?
Slightly over horizontal line
What is a 3 on the muscle function scale?
High over horizontal line
What is a 4 the muscle function scale?
High above hoirzontal line
What is a 5 on the muscle function scale
Very high above horizontal line almost vertical position
This is that SCM mass thats common w/ torticollis
Looks like a little pea
What grade is this: Early mild 0-6 months
* postural, muscle tightness
* <15 degrees lacking of passive cervical rotation
grade 1
What grade is this. Early moderate 0-6 months.
* muscle tightness
* 15-30 degrees of cervical rotation lacking
Grade 2
What grade is this. Early severe 0-6 months
* muscle tightness
* SCM mass
* > 30 degrees of cervical rotation lacking
grade 3
What grade is this. Late Mild 7-9 months
* Postural, muscle tightness
* < 15 degrees of cervical rotation lacking total
Grade 4
What grade is this: late moderate 10-12 months
* Postural, muscle tightness
* < 15 defrees cervical rotation (total)
Grade 5
What grade is this: Late severe 7-12 months
* muscle tightness
* > 15 degrees cervical rotation
Grade 6
What grade is this: Late extreme after 7 months
* SCM mass
* > 30 degrees of cervical ROM lacking
Grade 7
What grade is this: Very Late: after 12 months
* Muscle tightness
* > 30 degrees of cervical rotation lacking
* Postural muscle tightness or SCM mass
Grade 8 (proposed)
How often you’re seeing the pt depends on the below
part of CPG
Something w/ torticollis is that they might score higher on standarized test because that tightness makes it look like they have head control when they really dont.
Prone positioning while awake for grater than 1 cumulative hour per day, with no minimum amount of time per opportunity, appears to offset the transient effects of supine sleep positions on motor skill acquisition
* So they need an hour of tummy time per day - does not have to be straight
PT should document the amount of time the infant spends in positioning equipment as reported by parents (i.e., positioningseating decives, strollers, car etc…)
12 of CPG
Prognoses for the extent of symptom resolution
* Age of intiation of treatment
* Classification of severity
* Intensity of intervention
* Presence of comorbidities
* Rate of change
* Adherence to HEP
13 of CPG: Five components of first choice internvetions (what you should do first)
Environmental adaptations
* Crib position
* Caregiver position - don’t always put them in the same position in the crib
* Changing Table Position - how to hold your child - don’t always hold them on your L side, switch back and forth
Parent/Caregiver Education
* Print out
* Hands on demonstration
* Teach back method - explain to parent and amke them repeat back
Neck PROM
* Myofascial work - soft tissue
* Calm tissue elongation - doesnt take much
* Mannual soft tissue work
Neck and Trunk AROM
* Prone play
* Supported sitting
* Isolated Chin Tucks
Development of Symmetrical Movement
* Use a mirror
* Concentrate on midline positions
Stretching 1 rep x 30 seconds, 4x/day, 7 days/week
* however more stretching is ALWAYS better, so can go above this
14 on CPG - Supplemental Interventions
Microcurrent
* Improved tilt, neck rotation immediately
Kinesiological taping
* no good evidence
No evidence w/
* cervical manipulation
* Craniosacral
* Topcollars
* Fledenkaris
15 on CPG - refer consultation when outcomes are not fully achievd
- Rehabiliation Medicine
- Oral maxio Fascial Specialist
- Neurosurgery
- Plastic Surgery
- Botox interventions
- Assess plagiocephaly
- Differentaite diagnosis
- Surgery
16 of CPG - discontinue direct services when these 5 criteria are achieved
1) The CMT has resolved within accepted ranges of measurement error
2) There is no lignering seconary compensations of developmental delys
3) The parent/cargivers know how to assess for regression as the infant grows and when to contact their infants physician and/or the PT for reassessment
4) Discontinuation documentation reflects the expected outcomes for the episode of care, realtive to the baseline measures taken at the initial examination
