Neuro Peds - 03 - Torticollis Flashcards
What does Torticollis mean?
twisted neck
What is the physical manifestation of Torticollis?
abnormal neck posture
- lateral head tilt
- neck rotation
What are the 2 primary planes of motion involved with Torticollis?
rotation - to the opposite side
lateral flexion to the same side
What muscles are primarily involved with Torticollis?
SCM - for the rotation
Scalenes
Upper traps
which muscles are tight and which are weak (stretched) in Left Torticollis?
tight - Left SCM, Scalenes, Upper Traps
weak (stretched) - Right SCM, scalenes, upper traps
what are the 2 types of Torticollis?
Muscular, aka Congential Muscular Torticollis, aka CMT
Non-muscular - Sprengel’s Deformity, Klepper-Feil Syndrome
What is the etiology of Muscular Torticollis?
Birth trauma Fetal mal-position Uterine compression Inflammatory condition Difficult delivery –clavicular fractures, brachial plexus injury
What is the etiology of Non-muscular Torticollis?
Cervical skeletal malformation Visual impairment Gastroesophageal reflux Sprengel’s Deformity Klepper-Feil Syndrome (or Klippel-Feil)
can happen in utero
visual impairment can contribute
describe Sprengel’s Deformity:
one (usually left) or both scapulae fail to descend during early fetal development
75% girls.
Peri-scapular muscles may be fibrotic.
Shoulder motion restricted
– formation – and distending of the scapular – genetic deformity
describe Klippel-Feil syndrome:
Any 2 of 7 cervical vertebrae fused.
Worse if C1-C2.
(Case study with Noah – more apparent with growth, PT did not help).
If no progress, don’t crank.
Might have fused vertebra.
If no response to treatment, stop and look again. Monitor
how does the PT evaluate for Torticollis?
Palpation for fibrous mass Cervical x-rays R/O hip dysplasia Cranial and facial asymmetries Visual tracking Posture Gross motor screen
What condition is commonly associated with Torticollis?
Plagiocephaly
What else might the PT see with Torticollis?
(plagiocephaly)
Hip Dysplasia
Postural Asymmetry
Who else is on the team to resolve the Torticollis?
pediatrician neurosurgeon physical therapist orthotist (some OTs) for cranial band sometimes plastic surgeon
name 3 types of abnormal head shapes
plagiocephaly - asymmetrical
brachycephaly - flat head (wide)
scaphocephaly - cone head (long and narrow)
seen best when viewed from the top
what does the PTA do when the parent wants to know if a helmet is needed?
suggest evaluation
tell MD to make referral
how does the cranial helmet work?
Cranial helmet puts pressure on areas to round out head
what is critical to maintain head shape?
Stretching/elongation of tight muscles is critical to maintain head shape. Must avoid pressure on skull using a combination of positioning and molded cast.
when is the best time for Cranial Band Intervention?
between 3 months and 12 months when rate of growth of cranial circumference is accelerated.
when does ossification start (so you hope you are done with cranial band)?
18 months
What is the
Cranial Vault Asymmetry Index?
CVAI –Cranial Vault Asymmetry Index: Measure diagonally top of head and difference between two expressed as a percentage.
Calipers can be used but very difficult in wiggly infant and if off even a millimeter is inaccurate – now orthotist can scan cranial topography using a digital image.
describe the 5 levels of involvement on the Plagiocephaly Severity Scale
1 - normal - symmetrical - no helmet - CVAI < 3.5%
2 - mild - minimal asymmetry in one posterior quadrant - repositioning program for 2 months - CVAI 3.5 - 6.25 %
3 - moderate - two quadrants, mod-severe posterior quad flat, min ear shift/anterior involvment - reposition or cranial remolding - CVAI 6.25 - 8.75%
4 - severe - 2-3 quads, severe posterior quad flat, mod ear shift, anterior involvement, CVAI 8.75 - 11.0%
5 - very severe - 3-4 quad involved, severe posterior quad flat, severe ear shift, anterior involvement (orbit and cheek asymmetry), CVAI > 11.0%
When might a child with plagiocephaly not need the helmet?
when the case is mild
some cases so mild that the child grows out of it.
Level 2 PT probably the same as level 1 PT, if there is any level 1 PT
What is recommended for normal to mild cases of plagiocephaly?
positioning
and at all levels, positioning documented for insurance
What are the PT goals for Torticollis?
Achieve neutral head/neck alignment in all postures.
Cervical ROM WNL.
Strength WNL and equal bilaterally of cervical or other muscle weakness noted.
Balance and postural reactions WNL.
Patient EDUCATION
Good muscle balance
Both active and passive
Address other mm – trunk, etc
Head in odd position will interfere with reactions and such –
More persistent will affect more, of course
What are the PT interventions for Torticollis ? How long?
ROM Strengthening Balance and postural reactions Positioning Parent education/HEP
Duration: 2 to 6 wks
- RX duration for CMT is dependent on degree of restriction and involvement of other systems, such as motor, visual.
What are the PT treament principles for Torticollis?
HEP is absolutely key
- big parent challenge is adhering to program, understand technique
Usual Ther Ex principles
- Progress from AROM to gravity resisted as appropriate
- Strengthen in positions that are developmentally appropriate
- Inhibition techniques - rocking, oscillation…
Prevent substitutions
Avoid painful stretching
Use AROM, simple routine activities, parent/child natural interaction, positioning.
describe Tummy Time for
birth to 2 months
Basically helping to shift weight caudally if able to lift head off flat surface
If horizontal is too hard, then raise it up a bit. – parent chest, maybe. – chest especially nice because bonding with parent. Comforting to baby. And baby can’t see much else anyway.
describe Tummy Time for
3 to 5 months
Use toys and mirrors to encourage reaching and weight shifting. Eyes at horizon now.
_________
More – strength, weight shift. Reaching
Put toys in front for reaching
Some don’t like the floor if there’s nothing to see.
Boppy is helpful but she prefers a more firm surface for arms
When a baby is reaching, when they reach with the “good” arm it’s a good challenge for the bad side. Remember “demo” that made no sense.
describe Tummy Time for
6 to 9 months
airplane
Crawling, rolling at this age will help develop symmetrical strength.
Parent Education
teach them them muscles
or
just have them do same exercises on both sides.
remember, don’t talk down to parents.
describe seated positioning for Torticollis
Car seat, high chair, infant seat, other devices
Towel rolls or stuffed animals using 3 point system for symmetrical posture hips, trunk head.
Place toys on appropriate (tighter) side to increase AROM cervical rotation.
When head is off center, the hips will be off center in opposite direction
1st, fix hips.
2nd, fix head.
describe the Three-Point System in posititoning
looking for symmetry
counter force at hips
nothing near face
a single force is placed at the area of deformity or angulation; two additional counterforces act in the opposing direction
why is it important to keep doing PT exercises while wearing the cranial helmet?
Muscles help remodel bone.
Muscles need to work to help remodel bone.
quick - if it is left torticollis, which way to stretch the tight SCM?
rotate left
some tips for doing Lateral Neck Stretches
Just by putting the head on your arm, you are stabilizing head. Hold shoulder other hand and can pull a bit
Also works from in the lap.
Crook of arm – be careful about grading force.
Or supine – hold head and pull body
So, pull the body instead of the head, actually. Be careful.
Taping? Why?
Yes, taping on babies.
Because is like “hands on” the patient all the time.
will keep the shoulder down
will activate neck muscles
Name gross motor activities helpful for torticollis at 0-2 months
Supine visual tracking faces or rattle
Feeding positioning
Sleeping positioning on side with wedges
Tummy time - head lift/rotate to auditory or visual stimulation (near-sighted)
Pull to sit for symmetrical cervical flexor strength
Pretty much just getting them to look at you
Primarily they are eating and sleeping.
So things that will be done in these positions
Name gross motor activities helpful for torticollis at 3-4 months
Supine reach in midline orientation
Held upright with trunk support
-Vertical suspension for optical righting
– suspend vertically when eyes focus on mirror, turn body to rotate neck
- Stabilize trunk for ROM exs
Tummy time – encourage weight shift/reach
Reach prone – head righting more difficult to the uninvolved side
Rolling with L torticollis (head rotated r) – place on L side, stabilize head and roll body R from side to supine
Name gross motor activities helpful for torticollis at 5-6 months
Rolling to promote lateral neck flexion to the uninvolved side
Side propping for lateral neck and shoulder strength
Tummy time
Supported head/trunk righting on lap or ball
Head righting in sit
————–
Less time supine by 6 months.
Ball – work on lateral and posterior displacement in sitting.
More lateral flexion
Rolling – which does use head and neck
Name gross motor activities helpful for torticollis at 7-9 months
Increasing strength head, neck and trunk
Balance and equilibrium reactions on ball
Reaching/head righting in quadruped and standing
————————————————-
Starting to get the balance and equilibrium reactions
The therapy ball is pretty great
The reactions are good for activating neck muscles.
Torticollis Outcomes are what? Which type of torticollis will have these outcomes?
Good-Excellent outcomes have been reported with conservative PT intervention. Long term studies show Persistent craniofacial asymmetry Intermittent head tilt with fatigue Small percent with scoliosis No evidence of TMJ or cervical pain --------------- muscular torticollis
