Torticollis Flashcards
T/F: Torticollis is the 3rd most common congenital MSK anomaly
TRUE
after congenital hip dysplasia and club foot
List risk factors for Torticollis
- large birth weight
- male gender
- breech position
- multiple births
- primiparous mother
- difficult labor and delivery
- use of vacuum or forceps assist
- nuchal cord
- maternal uterine abnormalities
what is a primiparous mother?
a mom on her first pregnancy
Torticollis is assocaited with what other MSK conditions?
- Hip dysplasia
- Clubfoot
- CBPI → congenitial brachial plexus injury
T/F: 1/5th of children who present with a torticollis posture have a nonmuscular etiology
TRUE
List nonmuscular etiologies of Torticollis
- Klippel-Feil Syndrome
- CBPI
- Ocular lesions
- Sandifer Syndrome
- Dystonic syndromes
- Posterior Fossa pathology
- Postencephalitis
- ACM
- Syringomelia
Torticollis is associated with what S/S in an older child?
symptoms of HA, N/V
how do you define congenital muscular torticollis?
neck deformity involving shortening of the SCM that is detected at birth or shortly after
List the 4 subtypes of congential muscular torticollis
- Sternocleidmastoid Tumor (SCMT)
- Muscular Torticollis (MT)
- Postural Torticollis (POST)
- Postnatal Torticollis
Describe SCMT
- discrete mass palpable within SCM muscle
- normal x-rays
- histologic tissue changes include excessive fibrosis, hyperplasia, and atrophy
describe muscular torticollis
- tightness but no palpable mass
- normal x-rays
- head tilt
- ROM limitations
- cervical muscle imbalance
describe postural torticollis
- no mass, no tightness of SCM
- normal x-rays
- head tilt
- no PROM limitations
- AROM limitations
- cervical muscle imbalance
list possible causes of postural torticollis
- benign paroxysmal torticollis
- congenital absence of one or more cervical muscles or transverse ligament
- contracture of other neck muscles
how may postnatal torticollis come about?
- environment induced
- plagiocephaly induced
- positional preference induced
how is CMT severity classified?
using ultrasound images based on degree of muscle fibrosis and fiber orientation
CPG recommendations for grading CMT
CPG recommends classification that takes into account degree of ROM limitations and age at which treatment begins
how many grades of CMT are there?
7
describe grade 1 torticollis
early mild
present between 0-6 months with only postural preference or muscle tightness of less than 15 degrees cervical rotation
describe grade 2 torticollis
early moderate
present 0-6 months with muscle tightness 15-30 degrees cervical rotation
describe grade 3 torticollis
early severe
present 0-6 months with muscle tightness of more than 30 degrees cervical rotation or SCM nodule
describe grade 4 torticollis
late mild
7-9 months with only postural preference or muscle tightness of less than 15 degrees cervical rotation
describe grade 5 torticollis
late moderate
10-12 months with only postural preference or muscle tightness of less than 15 degrees cervical rotation
describe grade 6 torticollis
late severe
7-12 months with muscle tightness of more than 15 degrees
describe grade 7 torticollis
late extreme
present after 7 months with a SCM nodule
OR
12 months with muscle tightness of more than 30 degrees
what is CMT assocaited with?
- ipsilateral mandibular asymmetry
- ear displacement
- plagiocephaly
- scoliosis
- pelvic asymmetry
- congenital dislocated hip
- foot deformity
list different types of cranial deformities
- plagiocephaly
- brachycephaly
- scaphocephaly or dolichocephaly
- craniosynostosis
what is plagiocephaly?
malformation of the head marked by an oblique slant to the main axis of the skull
- term applied to any condition characterized by a persistent flattened spot on the back/side of head
- flat head syndrome
- anterior progression of the ear on the same side as the flattened occiput
what is brachycephaly?
a condition where the head is disproportionately wide
what is scaphocephaly?
a condition where the head is disproportionately long and narrow
common in babies born prematurely
what is craniosynostosis?
refers to early fusion of the suture of the bones of the skull
premature fusing restricts and distorts growth of the skull → may result in increased cranial pressure
Compare plagiocephaly vs Lamboid Craniosynostosis
- craniosynostosis often ruled out using lateral head x-rays and/or CT scans
- visual cues
- P → head takes on shape of a crooked rectangle
- LC → skull takes on trapezoid shape (wider in front, narrower in back)
what is the difference between acquired and deformational plagiocephaly?
- acquired → concordant with CMT
- deformational → the occiput, frontal bone, and full face become deformed by the molding forces induced by in utero constraint caused by compression of the fetal cranium between the maternal pelvic bone and lumbar sacral spine in the last trimester
how is severity of plagiocephaly determined?
- severity can be classified by rating scales → Argenta’s clinical classification scale
- can also take quantative measurement
- calipers
- digital photographic tecnhiques
- 3D digitial imaging
List risk factors for deformational plagiocephaly
- oligohydramnios
- uterine malformations
- cephalohematoma
- prominent maternal lumbar spine
- complications of delivery
- primiparity
- male gender
- cumulative exposure to supine
- neck problems
what is oligohydramnios?
not enough amniotic fluid leading to not enough cushioning
list risk factors for acquired plagiocephaly
- postnatal positioning
- preference to turn head on one side while sleeping
- little time in prone
- excessive use of infant carriers, car seats, strollers
- muscular torticollis
T/F: cranial facial asymmetry that is present at 6 months has a high probability of persisting into adolescence and adulthood
TRUE
T/F: plagiocephaly is mostly just a cosmetic issue
FALSE
used to be viewed this way
recent research demos increased prevalence of gross motor delay, lower developmental scores at preschool age, increased use of special ed and therapy by school age
describe neck positioning with Torticollis
- assocaited changes in body structure
- decreased ipsilateral cervical rotation
- decreased contralateral cervical lateral flexion
describe secondary impairments with Torticollis
- asymmetry of craniofacial skeletal structures
- asymmetry of masticatory and tongue muscles
- underdevelopment of ipsilateral jaw, elevation of TMJ, dental occlusion problems
- inferiorly and posteriorly positioned ipsilateral ear, asymmetry of ears with deformity of ipsilateral ear
- asymmetry of eyes
- ipsilateral eye smaller
- recessed eyebrow and zygoma on ipsilateral side
- deviation of chin point and nasal tip
- cranial base deformation
- occurs as early as 1 month
muscles impacted by torticollis other than the SCM
- platsyma
- scalenes
- hyoids
- tongue
- facial muscles
secondary trunk impairments with torticollis
- trunk curvature
- persistence of ATNR
- windswept hips
- elevated shoulders
- visual neglect
- decreased ipsilateral body awarenss
what should be included in the caregiver interview for a pt with torticollis?
- questions pertaining to pregnancy and birth
- family history
- medical care
- positioning
- developmental skills
Differential Dx algorithm for pt eval of torticollis
- thorough history
- physical exam
- neurological assessment
- plain radiographs
- opthalmologic consult, hearing consult
- MRI if opthalmologic consult is negative
List red flags in the initial presentation of torticollis in children
- age of presentation greater than 6 months
- pain
- neurological findings
- associated syndromes
- down syndrome, skeletal dysplasia
- trauma
- inflammatory or infectious history
- alternating sides
- atypical position
- such as rotation and lateral bending to same side
- late onset
describe motor characteristics of children with torticollis
- supine → difficulty centering head in midline
- bias toward extension and asymmetry
- visual gaze oriented toward side of head turning
- prone → altered forearm weight bearing with more weight distrubted over the arm, trunk, and pelvis on the affected side
- cascade
- abdominals
- trunk and extremity righting
Functional activities and participation difficulties in children with Torticollis
- breastfeeding
- looking to the involved side to scan environment
- reaching for a toy
- maintaining sitting
- creeping
- ambulating
- decreased interaction with environment and caregivers on the involved side
prognosis for torticollis is dependent on what factors
- age referred to intervention
- severity or ROM deficits
- thickness of SCM nodule
- comorbid conditions
- dosage of intervention
what does conservative management of toticollis include
- active and passive ROM
- caregiver training in ROM and positioning
- strengthening
- developmental activities
list treatment strategies for torticollis
- MFR
- joint mob
- ortheses
- HEP
- modalities
- ROM
- strengthening
- K-Tape
indicators Tot Collars
- 4 months or older
- constant head tilt of 5 degrees or greater for more than 80% of awake time
- perform all movement transitions and motor skills with a constant head tilt
- adequate PROM and head tilting reactions
what is microcurrent?
low intensity alternating current (200uA) applied over the involved SCM → infant should not perceive the current
followed by stretching
less sessions required and less crying
D/C guidelines for torticollis
- full PROM and AROM
- maintain midline 95% of the time
- no compensatory patterns
- equal and age-appropriate head righting
- symmetrical neck strength MFS scale
Torticollis prognosis
- most cases resolve within an average of 6 months with PT
- 90-99% of cases are resolved with conservative treatment
Medical management of Torticollis
- surgical intevention should be considered if improvement not evident after 6 months of conservative intervention
- indications include
- residual head tilt
- deficits of PROM greater than 15 degrees
- tight muscular band or tumor
- 8% of cases require surgical intervention
- release of SCM with a z-plasty
- botox injections
Medical managment of plagiocephaly
- 80% of head growth occurs before 12 months of age
- ideal time for repositioning to be effective is in the first 3 months
- if asymmetry is still obvious by 5-6 months, may need cranial remodeling band treatment
- DOC → dynamic orthotic cranioplasty
what is the purpose of a DOC helment
encourage symmetrical skull growth by providing total contact over prominent areas of the skull and providing relief inside the orthosis where growth is desired
List contraindications for Cranial Orthoses
- Craniosynostosis
- unshunted hydrocephalus
- children beyond 18 months of corrected age
- babies under 3 months of age
