torticollis

Question 1

definition of CMT

Answer 1

a postural deformity evident shortly after birth, typically presenting as side bending of the neck to one side and head/chin rotation to opposite side

Question 2

cause of CMT

Answer 2

shortening of SCM muscle and may be accompanied by other MSK or neuro conditions

Question 3

right sided torticollis

Answer 3

right SB
left rotation
tight R SCM

Question 4

incidence

Answer 4

as many as 16% of newborns (1 in 6) experience torticollis

more prevalent in males, with ratio of 3:2

CMT frequently accompanied with cranial deformation

15% of babies with CMT also have hip dysplasia

Question 5

3 types of CMT

Answer 5

postural
muscular
SCM MASS

Question 6

postural CMT

Answer 6

the infant exhibits a postural preference WITHOUT muscle tightness or restriction to PROM

mildest form

Question 7

muscular CMT

Answer 7

characterized by tightness of the SCM muscle and limitation of PROM

Question 8

SCM mass

Answer 8

presents with thickening of the SCM muscle and restricted PROM

Question 9

etiology of CMT - prenatal factors

Answer 9

longer body length

intrauterine crowding

Question 10

etiology of CMT - perinatal factors

Answer 10

birth trauma

Question 11

etiology CMT - post natal factors

Answer 11

positional preference
containers
GI reflux

Question 12

prognosis - referral before 1 month

Answer 12

98% of infants achieve near normal range within 1.5 months

Question 13

prognosis w referral between 1-6mos

Answer 13

prolongs intervention to about 6 months

Question 14

prognosis referral after 6 months

Answer 14

requires 9+ months of interventions with fewwer infants achieving near normal range

Question 15

possible complications if untreated

Answer 15

trouble bringing hands to midline

delayed visual development and visual tracking

problems w motor planning

decreased protective responses on affected side

asymmetrical motor skills and transitional movements

cranial deformation

Question 16

ket takeaways

Answer 16

named by side of tight muscle

frequently accompanied with cranial deformation

early diagnosis is key

Question 17

family interview - history

Answer 17

Age at initial visit (chronological and corrected age)
* Age of onset of symptoms
* Pregnancy history including maternal sense of whether the baby was “stuck” in one
position during the final 6 weeks of pregnancy
* Delivery history including birth presentation (cephalic or breech); use of assistance
during delivery such as forceps or vacuum suction
* Head posture/preference and changes in the head/face
* Family history of torticollis or any other congenital or developmental conditions
* Other known or suspected medical conditions
* Developmental milestones appropriate for age

Question 18

family interview - routines

Answer 18

feeding
sleeping
tummy time
time in equipemnt/devices
daycare/sitter

Question 19

posture and positioning - supine

Answer 19

Document the side of
torticollis, asymmetrical
hip, trunk, and extremity
positions, facial and skull
asymmetries, restricted
AROM

Question 20

prone posture

Answer 20

Document asymmetry of
the spine, the head on
the trunk, asymmetrical
use of the extremities,
and the infant’s tolerance

Question 21

supported upright positions posture

Answer 21

Document asymmetrical
preferential postures and
compensations in the
shoulders, trunk, and hip

Question 22

sidelying posture

Answer 22

Document asymmetries,
trunk flexion or
extension, head lifting,
leg position

Question 23

bilateral AROM - cervical rot and lateral flexion

Answer 23

Assess in supine and supported upright if age
appropriate
* Asymmetrical and compensatory movements
can indicate muscle tightness, restrictions or
weakness
* Treatment to improve AROM consistent with
goals of early intervention

Question 24

bilateral PROM - cervical rot and lateral flexion

Answer 24

Severity of CMT determined by difference between left and right PROM measures of
cervical rotation
* Normal value passive cervical rotation for child < 12 months: 110 ± 6 degrees
* Normal value passive lateral flexion for child < 12 months: 70 ± 2.4 degrees

Question 25

bilateral AROM/PROM - UE anD LE

Answer 25

Document infant’s natural movements * Passively move arms and legs through all available range at each joint * Passively move ribs and spine * Rule out: * Developmental dysplasia of hip (DDH): observe for symmetry and stability of hip, leg length symmetry, gluteal skin folds, hip scour test, Barlow and Ortolani Maneuvers * Brachial plexus injuries or clavicle fractures * Neurological impairments * Hypermobility * CNS lesions * Scoliosis

Question 26

pain or discomfort

Answer 26

Document any behaviors reflective of discomfort, or pain reactions in the infant and child during the examination process * Pain is not typically associated with the initial presentation of CMT * The FLACC is recommended to document baseline status * The PT should work with the parents and caregivers to differentiate actual pain responses from discomfort or behavioral reactions to stretching, anxiety, or the stress of an unusual environment.

Question 27

skin integrity

Answer 27

Document skin integrity * Symmetry of neck and hip skin folds * Presence and location of SCM mass * Size, shape and elasticity of SCM muscle and secondary muscles

Question 28

craniofacial asymmetries and head/skull shape

Answer 28

Up to 90% of infants with CMT will also have craniofacial asymmetry * Document cranial deformities, including plagiocephaly, brachycephaly, and dolichocephaly * Craniofacial asymmetries on the side of the torticollis may include: * smaller and elevated eye with changes in the orbit * recession of the ipsilateral ear * a reduced jaw height with malocclusion * possible gum line asymmetry

Question 29

cranial deformation

Answer 29

plagiocephaly brachycephaly dolichocephaly

Question 30

plagiocephaly

Answer 30

most common type of infant flat head syndrome. Generally, the back of the baby’s head is flat on one side.

Question 31

brachycephaly

Answer 31

second most common type of flat head syndrome. The back of the head is flattened instead of curved.

Question 32

dolichocephaly

Answer 32

less common type of flat head synfrome head is flattened on both sides

Question 33

craniosynostosis vs plagiocephaly

Answer 33

Premature closure of one or more cranial sutures * Prevalence ranges from 0.4% to 0.07% * Requires referral to neurosurgery

Question 34

gross motor function

Answer 34

Test of Infant Motor Performance (TIMP): 0-4 months * Alberta Infant Motor Scale (AIMS): 0-18 months * Peabody Developmental Motor Scales (PDMS-2): 0-5 years

Question 35

muscle function scale

Answer 35

0 = head below horizontal line 1 = head on the horizontal line 2 = slightly above line 3 = high above line but below 45dg 4 = head high above and more than 45 dg 5 = head very high almost vertical

Question 36

treatment - first choice

Answer 36

Neck PROM – Gentle stretching. Should not be painful to baby and stopped if infant resists or parent perceives changes in breathing or circulation. Each cheek on caregiver’s chest or floor. Neck & Trunk AROM – Exciting things to the non-preferred side. Tummy time, short spurts, total > 1hr/day. Symmetrical Movement Development – Both sides, both ways. Sidelying, rolling, reaching. Want bend and twist, not arching. Environmental Adaptations – Carry baby vs keeping them in holders, use towel rolls inside of swing or holder Parent/Caregiver Education – Alternate sides for holding, feeding and changing diaper

Question 37

discharge criteria

Answer 37

PROM within 5 dg of non affected side symmestrical active movement patterns age appropriate motor development no visible head tilt parents understand what to monitor in growth

Question 38

re eval should include

Answer 38

positional preference symmetry of movement developmental milestones

Question 39

consult primary care

Answer 39

When asymmetries of the head, neck, and trunk are not starting to resolve after 4-6 weeks of comprehensive intervention. 2. After 6 months of treatment with a plateau in resolution

Question 40

cranial reshaping helmet

Answer 40

head shaping not improving with positioning 4-10 months old length depends on severity

Question 41

key takeaways

Answer 41

Key Takeaways 1) Examination includes infant history, routines, body structures/posture, strength and mobility 2)Use decision tree to classify severity level 3) Follow first choice interventions 4)Use discharge criteria for developing goals and plan of care