Torticollis Flashcards
What is CMT?
Congenital Muscular torticollis. Postural deformity evident shortly after birth.
What causes CMT?
Unilateral shortening of the SCM characterized by IL side flexion, and opp rotation
What side is the CMT name by?
For the side of the tightness.
What is the prevalence of CMT?
3rd most common congenital MSK condition.
Male > Female
What do children with CMT have trouble developing?
Vision and midline motor activities.
What is CMT associated with 80-90% of the time?
Plagiocephaly
What is plagiocephaly?
Defined as slanting/flattening of the head. Occipital asymmetry.
What are some other skull characteristics you may see with plagiocephaly?
IL ear positioned anterior or inferior Frontal bossing Facial asymmetry Temporal bossing Posterior vertical cranial growth
Causes of plagiocephaly
Uterine constraint due to multiple births Assisted delivery with forceps or vacuum Premature birth Prolonged Labor Inadequate tummy time Nonvarying nursing/bottle feeding habits Developmental Delay Torticollis
Resolution of Plagiocephaly
Many head deformities resolve during the first few months of life if the infants head is frequently repositioned.
Can get worse over time
If significant at 4 mo helmeting may be needed
Concepts for positioning for play
Limit time in devices where head is resting on hard devices
Alternate infant position in the crib with head at either end
Promote tummy time!
What does helmet therapy do?
Redirect growth
Improve symmetry of cranial vault cranial base and face.
Etiology of CMT at birth
Due to constraint during last few weeks of gestation
What is fibroma in CMT?
Pseudotumor of infancy. Develops at 2-3 weeks of life resolves by 4-6 mo. Painless and in middle to lower 1/3 of the sternal portion of SCM.
What are the two categories of torticollis?
Acquired and Congenital (Acquired is subdivided into traumatic and atraumatic)
What disorders/conditions are associates with acquired non-traumatic torticollis?
Occular conditions, orthopedic abnormalities, sandifer syndrome, klippel-feil syndrome, Benign paroxysmal torticollis, infections conditions, neurologic syndromes.
Occular torticollis
Infant may tilt head to correct vision d/t visual impairment.
Potential impairments causing occular torticollis
Strabismus Nystagmus Inconsistent visual tracking Gaze aversion Typically due to unilateral superior oblique muscle weakness
What orthopedic abnormalities can it result in?
Can result in scoliosis
Sandifer syndrome
Onset in infancy/early childhood (18-36 mo peak)
Spasmodic neck dystonia with arching of the back and posturing of the neck back and UE.
May look like a seizure
GER or hiatal hernia
Severe hypotonia may be noted
Klippel-Feil Syndrome
Genetic
congenital fusion of C2-C7
Webbed short neck, low hairline
abnormalities of head/face/sex organs, muscles extremities and heart
Benign paroxysmal torticollis
Tort posture but involved side switches. Resolves around 2-3 y.o. Can be assoc with nausea vomiting ataxia, irritability and drowsiness. Migranes.
Comorbid conditions.
Hip dysplasia (+ on side of torticollis)
Club foot
Metatarsus adductus
Brachial plexus injury
Types of torticollis
SCM tumor/fibrotic nodule Muscular torticollis (tightness/thickening of muscle may have fibrotic band) Postural torticollis (without tumor or tightness)
Normal CROM to 12 mo
Rot: 100 deg Lateral Flex: 70 deg Extension: 45 Cervical Flex: 45 Capital Flex: 10
How many severities of torticollis are there?
Seven
Stratification of CMT
Age at initiation of Tx, type, amount of PROM tightness
What is early tort? late?
Early: 0-6 mo
Late: 7-12
what are the rotation limitation severities?
mild: 30
deficits on UE IL side
decreased reaching toward midline with forearm supination shoulder ER, and or flexion, decreased crossing midline during reaching, decreased development of protective extension reaction
Trunk/LE asymmetry
c surve or s curve in spine, with IL leg: decreased kicking/hands to feet Asym LE position in sitting Tripod position during creeping Asym in supported standing and sitting
Sequela of postural abnormalities
Neglect of IL hand, decreased awareness of IL visual field
Decrease symmetry in development of head righting, uneven WB, delayed gross motor skills, incomplete devel of automatic balance reactions
Other muscle involvement in tort
SCM Upper trap Scalenes Platysma Lev Scap Suboccipitals Neck extensors Muscles of mastication, UE, Trunk LE
CMT evaluation: general history
Pregnancy: complications/bed rest/decreased amniotic fluid
Delivery: full term?, method, length/weight at birth, presence os skull or facial asymmetry at birth, birth order
Current health: prone play tolerance, preferred sleep position, feeding/GI, refulx ,feeding pos.
Devices: how long, which ones
CMT evaluation: torticollis history
When was tort first noticed? Has it changed since initially noticed? Sudden onset? Testing? Hx of treatment to date
CMT systems review
Vision screen (midline visual focus, tracking, eyes moving together)
Hearing Screen
Neuro Screen (ATNR should be int. by 4-5 mo), presence of sustained clonus, muscle tone
Pain Screen: NIPS, FLACC
Integument screen: folds, redness
Muscle function scale for lateral righting
infants of 2 mo had med score of 1
inc to 3-4 by 10 mo.
Don’t use in infants
Tests for hip dysplasia
Barlow/Ortilani
Galleazi: (+) leg/knee lower on side of dislocation (hooklying)
Thigh/gluteal folds: asymmetry on side of dislocation
Hip Abduction
FIrst choice of treatment
Neck PROM Neck and Trunk AROM (strengthening) Development of symmetrical movement Environmental adaptations/positioning Parent/caregiver education
Positioning techniques
Nesting & Prone towel rolls with functional activities.
Stretching protocol for torticollis
Daily basis (at least 3x/day up to 6-8x/day) Low load sustained stretches recommended 10-30 sec up to 2 min Hand placement is important (stabilize shoulder/trunk, support infant & prevent compensations)
Strengthening techniques
tummy time active rotation prone and sitting active flexion (work on symmetry) Rolling Lateral flexion head righting
When is medical management recommended
lack of progress after 6 mo conservative treatment or child begins PT after i eyar of age and has significant restrictions or mass. (Botox, surgical release)
Surgery indications
Not responding after 6 mo
Approaching 1 yr with no resolution
Deficits of PROM rotation and lateral flexion > 15 degrees
Tight fibrotic muscular band or tumor
