Torticollis Flashcards
Torticollis describes
A posture, not a dx
Torticollis
Lateral tilt to one side, rotation to opposite side
Named for tilt
1 in 5 children w/ torticollis have a ____ etiology
Non muscular
Diff dx include hx, physical exam, imaging
Acquired torticollis
Traumatic or non traumatic
Congenital torticollis
Postural
Congenital muscular torticollis
Acquired traumatic torticollis
Soft tissue injury
Fracture neck/clavicle —> spasm, BPI
AA rotation subluxation due to injury
Acquired non traumatic torticollis - inflammation
Inflammation conditions causing rotary subluxation of C1 on C2 including: Osteomyelitis of Cspine Juvenille RA Tonsillitis Mastoidits
Acquired non traumatic torticollis - ocular
Oculomotor weakness or ocular lesion
Sup oblique palsy
Congenital nystagmus of diplopia
Acquired non traumatic torticollis - neuro
Account for 10% non muscular torticollis
Tumors most common
Arnold-chiari malformation
Acquired non traumatic torticollis - bony deformities
Fusion of 1 or more cervical vert
Hemivertebrae
Acquired non traumatic torticollis - BPT
Benign paroxysmal torticollis
Side of tilt alters
Etio UK, suspect neuro
Typically resolved by 3-5 yrs w/out tx
Acquired non traumatic torticollis - sandier syndrome
Hiatal hernia and or GERD causes posturing of head to decrease pain of esophagitis
Acquired non traumatic torticollis - causes
Inflammation Oculomotor Neurological Bony deformity BPT Sandier syndrome
Congenital postural torticollis
Muscular
Caused by positioning of head and neck very soon after birth
First sign: mild preference for rotation or mild tilt
Becomes reinforced by positioning, commonly undiagnosed
Congenital muscular torticollis (CMT)
Unilateral fibrosis of SCM In utero or during birth process
Etio varies - position in utero, ischemic injury to SCM in utero/during birth
3rd most common congenital musculoskeletal anomaly in infancy
CMT
Males > females
Approx 2/3 of babies w/ CMT have
Palpable tumor in SCM,
Appears during 0-3 mo
Gradually resolve by 4-6 mo
Common dx accompanying CMT
Congenital hip dysphasia (esp males)
Club foot
Metatarsus adductors
BPI
CMT is seen more commonly in
Multiple births, esp in lower baby in utero
Failure to treat CMT
Persistent neck tilt and contracture Plagiocephaly Delayed/ asymmetrical motor skills Cervical/thoracic scoliosis Craniofascial deformities
Most common cranial deformity seen with CMT
Plagiocephaly
Sig craniofacial deformities from failure to tx CMT
Asymmetry of orbital fissures
Mandibular asymmetry
Feeding problems
Torticollis objective
Measure tilt of lateral flex
Active neck rotation al positions
PROM: bilateral lateral flex, flex, ext
Palp all cervical muscles and fascia, plus shoulder muscles, trunk, pelvis (secondary tightness)
Frequently seen postural reactions in torticollis
Diff living head in prone On involved side -decreased/absent head and trunk righting -decreased/absent protective -poor equilibrium
Torticollis developmental skills
Prone may be delayed
Rolling may be delayed or asymmetrical
Quick rule of thumb to measure lateral neck flexion
40 deg - chin to nipple
70 deg - chin to b/n nipple and shoulder
90- chin over shoulder
100 - chin past shoulder
“Normal” PROM for 2-10mo rotation
100-120
“Normal” PROM for 2-10mo lateral flexion
65-90
Typical AROM 2-10 mo lateral flexion
Most 2 mo able to maintain head in line w/ body
By 10 mo, head held high or very high above horizontal
4 goals of PT intervention for torticollis
- **parents to be indep w/ home program
- Full cervical AROM and PROM
- Age-appropriate postural control, motor milestones
- Midline control of head, neck and body, symmetrical movement patterns
3 components of pt intervention for torticollis
1.Stretching
2. Positioning,
3. strengthening, handling
Postural control, motor milestones
Key points for stretching torticollis
Low intensity, sustained, pain free (avoid micro trauma to muscle)
Performed frequently throughout the day for more rapid resolution
Hand placement important
Torticollis: PROM HEP
Lateral flexion and rotation for affected SCM
Progress to teach other as they become proficient
Stretch every diaper change
Perform each stretch 3 times for 10-30 s or longer
Torticollis AROM: if neck flexors or extensor are tight
Can use
Passive, active stretch
Massage
MFR
Contras to stretching for torticollis
DS
Spina bifida
Vertebral or spinal core abnormalities
Compromised circulatory or respiratory system
Positioning, strengthen, handling torticollis: start w/
Tummy time
-assist w/ earlier dev of motor milestones
Improves arm, shoulder girdle, neck, ab strength
Good for gentle stretch/ prom of trunk hips and neck
Football hold
____ is almost always diminished in infants w/ torticollis
Postural control
Begin working on upright postural control at
4 mo
Torticollis and righting reaction
Contralateral SCM elongated and weak
Affected shorter but also weak
Symmetry while working on gross motor skills in both directions
Supine: hands to mind line Prone: on forearms or hands Rolling to both sides Quad Sitting and reaching/WB on both hands
PT intervention for torticollis w/ limited research
Myofascial release
Craniofacial therapy, feldenkrais, Soft tissue massage
Incorporate visual tracking and sensory awareness/stim toward side of involved SCM
Follow up for torticollis
3-12 mo after d/c and when walking
Primary factor affecting torticollis outcome
Age at initiation of tx
Severity of CMT
Presence of SCM mass
Compliance w/ HEP
Conservative tx for torticollis very effective if
Initiated prior to 1yr age
Torticollis progression-regression pattern occur w/
Growth spurt
Teething
Illness
Fevers
Sx required for complete resolution of torticollis in
8-10% cases
3-6 mo of thorough conservative therapy w/ residual head tilt and tight muscle arm band and fascia asymmetry
Fascia asymmetries become irreversible if not corrected by
12 yrs old
Positional plagiocephaly
An abnormal or flattened headshape resulting form external molding forces to cranium
Plagiocephaly: MD MUST rule out
Craiosynostosis: rare condition where 1 or more cranial sutures fuse prematurely
Deformation of head occurs
In utero or up to approx 4 yrs old
Risk factors for plagiocephaly
CMT/positional preference Intro-uterine constraint Multiples First born child Gender Supine sleeping (or excessive use of seating devices)
Possible adverse effects of non resolved plagiocephaly
Perm cranial/facial asymmetry
Elevated risk of auditory and visual processing disorder
Negative social and self esteem issues
Possibly neuro delays
Tx options for positional plagiocephaly
**Reposition
Cranial banding/helmets
Sx
When to implement repositioning for plagiocephaly
Parents must be VERY active in HEP
Best for young infants (<4m) w/ mild flattening
Difficult to perform on infants w/ tort.
Repositioning tx for plagiocephaly
Increase tummy time, decrease supine Alt head position during sleep Alt side of feeding Place toys/objects to non preferred side Avoid excess use of seats
Cranial banding/helmeting
Moderate to sever cases non responsive to reposition, 4mo and older
Early banding
Proven to work faster and more effectively than repositioning alone
Does plagiocephaly improve on its own?
No
Severe plagiocephaly deformity
Corrected more “quickly and effectively” w/ cranial orthosis than repositioning and PT
Most important for choosing cranial banding product
FDA approval
Company is experienced w/ children
Company can demonstrate safety and success of product
DOC band use
Young infants (<6m ideal)
Very light weight and custom fit
FDA for 3-18 m old
DOC band protocol
23 hrs/day
Clinic visits to remove foam lining
Anthropometric before and after
Tx time in 1 band 2-4 mo
Sx tx for plagiocephaly
Only when child is older than 2y and has severe to extreme deformity
Generally standoff of car only for tx of craniosynostosis
Scaphocephaly
Midline shortens
Longer A-P
Typical plagiocephaly
Diagonal, pushed over to one side
Brachyocephaly
Gets wider
Plagiocephaly named for
Side that’s flattened
Describe width/dimensions
