Torticollis and Plagiocephaly Flashcards
Torticollis incidence
- 3rd most common congenital musculoskeletal anomaly after congenital hip dysplasia and club foot
- Incidence of 16%
- Cranial deformity occurs in up to 90% of babies diagnosed with torticollis
- Early treatment is crucial: 80% of skull growth occurs by age 2
Torticollis risk factors (9)
- Large birth weight
- Male gender
-
Breech position
- 17-40% as compared to 1.5-7% of the population
- Multiple births
- Primiparous mother
-
Difficult labor/delivery
- 22-42% compared to 3-15% of the general population
- Use of vacuum/forceps assist
- Nuchal cord
- Maternal uterine abnormalities
torticollis is associated with?
- Hip dysplasia
- 10-20% compared to 1.2-1.9% of the general population
- Clubfoot
- CBPI
T/F: 1/5 children who present with torticollis posture have a nonmuscular etiology
True
non muscular etiologies
- Klippel-Feil Syndrome
- CBPI
- Ocular lesions
- Sandifer Syndrome
- Dystonic Syndromes
- Posterior Fossa Pathology
- Torticollis is an initial sign
- Usually occurs in older children
- Associated with symptoms of HA, NV
- Postencephalitis
- ACM
- Syringomyelia
congenital torticollis definition and subtypes
- Definition: neck deformity involving shortening of the SCM that is detected at birth or shortly after
- Subtypes
- Sternocleidomastoid tumor
- Muscular torticollis
- Postural torticollis
- Postnatal torticollis
SCM tumor torticollis
- Definition: discrete mass palpable within the SCM muscle
- Normal x-rays
- Histologic tissue changes include:
- Excessive fibrosis
- Hyperplasia
- Atrophy
muscular torticollis
- Tightness but no palpable mass
- Normal x-rays
- Impairments
- Head tilt
- ROM limitations
- Cervical muscle imbalance
postural torticollis
characteristics and 3 possible causes
- No mass
- No tightness of SCM
- Normal xrays
- Impairments
- Head tilt
- No PROM limitations
- AROM limitations
- Cervical muscle imbalance
- Possible causes
- Benign paroxysmal torticollis
- Congenital absence of one or more cervical muscles or the transverse ligament
- Contracture of other neck muscles
postnatal muscular torticollis causes
- Environment
- Plagiocephaly
- Positional preference
classification of congenital torticollis
- Classification: severity classified with US images based on degree of muscle fibrosis and fiber orientation
- Classification that takes into account degree of ROM limitations and age at which treatment begins
grade 1 early mild congenital muscular torticollis
Present between 0-6 months with only postural preference or muscle tightness of <15 degrees cervical rotation
grade 2 early moderate congenital muscular torticollis
Present between 0-6 months with muscle tightness 15-30 degrees cervical rotation
grade 3 early severe congenital muscular torticollis
Present 0-6 months with muscle tightness of more than 30 degrees cervical rotation or SCM nodule
grade 4 late mild congenital muscular torticollis
7-9 months with only postural preference or muscle tightness of less than 15 degrees cervical rotation
grade 5 late moderate congenital muscular torticollis
10-12 months with only postural preference or muscle tightness of less than 15 degrees rotation
grade 6: late severe congenital muscular torticollis
7-12 months with muscle tightness of >15 degrees
grade 7: late extreme congenital muscular torticollis
Present after 7 months with SCM nodule or 12 months with muscle tightness >30 degrees
characteristics congenital muscular torticollis (7) and changes in body structure (2)
-
Characteristics
- Ipsilateral mandibular asymmetry
- Ear displacement
- Plagiocephaly
- Scoliosis
- Pelvic asymmetry
- Congenital dislocated hip
- Foot deformity
-
Changes in body structure
- Decreased ipsilateral cervical rotation
- Decreased contralateral lateral flexion
torticollis motor characteristics
- Difficulty centering head in midline in supine
- Bias toward extension and asymmetry
- Visual gaze oriented toward side of head turning
- Prone position: altered forearm weight bearing with more weight distributed over the arm, trunk, and pelvis on the affected side
- Cascade: abdominals, trunk and extremity righting
functional activities and participation difficulties
- Breastfeeding
- Looking to the involved side to scan the environment
- Reaching for a toy
- Maintaining sitting
- Creeping
- Ambulating
- Decreased interaction with environment and caregivers on the involved side
other muscles that may be affected
- Platysma
- Scalenes
- Hyoids
- Tongue
- Facial muscles
secondary torticollis impairments
- 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 1st month)
- Trunk curvature
- Persistence of ATNR
- Windswept hips
- Elevated shoulders
- Visual neglect
- Decreased ipsilateral body awareness
torticollis PT exam
- Pregnancy/birth hx
- Family hx
- Medical care
- Positioning
- Developmental skills
- Ophthalmologic consult
- MRI if consult is negative
- Hearing consult
- Neurological assessment
- Plain radiographs
- Physical examination
- Differential diagnosis
Red flags in initial presentation of torticollis in children:
- Age >6 months at presentation
- Pain
- Neurologic findings
- Associated Syndromes (Down Syndrome, Skeletal Dysplasia)
- Trauma
- Inflammatory or infectious history
- Alternating sides
- Atypical position (such as rotation and lateral bending to the same side)
- Late onset
conservative management for torticollis
- Active and passive ROM
- Caregiver training in ROM and positioning
- Strengthening
- Developmental activities
- Duration dependent on:
- Age
- Severity
- Family circumstances
team for torticollis intervention
- Physician
- PT
- Infant
- Caregiver
- EI coordinator
- OT/ST
- Treat the infant as a whole
precautions for torticollis conservative management
- Monitor infant for signs of stress
- Maintain the neck in N in the sagittal and transverse plane while stretching
- Keep the stretching gentle
- Use age appropriate distractions to prevent distress
treatment strategies for torticollis management
- Myofascial release
- Joint mobs
- Orthoses
- HEP
- Modalities
- ROM
- Strengthening
- Kinesiotape
TOT Collar indications
- Indications
- 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
microcurrent
- Low intensity alternating current (200 uA) applied over the SCM
- Infant should not perceive the current
- Should be followed by stretching
- Less sessions required
- Less crying
kinesiotaping
Weak but promising results when applied to relax the affected side
torticollis surgical management
- Surgical intervention should be considered if improvement is not evidence after 6 months of conservative intervention
- Indications
- Residual head tilt
- Deficits of PROM >15 degrees
- Tight muscular band/tumor
- Required in 8% of cases
- Procedures
- Release of SCM with a Z plasty
- Botox injections
torticollis d/c guidelines
- Full AROM and PROM
- 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
- Prognostic factors
- Age referred to intervention
- Severity or ROM deficits
- Thickness of SCM nodule
- Comorbid conditions
- Dosage of intervention
Plagiocephaly definitions
- Definition: malformation of the head marked by an oblique slant to the main axis of the skull
-
Definition: any condition characterized by a persistent flattened spot on the back or side of the head (flat head syndrome)
- Anterior progression of the ear on the same side as the occiput
- The head takes on the shape of a crooked rectangle
difference between deformation and acquired plagiocephaly
- 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
- Acquired: concordant with CMT
difference between brachycephaly, scaphocephaly, and craniosynostosis
- Brachycephaly: a condition where the head is disproportionately wide
-
Scaphocephaly/dolichocephaly: a condition where the head is disproportionately long and narrow
- Common in babies born prematurely
-
Craniosynostosis: 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)
- Lambdoid craniosynostosis: the skull takes on a trapezoid shape (wider in the front, narrower in the back)
- Ruled out using lateral head x-rays and/or CT scans
plagiocephaly severity classification
- Rating scales
- Argenta’s clinical classification scale
- Quantitative measurement
- Calipers
- Digital photographic techniques
- 3D imaging
risk factors for deformational plagiocephaly
- Oligohydramnios
- Uterine malformations
- Cephalohematoma
- Prominent maternal lumbar spine
- Complications of delivery (forceps, prolonged labor)
- Primiparity
- Male gender
- Cumulative exposure to the spine
- Neck problems
risk factors for acquired plagiocephaly
- Postnatal positioning
- Preference to turn head to one side while sleeping
- Little time in prone
- Excessive use of infant carriers, car seats, strollers
- Muscular torticollis
prognosis for plagiocephaly
- Cranial facial asymmetry that is present at 6 months of age has a high probability of persisting into adolescence/adulthood
- Increased prevalence of gross motor delay
- Lower developmental scores at preschool age
- Increased use of special ed and therapy by school age
plagiocephaly intervention for medical mangement
- Timing
- 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 remodeling band treatment (DOC)
- DOC
- Encourages symmetrical skull growth by providing total contact over prominent areas of the skull and providing relief inside the orthosis where growth is desired
- Contraindications
- Craniosynostosis
- Unshunted hydrocephalus
- Children beyond 18 months of corrected age
- Babies under 3 months of age
- Factors affecting correction
- Age at the beginning of treatment
- Type and severity of treatment
- Caregiver adherence
