Torticollis and Plagiocephaly Flashcards
CMT
congenital muscular torticollis
what does torticollis lead to (positioning)
ipsilateral SB and contralateral rotation
what side is torticollis named by
side of muscle shortening
what does torticollis commonly occur with
- hip dysplasia
- brachial plexus injury
- metatarsus adductus
- plagiocephaly
- facial asymmetries
- may see shortening of scalenes, levator scapulae, upper trap
prenatal and perinatal theories for torticollis
prenatal
- ischemic injury, intrauterine compartment syndrome, intrauterine crowding, hereditary factors
perinatal
- neurogenic injury, birth trauma (direct injury to the muscle or rupture of muscle during birthing process)
risk factors for torticollis
- large birth weight
- multiple birth
- male gender
- breech position
- difficult labor or delivery
- use of vacuum or forceps for delivery
- maternal uterine abnormalities
3 types of ways to differentially diagnosis torticollis when it is a non-muscular etiology
- osseous (klippel-feil syndrome and hemivertebrae)
- non-ossseous (grisels syndrome, sandifer syndrome)
- neurologic (brachial plexus injury, ocular dysfunction, arnold-chiari malformation)
klippel feil syndrome
fusion of 2 cervical vertebrae
hemivertebrae syndrome
one cervical vertebrae develops on one side and not the other
grisel’s syndrome
atlanto-axial subluxation caused by upper respiratory issue
sandifer syndrome
caused by GERD
what are the 3 types of CMT
- postural/positional torticollis
- muscular torticollis
- sternomastoid tumor
postural/positional preference
- infants born with postural preference
- no tightness of SCM and no PROM restrictions
- no mass, x-rays normal
muscular torticollis
- tightness of SCM with ROM limitations
- no mass, x-rays normal
sternomastoid tumor
- discrete mass or fibrotic thickening of SCM
- PROM limitations
- x-rays normal
found within SCM belly and appears within first 2 weeks of life and gradually disappears
associated fibrotic tumor
dx of torticollis
- often within first 2-3 weeks after birth, milder cases up until 6 months of age
- parents or pediatricians note a head tilt or rotational preference
- clinical presentation
- palpation of SCM
- x-rays (not always)
important aspects of birth/health history for torticollis
- chronological/corrected age
- age of onset
- pregnancy hx
- delivery hx
- birth presentation
- head posture/preference and head/face asymmetries
- family hx
- other medical conditions
- developmental milestones
assessing posture in torticollis
- general posture in all developmental positions
- measure degree of resting head tilt via still photography in supine
how to measure resting head tilt
- draw line through acromion and through midpoints of both eyes
- intersection angle to measure head tilt
ways to measure cervical rot and SB
- % of unaffected side
- tape measure
- arthrodial protractor
- anatomical landmarks
normal lateral flexion
70 deg
normal rotation
110 deg
nipple line rotation
40deg
between nipple line and shoulder
70deg
shoulder
90 deg
past shoulder
100deg
how to perform AROM in infants <3 m/o
performed in supine
how to perform AROM in infants > 3 m/o
performed in sitting
how to measure muscular strength in infants less than 2 m/o
muscle function scale (MFS)
score of 5 on MFS
- head held high above horizontal line, almost vertical
- > 75deg
score of 4 on MFS
- head held high over horizontal line > 45deg
- > 45 <75
score of 3 on MFS
- head held high over horizontal, but < 45 deg
- > 15 deg < 45deg
score of 2 on MFS
- head held slightly over horizontal line
- > 0 < 15 deg
score of 1 on MFS
- head held in horizontal
- 0 deg
score of 0 on MFS
- head below horizontal
- < 0deg
how to perform MFS and how is it scored
- hold infant vertically in front of mirror and then tip them horizontally
- observe righting position
- must be held for 5 seconds
head tilt to maintain binoocularity or to optimize visual acuity
ocular torticollis
how to test for ocular torticollis
sit up test
easy outcome to measure developmental/gross motor exam for torticollis
AIMS
infants with CMT, prone positioning at least _____ x/day is correlated with higher AIMS scores
3
interventions started ____ will have 98% of pts with normal ROM within 1.5 months
before 1 month
interventions beginning _____ may need interventions for > 6 months
after 1 m/o
waiting until ____ may require 9-10 months of tx and may not achieve full ROM without surgical intervention
after 6 months
5 first choice interventions for torticollis
- PROM
- neck and trunk AROM
- developmental exercises to promote symmetry of movements
- environmental adaptations
- parent education
supplemental interventions for torticollis
- STM
- kinesiotape
- TOT collar
if conservative tx fails after how many months should you refer and at what age should surgery be performed by to allow for better outcomes
- 6 months of conservative tx
- before age 8
criteria for discharge from PT for torticollis
- PROM within 5 deg of non-effected side
- symmetrical active movement patterns
- age appropriate motor development
- no visible head tilt
- parents/caregivers understand what to monitor as child grows
asymmetrical flattening of skull
plagiocephaly
causes of skull deformation
- neonatal: first born, prolonged labor or tool assisted delivery, prematurity or low birth weight, torticollis
- environmental factors: prolonged placement in one position, lack of prone position, increased time in positioning device
premature fusion of cranial sutures
craniosynostosis
positional plagiocephaly features
- ipsilateral frontal bossing
- ipsilateral ear displaced anteriorly
- contralateral occipital bossing
- parallelogram shape
craniosynpstosis features
- contralateral frontal bossing
- ipsilateral ear displaces posteriorly
- ipsilateral occipitoparietal flattening
- contralateral parietal bossing
- trapezoid shape
which is conservatively managed is which has to be managed surgically (plagiocephaly vs craniosynostosis)
- conservative = plagiocephaly
- surgically = craniosynostosis
back of head becomes flattened symmetrically
brachycephaly/dolichocephaly
sagittal synostosis - skull becomes enlarged
scaphocephaly
1st choice interventions for plagiocephaly for infants 0-4 m/o without torticollis
- parent education, repositioning exercises
- goal: shift infant off flattened areas to encourage symmetrical head shape
- referral to PT if resistant to repositioning, neck tightness, head shape worsens or does not improve
- goal: encourage symmetrical skull growth
cranial remodeling orthosis (CRO)
what age group is CRO for
3-18 months with moderate to severe skull deformity
optimal age for initiating CRO tx
4-6 months
how often is CRO worn
23 hours/day
how often is follow up for CRO
2-3 weeks
goal: parent education, resolve ROM deficits, strengthen weak muscle groups, promote age appropriate motor development
PT
- measures plagiocephaly
- measurement is taken diagonally
- 3 measurements and take the average
cranial vault asymmetry index (CVAI)
- measures brachycephaly
- 3 measurements
- measure medial/lateral and anterior/posterior
cephalic index (ratio) (CI)
