Torticollis and Plagiocephaly Flashcards
What were some of the consequences of the “back to sleep” program?
- Decrease in sudden infant death syndrome
- Missed “tummy to play” time
- Weak arm, neck, shoulder and trunk muscles
- Delays in developmental milestones
- baby containers exacerbate problems
an idiopathic postural deformity of the neck evident at birth or shortly therafter
congenital muscular torticollis
What are the characteristics of torticollis?
- Ipsilateral Head Tilt
- Contralateral Cervical Rotation
- Secondary to unilateral shortening of the SCM
What are the comorbid conditions associated with torticollis?
- Cranial Deformation (typically Plagiocephaly)
- Hip Dysplasia
- Brachial Plexus Injury
- Distal Extremity Deformation
- Early Developmental Delay
- Persistent Developmental Delay
- Facial Asymmetry that may affect cosmesis
- Temporal-mandibular joint dysfunction
What are the risk factors for torticollis?
- Large birth weight*
- Breech presentation
- Use of forceps at delivery
- Asymmetrical head or face (22 fold increase)
- 1st pregnancy (6 fold increase)
- Birth trauma (4 fold increase)
- Birth length (2 fold increase)
- CPG suggests presence of 2+ of these factors (those italicized) warrants referral for preventative care and parent education
When a child presents with torticollis, what systems should you screen for?
- Musculoskeletal: Symmetry, screen for cervical vertebrae anomaly, rib cage symmetry, hip dysplasia
- Neurological: Tone, Reflexes, Cranial Nerve Integrity, Brachial Plexus Injury, Temperament, Milestones
- Integumentary: Abnormal skin folds at the hips (indicative of developmental hip dysplasia), color and condition of skin, signs of trauma that may cause asymmetric posture
- Cardiopulmonary: Symmetrical coloration, rib cage expansion, clavicle movement to rule out Brachial Plexus Injury
- Vision: Screen Tracking, check for nystagmus
- Gastrointestinal: History of reflux or constipation, preferential feeding from one breast
- Positional preference
- Structure and movement symmetry of the neck, face, head, spine, trunk, hips, upper and lower extremities
What are red flags that require referral?
- Hip dysplasia
- Skull and/or facial asymmetry, including plagiocephaly & brachycephaly
- Atypical presentation
- Lateral flexion and rotation to the same side – not consistent with torticollis
- Plagiocephaly and tilt to the same side – indicative of ^^ - Abnormal tone
- Late-onset torticollis (>6 months) – with no hx, concerning
- Visual abnormalities -Nystagmus, strabismus, abnormal visual tracking, gaze aversion
- History of acute onset
What are the markers for measuring rotation ROM?
- Nipple = 40 degrees
- Between nipple and shoulder = 70
- Shoulder = 90 degrees
- Beyond shoulder = 110 degrees, normal
- rotation ROM norm = 110
- lat flex ROM norm = 70
How are the grades for testing the SCM strength graded? (tilting baby to one side, seeing how they hold their head up)
4-very high over horizontal line 3 -high over horizontal line 2-slightly above horizontal line 1-holding on horizontal line 0-below horizontal line - infant held horizontally >5s
how can you assess torticollis through digital imagery?
baby lays supine
- draw straight line between acromion processes
- draw line through eyes
- assess angle between the two, should be 0 for normal
What is present in a Grade 1 level of severity with torticollis?
- Present from 0-6 months
- Postural Preference
- Muscle tightness lacking <15 degrees of cervical rotation
“Early Mild”
What is present in a Grade 2 level of severity with torticollis?
- Present from 0-6 months
- Muscle tightness lacking 15-30 degrees of cervical rotation
“Early Moderate”
What is present in a Grade 3 level of severity with torticollis?
- Present from 0-6 months
- Muscle tightness indicated by >30 degree loss of cervical rotation ROM
- Presence of an SCM Mass
“Early Severe”
What is present in a Grade 4 level of severity with torticollis?
- Presentation at 7-9 months
- Postural Preference
- <15 degree loss of cervical rotation
“Late Mild”
What is present in a Grade 5 level of severity with torticollis?
- Present at 10-12 months
- Muscle tightness lacking <15 degrees of cervical rotation
“Late Moderate”
What is present in a Grade 6 level of severity with torticollis?
- Present from 7-12 months
- Muscle tightness lacking >15 degrees of cervical rotation
“Late Severe”
What is present in a Grade 7 level of severity with torticollis?
- Present after 7 months with SCM mass
- Present after 12 months with muscle tightness indicated by >30 degree loss of cervical rotation ROM
“Late Extreme”
What are the recommended tools for assessment of activity and developmental status?f
- Test of Infant Motor Performance (TIMP)
- Up to 4 months corrected age
- Common in NICU, looking for symmetrical movement - Alberta Infant Motor Scales (AIMS)
- 4-18 months corrected age
- Symmetrical movement and gross motor development
- there is increased incidence of persistent developmental delay with CMT, usually resolves around 10 mos but up to 10% do not
How long should intervention last when treatment of CMT is initiated at 3 months?
- 5 - 3 months (6-12 weeks)
- rotation resolves first, then flexion
How long should intervention last when treatment of CMT is initiated in children over 3 months?
3-6 months
- rotation resolves first, then flexion
What is a poor prognostic indicator for CMT?
presence of an SCM mass at initial diagnosis
- increased tx time necessary for increased fibrosis within mass
What are the alternative options after conservative treatment of CMT has failed?
- Zplasty (surgery)
- Botox - off label usage with black box warnkingl long term studies on effectiveness and safety are warranted
- only considered if a 6 month bout of PT has failed, or if child is > 12 months at age of referral
How should CMT be managed with PT?
- AROM & PROM to address impairments in body structure and function - Neck, trunk, UE
- Promote fine and gross motor development as well as cognition
- Positioning for active movement away from the tightness
- Infants suspected of having a nonmuscular condition causing asymmetry or torticollis posturing should have a full evaluation prior to initiation of PT treatment
What are the risk factors for plagiocephaly?
- premature birth
- hypotonic muscle disorders
- congenital torticollis
- difficult delivery
- intrauterine constraint
- environmental factors
What facial characteristics are seen in plagiocephaly?
- Asymmetry of the craniofacial skeletal structures
- Asymmetry of the masticatory and tongue muscles
- Jaw - Contralateral underdevelopment; Deviation of the mandible and gum line toward contralateral side
- Ear- Ipsilateral anterior
- Eye - Ipsilateral eye forward and forehead larger; Contralateral recessed eyebrow and zygoma (squinty eye)
- Nose - Deviation toward contralateral side
in the case of plagiocephaly, how often should head measurements be taken?
every 4-6 weeks
How can you diiferentiate synostotic plagiocephaly from positional head deformity?
- Palpable ridge suggests synostosis
- Ear on flattened side more posterior than the other ear suggests synostosis
- Forehead protruding on the side of the flattening suggests PHD
- A unilateral bald spot suggests PHD. Physician should palpate occiput for flattening
- “Parallelogram-shaped” head suggests PHD
Wehn is the optimal time to treat plagiocephaly?
0-3 months
- rapid brain growth, skull is still malleable
with a 4 mm CVAI, intervention suggested is:
- Monitoring (measurements)
- Early sleep positioning program & awake supervised tummy time
- Avoidance of lying (pressure) on flattened areas
What is the cranial orthotic treatment length?
Length of treatment is 3-5 months and increases up to 5-6 months when patients are 12 months and older
- if CMT present, additional 2-4 weeks needed
