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Pediatrics > Torticollis, CMT > Flashcards

Torticollis, CMT Flashcards

1
Q

torticollis

A
  • describe a posture

- lateral tilt to one side and rotation to the opposite side

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2
Q

differential diagnosis of torticollis

A
  • must perform on every infant with torticollis posture
  • 1 in 5 children with torticollis have a non-muscular etiology
  • differential diagnosis can include: history, physical examination, imaging
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3
Q

acquired: traumatic torticollis

A
  • soft-tissue injury
  • fractured neck or clavicle, causing: muscle spasm, brachial plexus injury
  • atlanto-axial rotatory subluxation due to injury
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4
Q

acquired: non-traumatic torticollis

A
  • inflammatory conditions causing rotary sublaxation of C-1 on C-2, including:
  • osteomyelitis of c-spine
  • juvenile rheumatoid arthritis
  • tonsillitis
  • mastoiditis
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5
Q

bony deformities of non-traumatic torticollis

A
  • fusion of 1 or more cervical vertebrae

- hemivertebrae

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6
Q

neurologic conditions of non-traumatic torticollis

A

-neurologic conditions. account for 10% of non-muscular torticollis. tumors are the most common. Arnold-chiari malformation

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7
Q

oculomotor weakness or ocular lesion in non-traumatic

torticollis

A

-oculomotor weakness or ocular lesion- termed “ocular torticollis” -superior oblique muscle palsy. congenital nystagmus or diplopia

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8
Q

Benign Paroxysmal torticollis (BPT) non - traumatic tortyicollis

A
  • side of tilt alters
  • etiology unknown but suspected to be neurological in origin. can be associated with vomiting, ataxia, pallor, drowsiness, seizures

-typically resolvesby 3-5 years of age w/o treatment

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9
Q

sandifer syndrome non-traumatic torticollis

A
  • hiatal hernia &/or gastric reflux causes posturing of head to decrease pain of esophagitis
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10
Q

congenital : postural torticollis

A
  • muscular in nature
  • caused by positioning of head and neck very soon after birth
  • first sign can be just a milf preference for rotation or mid tilt
  • this becomes reinforced by positioning in crib, positioning with feeding, seating devices etc
  • commonly undiagnosed
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11
Q

congenital: muscular torticollis (CMT)

A
  • occurs in utero or during birth process
  • defined as a unilateral fibrosis of the SCM
  • etiology of fibrosis is varied: in-uterine positioning or constraint of the baby’s head/neck in a laterally flexed posture. ischemic injury to the SCM while in utero or during birth
  • CMT is the 3rd most common congenital musculoskeletal anomaly of infancy
  • seen more commonly in multiple births than singletons “cramped positioning”
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12
Q

tumor in SCM– CMT

A

-approx. 2/3rd of babies with CMT have palpable tumor in SCM

  • appears during 0-3 mo of age
  • tumor should gradually resolve by 4-6 mo old
  • if it needs surgical removal, findings are usually a fibrous mass
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13
Q

PT intervention for muscular torticollis

A
  • all PT evaluation and treatment methods apply to muscular torticollis
  • obtaining a thorough history can help you with: differential diagnosis, setting goals, determining an accurate prognosis
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14
Q

failure to treat CMT can lead to:

A
  • persistent neck tilt and contracture. SCM and surrounding soft tissues may not grow relative to child’s skeletal and muscular growth
  • plagiocephaly (flattened are of skull). the most common cranial deformity seen with CMT
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15
Q

delayed and/ or asymmetrical motor skills

A
  • if baby rotates the head only to the right turn body to right
  • always leading motion with head vs. with LEs. no co-contraction of abdominals of LE flexion
  • right head rotation getting in the way of looking forwards or to left in sitting
  • altering body mechanics &trunk posture
  • decreased midline postural stability
  • diminished ability to organize postural responses
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16
Q

failure to treat cervical and/or thoracic scoliosis

A
  • instead of head tilting, child bring trunk to side to level visual field
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17
Q

failure to treat: significant craniofacial deformities

A
  • asymmetry of orbital fissures (one opening smaller than the other)
  • mandibular asymmetry (lateral deviation)
  • feeding problems (muscle asymmetry)
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18
Q

PT examination of torticollis: detailed history

A
  • pregnancy
  • length of gestation
  • head/neck placement in utero
  • complications
  • multiples
  • delivery complications
  • use of forceps or suction
  • physical trauma during birth
  • long labor
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19
Q

PT examination of torticollis: medical

A
  • age at onset
  • age at diagnosis
  • previous medical history and testing to diagnose muscular torticollis
  • presence of SCM tumor at any time
  • concurrent diagnoses
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20
Q

PT objective eval of torticollis

A
  • measure tilt of lateral flexion in all positions
  • assess active neck rotation in all positions
  • assess passive neck ROM into: bilateral lateral flexion, flexion, extension
  • assess skin integrity
  • palpate all cervical muscles and fascia
  • observe trunk, shoulder and arm positiong in supine, prone, sit, movements
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21
Q

PT assess postural reactions

A
  • difficulty with lifting head in prone

- on involved side: decr or absent head& trunk righting rxns. decr or absent protective rxn. poor equilibrium rxn

22
Q

quick rule of thumb to measure lateral flexion

A

40 deg= chin to nipple
70 deg= cin to between nipple & shoulder
90 deg= chin over shoulder
100 deg= chin past shoulder

23
Q

Norm for PROM and AROM for 2-10 mo

  • rotation
  • lateral flexion
A

Rotation: PROM 100-120;

lateral flexion: PROM 65-90; AROM 2 mo able to maintain head in line w/ body. by 10 mo head held high or very high above horizontal

24
Q

4 Goals of PT Intervention

A
  1. Key piece= parents to be independent with home program
  2. full cervical AROM &PROM
  3. age -appropriate postural control & motor milestones
  4. Midline control of head, neck and body & symmetrical movement patterns
25
Q

3 components of PT intervention for torticollis

A

1 stretching (HEP)

  1. Positioning, strengthening, handling
  2. Postural control, motor milestones
26
Q

Key points form clinical practice guidelines

A
  • should be low intensity, sustaines, pain free to avoid microtrauma to muscle tissue
  • if performed frequently throughout the day you see more rapid resolution
  • hand placement is important!
27
Q

HEP stretching

A
  • can desensitize neck and shoulder region first with heat or massage
  • teach parents to be gentle yet firm
  • be honest with parents that the infants generally don’t enjoy the stretching
  • work with parents on play and distraction techniques to make exercise more enjoyable
28
Q

PROM stretching HEP

A
  • begin with lateral flexion and rotation stretches for the affected SCM
  • progress on to teach parents other stretches as needed and as they become proficient
  • general rule of thumb: stretch every diaper change. perform each stretch 3 times for 10-30 sec
29
Q

contraindication/precautions for stretching

A
  • downsyndrome
  • spina bifida
  • vertebral or spinal cord abnormalities
  • compromised circulatory or respiratory systems
30
Q

postural control in torticollis

A
  • is almost always diminished in infants with torticollis.

- begin working on upright postural control at 4 months

31
Q

postural control & motor milestones

A
  • postural control is important in the development of motor milestones & when: substaining posture vis co-contraction
  • regaining posture via righting and equilibrium reactions
  • transitioning between postures equally to both sides and in diagonal/rotational motions

-work on trunk strengthening. equilibrium rxn. righting rxns. contra SCM will be elongated and weak. affected SCM will be shortened but also weak

32
Q

frequency & duration of PT treatment for torticollis

A
  • depends on : severity of CMT, age of child, parent’s compliance with home program
  • can decr sessions as child imporved and parent demonstrates good compliance
  • follow up recommended 3-12 mo after discharge and when walking
33
Q

prognosis for torticollis

A
  • primary factors affecting treatment outcome: age at initiation of treatment, severity of CMT, presence of SCM mass, compliance with home program
  • conservative treatment very effective if initiated prior to 1 year of age
  • patterns of progress and then regression over time are natural and can occur with: growth spurts, teething, illness, fevers
34
Q

treatment for persistent torticollis

A
  • Bo-tox not FDA approved yet for torticollis in infants
  • surgery is required for complete resolution in approx. 8-10% of cases. criteria 3-6 mo of thorough conservative therapy with residual head tilt & tight muscular badn & facial asymmetry

-facial asymmetries become irreversible if not corrected by 12 years old

35
Q

Positional plagiocephaly

A
  • an abnormal or flattened headshape resulting from external molding forces to the cranium
36
Q

craniosynostosis

A

-rare condition where 1 or more cranial sutures fuse prematurely

37
Q

positional plagiocephaly: differential diagnosis

A

diagnosis can be made by physician’s visual assessment

  • sometimes requires CT scan for diagnosis
  • x-ray alone is not definitive for diagnosis of craniosynostosis
38
Q

scaphocephaly

A
  • longer front to back
39
Q

brachycephaly

A

longer side to side flat back

40
Q

plagiocephaly

A
  • longer diagonal
41
Q

risk factors for plagiocephaly

A
  • CMT/positional preference of child
  • intra-uterine constraint
  • multiples
  • first born child
  • gender
  • supine sleeping position
42
Q

possible adverse effects of non-resoved plagiocephaly

A
  • permanent cranial &/or facial asymmetry
  • elevated risk of auditory & visual processing disorders
  • negative social and self esteem issues
  • possible neurodevelopmental delays
43
Q

three treatment options for positional plagiocephaly

A
  1. repositioning
  2. cranial banding/ helmets
  3. surgery
44
Q

Repositioning. when to implement

A
  • if parents are willing to be VERY active in TX at home
  • best for young infants (- 4 mo) with mild flattening
  • difficult to perform on infants with torticollis. but may be required by insurance prior to banding approval
45
Q

repositioning: treatment

A
  • increase Tummy time and decr time in supine
  • alternate head position during sleeo
  • alternate side of breat/ bottle feeding
  • place toys and objects to non-preferred side in car seat, watching TV, eating
  • avoid excessive use of car seats/ bouncy seats/ swings-neck/ trunk strnegtehning activities
  • work on developmental skills if delayed
46
Q

Cranial Banding/ helmeting

A
  • standard of care for moderate to severe cases not responsive to repositioning & 4 mo and older.
  • early banding is clinically proven to work faster and more effectively than repositioning alon
  • untreated plagiocephaly does not improve on its own
  • severe deformity corrected more “ quickly and effectively” with cranial orthosis vs. repositioning and physical therapy
47
Q

active banding

A
  • mild application of corrective pressures maintains previous growth in larger areas while redirecting all new growth into flattened regions
48
Q

DOC band

A
  • works best on young infanats
  • the younger the child, the faster the growth & more malleable the cranium
  • very lightweight and cutom-fit
  • FDA indicated for use on infants from 3-18 months of age
49
Q

DOC band treatment protocol

A
  • worn 23 hours a day
  • clinic visits to remove foam lining
  • anthropometric measurements & clinical photoggrahy before & after
  • treatment time in 1 band: 2-4 mo
50
Q

surgical treatment

A
  • performed on positional plagiocephaly only when the child is older than 2 years and has a severe to extreme deformity
  • generally standard of care only for tx of craniosynostosis

Pediatrics (19 decks)

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