Torticollis, CMT Flashcards
torticollis
- describe a posture
- lateral tilt to one side and rotation to the opposite side
differential diagnosis of torticollis
- 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
acquired: traumatic torticollis
- soft-tissue injury
- fractured neck or clavicle, causing: muscle spasm, brachial plexus injury
- atlanto-axial rotatory subluxation due to injury
acquired: non-traumatic torticollis
- inflammatory conditions causing rotary sublaxation of C-1 on C-2, including:
- osteomyelitis of c-spine
- juvenile rheumatoid arthritis
- tonsillitis
- mastoiditis
bony deformities of non-traumatic torticollis
- fusion of 1 or more cervical vertebrae
- hemivertebrae
neurologic conditions of non-traumatic torticollis
-neurologic conditions. account for 10% of non-muscular torticollis. tumors are the most common. Arnold-chiari malformation
oculomotor weakness or ocular lesion in non-traumatic
torticollis
-oculomotor weakness or ocular lesion- termed “ocular torticollis” -superior oblique muscle palsy. congenital nystagmus or diplopia
Benign Paroxysmal torticollis (BPT) non - traumatic tortyicollis
- 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
sandifer syndrome non-traumatic torticollis
- hiatal hernia &/or gastric reflux causes posturing of head to decrease pain of esophagitis
congenital : postural torticollis
- 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
congenital: muscular torticollis (CMT)
- 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”
tumor in SCM– CMT
-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
PT intervention for muscular torticollis
- 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
failure to treat CMT can lead to:
- 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
delayed and/ or asymmetrical motor skills
- 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
failure to treat cervical and/or thoracic scoliosis
- instead of head tilting, child bring trunk to side to level visual field
failure to treat: significant craniofacial deformities
- asymmetry of orbital fissures (one opening smaller than the other)
- mandibular asymmetry (lateral deviation)
- feeding problems (muscle asymmetry)
PT examination of torticollis: detailed history
- pregnancy
- length of gestation
- head/neck placement in utero
- complications
- multiples
- delivery complications
- use of forceps or suction
- physical trauma during birth
- long labor
PT examination of torticollis: medical
- age at onset
- age at diagnosis
- previous medical history and testing to diagnose muscular torticollis
- presence of SCM tumor at any time
- concurrent diagnoses
PT objective eval of torticollis
- 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
PT assess postural reactions
- difficulty with lifting head in prone
- on involved side: decr or absent head& trunk righting rxns. decr or absent protective rxn. poor equilibrium rxn
quick rule of thumb to measure lateral flexion
40 deg= chin to nipple
70 deg= cin to between nipple & shoulder
90 deg= chin over shoulder
100 deg= chin past shoulder
Norm for PROM and AROM for 2-10 mo
- rotation
- lateral flexion
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
4 Goals of PT Intervention
- Key piece= parents to be independent with home program
- full cervical AROM &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 (HEP)
- Positioning, strengthening, handling
- Postural control, motor milestones
Key points form clinical practice guidelines
- 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!
HEP stretching
- 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
PROM stretching HEP
- 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
contraindication/precautions for stretching
- downsyndrome
- spina bifida
- vertebral or spinal cord abnormalities
- compromised circulatory or respiratory systems
postural control in torticollis
- is almost always diminished in infants with torticollis.
- begin working on upright postural control at 4 months
postural control & motor milestones
- 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
frequency & duration of PT treatment for torticollis
- 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
prognosis for torticollis
- 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
treatment for persistent torticollis
- 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
Positional plagiocephaly
- an abnormal or flattened headshape resulting from external molding forces to the cranium
craniosynostosis
-rare condition where 1 or more cranial sutures fuse prematurely
positional plagiocephaly: differential diagnosis
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
scaphocephaly
- longer front to back
brachycephaly
longer side to side flat back
plagiocephaly
- longer diagonal
risk factors for plagiocephaly
- CMT/positional preference of child
- intra-uterine constraint
- multiples
- first born child
- gender
- supine sleeping position
possible adverse effects of non-resoved plagiocephaly
- permanent cranial &/or facial asymmetry
- elevated risk of auditory & visual processing disorders
- negative social and self esteem issues
- possible neurodevelopmental delays
three treatment options for positional plagiocephaly
- repositioning
- cranial banding/ helmets
- surgery
Repositioning. when to implement
- 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
repositioning: treatment
- 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
Cranial Banding/ helmeting
- 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
active banding
- mild application of corrective pressures maintains previous growth in larger areas while redirecting all new growth into flattened regions
DOC band
- 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
DOC band treatment protocol
- 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
surgical treatment
- 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
