Torticollis & Plagiocephaly

Question 1

What is congenital muscular torticollis (CMT)?

Answer 1

• Postural deformity resulting from unilateral shortening & fibrosis of SCM
• Muscle tumor often evident visually or on palpation
• Evident at birth

Question 2

What is the common presentation of CMT?

Answer 2

Head tilt to side of tight muscle/tumor with chin rotated away towards opposite shoulder

Question 3

What is the incidence of CMT?

Answer 3

• 0.4-2%

- 12.5% incidence of hip dysplasia in babies with torticollis

Question 4

How does the presentation of CMT vary?

Answer 4

• May have lump in SCM & restricted ROM, no lump & restricted ROM or positioning without restricted ROM
• 28-47% have a tumor
• Tumor resolves over 5-21 months

Question 5

What is the aetiology of CMT?

Answer 5

• Unknown

- Possibly associated with ischaemia, birth trauma, intrauterine positioning of head, compartment syndrome

Question 6

What is the aetiology of prenatal deformational plagiocephaly?

Answer 6

• Moulding forces induced by inutero constraint

- Compression of fetal skull between maternal pelvic bone and lumbar sacral spine

Question 7

What is the aetiology of acquired deformational plagiocephaly?

Answer 7

• Develops in the first 3 months
• Non synostotic plagiocephaly
• Peak prevalence at 4 months

Question 8

What risk factors are associated with plagiocephaly?

Answer 8

• Oligohydramnios
• Uterine malformation
• Cephalohaemotoma
• Complicated birth / assisted delivery
• Primiparity
• Male
• CMT/infant neck problems

Question 9

What are the differential diagnoses of plagiocephaly?

Answer 9

• Skeletal abnormalities
• Pterygium colli (web of skin from acromion to mastoid)
• Occular torticollis (head tilt but no restriction in ROM)
• Brachial plexus lesions
• Posterior fossa pathology
• Arnold Chiari malformation & syringomyelia

Question 10

What are some of the skeletal abnormalities that may be differential diagnoses for plagiocephaly?

Answer 10

• Unilateral lambdoid or coronal craniosynostosis
• Congenital anomalies of occipital condyles & cervical spine
• Klippel-Feil syndrome (fusion of cervical vertebrae)

Question 11

What does the subjective assessment of CMT & plagiocephaly include?

Answer 11

• Prenatal/birth history
• Side of ?CMT/head preference
• Other congenital abnormalities, medications
• X-rays or imaging
• Age of diagnosis/concerns
• Time in play, care & sleep positions
• Feeding issues
• Parental current concerns

Question 12

What does the objective assessment of CMT & plagiocephaly include?

Answer 12

• Resting head position
• Palpation of mm for tumor and tone
• Cervical spine AROM/PROM
• Skin creases
• UL & shoulder girdle function
• In older infants trunk & LL screened for weight shift and weight bearing
• Spinal motion/mobility

Question 13

What should be screened when assessing CMT & plagiocephaly?

Answer 13

• Hip asymmetry
• Vision & hearing
• Motor development

Question 14

How can skull shape be assessed?

Answer 14

• Photos
• Tape measure
• Callipers
• Bendy rulers
• Charts
• Digital devices with software analysis
• Radiological imaging
• 3D scanning devices

Question 15

What should be observed when assessing skull shape?

Answer 15

• Occipital/parietal, frontal/temporal flattening
• Bulging parietal area,
• Bossing of frontal area
• Head height differences
• Ears, eyes and cheek size & alignment
• Mandible position & TMJ function
• Facial mm asymmetry

Question 16

What are the physio treatment strategies for CMT & plagiocephaly?

Answer 16

• Early diagnosis & intervention
• Physio between 3-6 months
• Identify impairments & develop treatment plan
• Advice
• Handling
• Positioning (sleep supine, play sidelying/prone/sitting)
• HEP for ROM, passive stretching & developmental stimulation

Question 17

What are the goals of early physio treatment?

Answer 17

• Restore full neck movement as early as possible
• Stop skull base deformity
• Prevent craniofacial asymmetry
• Prevent bony & postural changes

Question 18

When can active exercises be included as treatment for CMT & plagiocephaly?

Answer 18

• Once infant has active head control (approx 4 months)

- Exercises use tracking of toys/mirror to encourage cervical rotation

Question 19

When should passive stretches be performed?

Answer 19

With every nappy change

Question 20

What are the guidelines for helmet therapy?

Answer 20

• Start at 3-4 months

- 15-22 hours per day

Question 21

What evidence is there for physio for asymmetric head shape in infants <3 months?

Answer 21

• Repositioning & physio effective if <3 months

- Most successful in 2nd-4th week of age (skull most malleable)

Question 22

What evidence is there for physio for asymmetric head shape in infants >3 months?

Answer 22

• At 4-6 months, continue physio & repositioning if mild-mod
• Consider orthotic for severe

Question 23

What evidence is there for treatment of asymmetric head shape in CMT?

Answer 23

• 90-100% of infants who receive early physio report resolution of symptoms before 1 year old

Question 24

What are the consequences of untreated CMT?

Answer 24

• Progressive limitation of cervical movement
• Craniofacial asymmetry
  (including mandibular hypoplasia)
• Plagiocephaly
• Compensatory scoliosis
• Delayed early motor milestones
• Functional asymmetry similar to hemiplegia

Question 25

What are the consequences of untreated plagiocephaly?

Answer 25

• Synostotic: surgical treatment required

- Non Synostotic: no consensus, likely natural resolution in absence of developmental delay

Question 26

When are surgical interventions required for CMT?

Answer 26

• 5-10% of cases
• Symptoms persist after 12 months
• > 15deg rotation difference after 6 months

Question 27

When is surgery undertaken in CMT?

Answer 27

• From 4 years when child is old enough to comply with post op instructions
• Tenotomy of SCM, excision of tumor

Question 28

What are the post surgery interventions for CMT?

Answer 28

• Passive stretches
• Active correction
• Collar