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Tackling Torticollis

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About one in 250 infants are born with congenital muscular torticollis (CMT) which is most often due to tightness in the sternocleidomastoid muscle or the muscle that connects the breastbone and the collarbone to the skull.

CMT is typically diagnosed within the first two months of a baby's life and is most often identified when the baby holds her head to one side, has limited neck movement, and/or has a small bump on the side of her neck.

Babies with torticollis may also develop asymmetrical head shape or positional plagiocephaly. CMT, often due to sleeping with the head turned to one side, puts constant pressure on the back of the head which leads to flattening. This may also be accompanied by frontal bulging. The asymmetry may cause spinal misalignment and uneven distribution of weight over the legs, leading to the development of orthopedic problems.

Because the condition limits a child's ability to turn his head to see, hear and interact freely with his environment, torticollis may lead to delayed cognitive development, delayed whole body awareness, weakness and difficulties with balance.

"Infants presenting with torticollis have less opportunity to track and look from the right to the left side and do not interact with their immediate environment with both hands symmetrically. They prefer looking to one side and are initially unable to roll from back to belly using their necks," shared Geetha Bharathan, PT, MS, physical therapist, Children's Specialized Hospital in Toms River, NJ.

Children's Specialized Hospital, with nine sites in New Jersey, is the largest pediatric rehabilitation health system in the country. The hospital serves children affected by traumatic brain injury, spinal cord injury and dysfunction, premature birth, autism, developmental delays, mental health issues and other life-changing injuries or illnesses.

Identification and Treatment

"Therapeutic intervention for a child with torticollis addresses the primary or secondary musculoskeletal, neuromotor and sensory impairments that arise from the muscular asymmetry of birth," explained Ellen Brennan, PT, DPT, physical therapist, Children's Specialized Hospital.

Physical therapy interventions aim to strengthen muscles, correct muscle imbalance and gain in cervical spine range of motion, and facilitate postural control, symmetry and biomechanical alignment along with normal soft-tissue and muscle-length tension.

Infants with torticollis present with developmental delays including rolling supine to prone, sitting, crawling and pulling to stand. They frequently crawl from one side with reduced elongation and weight bearing from the same side as torticollis, Bharathan said.

The strategy of the PTs at Children's Specialized Hospital's Toms River facility includes myofascial release using craniosacral therapy techniques, active stretching protocols using positioning strategies and functional play activities and neuro-developmental based handlings.

"Physical therapists must closely monitor a child with congenital muscular torticollis for the development of secondary impairments in strength and development until the primary impairment of musculoskeletal restriction is resolved," Dr. Brennan said.

Bharathan has consistently observed in her practice that impaired mobility and muscle tightness causes compensatory shortenings in the cranial base or small muscles of the posterior neck and upper cervical spine, anterior neck muscles and the floor of the mouth. This can interfere with oro-motor functions including swallowing, chewing and facial symmetry within a few months of birth.

At Children's Specialized Hospital, the PT program for torticollis uses a multisystem assessment to set functional and task oriented goals that allow the child to optimally interact with the environment in varied positions including supine, side lying, prone, sitting, quadruped and standing while maintaining midline head-neck orientation, according to Bharathan.

Prone play is important for the development of symmetrical shoulder strength and active elongation of the flexor musculature. Ipsilateral side lying is important for elongation of the lateral neck, trunk and hip musculature and development of strength of the contralateral musculature.

"An infant's neck is short and highly sensitive to passive ROM stretching even with no true restriction present," Bharathan shared. The therapists' gentle/light touch while working on cranial base releases along with other peripheral diaphragm releases softens the structures around the neck and shoulder without eliciting protective spasm/tightness.

The PTs believe that therapeutic taping may be used as an adjunct in infants and older children. Use of therapeutic taping on the ipsilateral scapula facilitates sustained muscle activation to correct the neck tilt. Therapeutic taping of the distal trunk and abdominal oblique muscles facilitates postural control.

According to Bharathan, physical therapy has been the primary intervention for torticollis; however, there are few studies to demonstrate the effectiveness of various interventions used by PTs. There is debate over the impact of torticollis on the developmental milestones and whether the condition needs any developmental intervention at all.

Bharathan is presently following this population and has observed delays in developmental milestones in the initial periods but sensitivity to various therapeutic interventions including cranio-sacral therapy, therapeutic taping and neuro-developmental handlings. "My focus is to study the impact of torticollis with or without plagiocephaly on developmental milestones and the effectiveness of therapeutic taping in this population," she said.

If Left Untreated

The child with CMT who does not receive treatment is at high risk for significant developmental asymmetry, according to Dr. Brennan. Activation of the contralateral neck musculature is more difficult when positional plagiocephaly develops.

In this case, the child chooses patterns for movement that use the ipsilateral strength and soft tissue limitation and avoid the contralateral weakness, causing further asymmetry in strength through the shoulder, trunk and hips. The older child with these secondary impairments of ipsilateral soft-tissue restriction and contralateral weakness presents with scoliosis, plagiocephaly and the associated activity and participation restrictions.

Infants with torticollis who go untreated may be at increased risk for early motor delay, global delay, impaired balance and coordination, delay in acquisition of gross motor skills, and reinforcement of altered movement patterns due to adaptive motor behavior.

"In the short term, infants who go untreated are at risk of progressive muscle and soft tissue tightness, inability to interact and play symmetrically, and positional deformation of skull," shared Bharathan. These infants may have decreased head-neck control, delayed developmental milestones, impaired trunk rotation with progressive loss of ROM in pelvic-hip complex and rib cage mobility and decreased postural control and balance responses.

Untreated infants over the long term may compensate with shoulder elevation, adducted arm with elbow flexion and medial rotation of opposite leg, and supination of feet. Significant facial asymmetry, mal-alignment in posterior cervical spine with compensatory changes in muscles and structures on the contra lateral side are not uncommon.

Parent Education is Key

Educating parents on repositioning and developmentally supportive positioning is essential to the proper progress of children with torticollis, according to Bharathan. Wedges, tiny bolsters, blanket rolls and horse-shoe shaped neck pillows are easily available and effective home positioning devices that assist in repositioning.

"Positioning and handling are imperative to prevent secondary impairments," shared Dr. Brennan. "The families are taught gentle stretching exercises and are encouraged to position the child in positions other than supine for play."

Bharathan recommends supervised tummy time at frequent intervals. She demonstrates different positions for infants to lie down and play and emphasizes the importance of changing the infant's orientation in the crib every day and placing blanket rolls under shoulders/chest to assist the infant in overcoming the effects of gravity.

"Gravity is the greatest challenge as well as facilitator for typical development and when faced with weak muscles, an infant will take the course of least resistance which leads to asymmetry," observed Bharathan.

The PTs instruct parents on properly positioning the infant during and after feeding to address postural control as well as gastrointestinal related issues like GER, spitting, abdominal bloating and constipation.

Parents are educated on repositioning during carrying, sleeping, playing and feeding that can be easily integrated into the child's daily routine. Parents learn to incorporate active stretching techniques, for example, during every diaper change.

The PTs focus on play activities that incorporate active stretching while visually tracking toys, such as reaching with hands and incorporating midline and bilateral integration and active chin tuck and neck flexion/extension and rotation. "We demonstrate these activities during our parent education and trainings so parents may continue them as part of the home program," Bharathan shared.

With proper gains in ROM, postural symmetry and meeting gross motor milestones, children are typically discharged with clear instructions on home activities. The PTs recommend active stretching components and activities like obstacle crawling and stair crawling, and use of swings, slides and other climbing equipment in the toddler areas of the playground.

Parents are encouraged to look for any regression observed in this population until 3 years of age. Parents must keep in mind, however, that with gains in every motor milestone, the child may regress temporarily but will always catch up as he masters the new skill.

"Parents should be comfortable with assessing signs of asymmetry as the child moves through the developmental progression and should be equipped with the necessary 'tools' for intervention should they notice a regression in head alignment," Dr. Brennan told ADVANCE.

As the infant gains strength in neck and trunk musculature, the caregivers are taught strengthening exercises that use age appropriate balance responses and transitions. The caregivers are taught infant massage and handling that will help to promote balanced, healthy tissues and somatosensory development.

Upon discharge from PT, the caregivers should be comfortable with passive and active range of motion exercises, according to Dr. Brennan. "Successful intervention for the child with torticollis is fully dependent on how successful the caregivers are in integrating treatment strategies into the child's daily routine," she observed. 

Rebecca Mayer is senior regional editor of ADVANCE and can be reached at rmayer@advanceweb.com



 

Hello Monica

I don't know if you were able to find pediatric physical therapists in your area yet. (I just saw your post.) If you have not yet connected with an experienced physical therapist who can address treatment of infant torticollis, I would call the APTA (American Physical Therapy Association) and ask for a list of certified, pediatric, physical therapists close to you. Note that a physical therapist can be very good, experienced, and certified in multiple disciplines, just not certified by the APTA certification process. But, it is a good place to start. Also, most certainly, Monica is correct in physical therapists with significant pediatric saying that the therapists you previously saw were not experience. And last, note that although there may be chiropractors who have been successful in treatment of pediatric torticollis, pediatric physical therapists have the training and the scope of practice that generally no other practitioner has, e.g., therapeutic exercise, orthopedics, and manual therapy.

Sharon Tracy,  Physical Therapist,  Private Clinic; SchoolsAugust 13, 2014
Brooklyn, NY



Monica,

The physical therapists you saw in MT were likely not pediatric physical therapists. Physical therapists specialize in certain areas, just like physicians do, and if the PTs in MT were specialized in orthopedics or geriatrics then they probably didn't have the expertise to treat your child like the author of this article does. From my experience Torticollis is quite treatable with proper physical therapy intervention, and the earlier the treatment the better. In a town the size of Charleston there should be some PTs in your area that have plenty of expertise and experience to treat your child. I would recommend seeking out a PT clinic that specializes in pediatrics, not just a general PT office that mostly sees adult orthopedic problems. I would just google "pediatric physical therapy" in Charlston, or if that doesn't yield results you might call a few pediatrician offices around town and ask if they have any recommendations for a good pediatric physical therapist. From the way you describe your child's situation, it sounds like there may be some sensory or motor planning/motor control issues that may or may not be related to the torticollis. A good pediatric PT could do an assessment and probably have some good interventions and ideas to help normalize your child's gait deviation. Best of luck with your little one.
-Blaine, PT from Wyoming

Blaine June 24, 2014
Rock Springs, WY



Your article was very informative. My baby is currently 11 months. He had infant torticollis. We used chiropeactic care and some hone exercises and his neck tilt resolved around 8 months of age. However, when he started pulling up he would not put weight on his right foot, he would hold it on this tipy toes. Once he got better at standing he started putting weight on it fine, with the occasional tippy toe. All the chiropractors we have seen have found his pelvis oit of alignment. Now he is starting to walk and again is not puting any weight on his right foot, he drags that leg behind him with the toes extended laterally. We had stopped chiropractic care for a few months and just recently restarted and at the last appoinent the doctor said his pelvis was severely rotated. When we got home he was a little better, not dragging the leg anymore but still not puting any weight on it. What type of treatment would you recommend? We have seen 2 different PT in Montana where we were during his infancy but they were very unhelpful, not even close to the level of expertise you demonstrate. I lime the ideas of the spinal release and cranio sacral therapy but these PT were not familiar with any of that. I basically got "make him loom the orher way when he plays and stretch his neck when you change his diaper". How do i find someone that would incorporate all the.techniques you recommend? Thank you so much for your help, i really want to help him as i see him struggling aand getting frustrated and i dont want to.create long term improper alignment but i dont know where to.start. pediatriciand have not been very helpful either.we curently live in charleston sc.

monica bakerJune 20, 2014




     

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