TORTICOLLISDiagnosis, Assessment, and Treatment of Infants and Children

Krystle Chilibecki, MScPT

PresenterPresentation NotesWelcome participantsTell them where bathrooms areTell no touching babiesSpeak about research issue: can find something to support every opinion so this is based on our clinical experience

Objectives

Provide an overview of the assessment and treatment of torticollis

Provide a brief introduction to common head shape abnormalities in infancy

Definition

Abnormal posturing of the neck

Lateral translation of the head on the trunk

Rotation and lateral head tilt

Most often affects sternocleidomastoid muscle

Not a diagnosis!

PresenterPresentation NotesNot a diagnosis-discribes a posture only

Let’s review: Anatomy of the Neck

PresenterPresentation NotesDiscuss that many muscles can be involved, does not only effect SCM

Types of Torticollis

Congenital

Acquired

Congenital Muscular Torticollis (CMT)

Etiology

Intrauterine crowding

Difficult labours and deliveries causing muscle damage

Ischemic injury due to abnormal vascular patterns (similar to compartment syndrome)

PresenterPresentation NotesDifficult labours in up to 30 - 60% casesMost cases no cause can be identified and that’s ok

CMT: A Three Dimensional Deformity

Affects growth and development of

Cranial facial system Vertebral column Shoulder girdle Pelvic girdle Extremities Visual perceptual system

PresenterPresentation NotesWhy our assessment is 3 pages long, needs to be extensiveTalk about new patient who has everything in pictureNo concept of midline

Congenital Torticollis

Four categories

Congenital torticollis with abnormal spinal x-rays Postural torticollis without muscle tightness or

pseudotumour Congenital muscular torticollis (CMT) with muscle

tightness and pseudotumour (aka fibromatosis colli or SCM tumour)

Muscular torticollis (MT) with muscle tightness and without pseudotumour

PresenterPresentation NotesAbnormal xrays: Klippel-Feil Syndrome, Scoliosis/Hemi-vertebrae, Unilateral atlanto-occipital fusions, Unilateral absence of C1 facet, Sprengle’s deformityWithout tightness or pseudotumour: will talk about what a pseudotumour is on next slide. Often due to muscle weakness or preference to look to one sideCan be impacted by vision problemsPotential Causes:Benign Paroxysmal Torticollis, Congenital absence of one or more cervical muscles, Congenital absence of transverse ligament, Contracture of scalenes, omohyoids, Chiari MalformationDescribe pseudotumour: normally size of pea, likely hard, tends to become less noticable as patient grows as it stays the same, typically diagnosed at birth and have US to rule out pathology

Non-Congenital (Acquired) Torticollis

Three types

Traumatic

Painful

Non-traumaticOcular torticollis

PresenterPresentation NotesClavical fractureManual manipulation of neck Painful: reflux, Sandifer Syndrome: haita hernia, abscess, infections, osteoblastoma: cancer of bone, neck injury Non traumatic: rotary subluxtion of c1 and c2 (caused by inflammation) often resolves as inflammation resolves

Ocular Torticollis

Tilt to maintain binocularity and/or to optimize visual acuity

Variety of conditions may be responsible Treatment may be surgical Referral to developmental

optometrist necessary

Torticollis

Now you know what it is….but how do you use that knowledge?

Assessment

Infant should be undressed

Occurs in various age-appropriate positions.

PresenterPresentation NotesSupine, prone, sitting etc.Reminder: infants should be able to hold head in midline in supine by 3-4 months of age. This is also when we expect to see righting reactions emerging.Make friends with baby and parent, establish a relationshipPull curtainsNeed a few fun toys or something to grab attention

Assessment Form

PresenterPresentation NotesTake it or leave itCan be altered to fit your clinic needssimple, fast and effectiveCan be done in approx ½ hour

Hemihypoplasia

Enlargement of one side of the body or part of the body

Can be whole body or isolated to one body part CMT: Decreased vertical dimension of face Can include: cheek, lip, nose, ear, eye, tongue, jaw,

roof of the mouth, or teeth

PresenterPresentation NotesImportant to do a scan of rest of body to ensure limbs are not affectedcan also affect internal organsIf severe - Referral back to Dr. for further investigations required, often need ortho consult

Hemihypoplasia

Using a Goniometer!

PresenterPresentation NotesNot necessary,We chart as a percentage of full range, most important things is that staff reports in the same way. Range is usually recorded as child will move from 0-15

Muscle Function Scale for Infants

Ohman et al./physiotherapy theory and Practice 25 (2009) 129-137

PresenterPresentation NotesBaby should be tipped all the way to vertical

Muscle Cording Upper Trap Tightness

Cording vs. Tautness

PresenterPresentation NotesDiscussion difference between cording vs. tautness

Birthmarks and Dimples

Why check for them? May be linked to neurological conditions

Which ones are important? Coarse long hair Dimples in midline where base is not easily visible Birthmarks in midline Webbing between fingers or toes

Unsure? Refer back to doctor or to head shape clinic

PresenterPresentation NotesNeuro conditions: spina bifida, tethered cord etc.

Birthmarks and Dimples

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Now on to…

HEAD TILTPresent

↓ ROM

↓ PROMPreference: • games to

encourage rotation to opposite side

• environmental modifications

Weakness (↓ Righting Reactions)

Strengthening• diagonal

carry • righting rxns

↓ AROM

Improving

TOT Collar

Improving

Further Consults:• optometry• opthalmology• physician/

pediatrician• physiatry• request imaging• Neurosurgery• Orthotist referral

Other Causes• occular• reflux • spasmodic

Try:• core/postural

pelvic stabilization

• other splinting positioning (ie: foam wedge cushion, kentucky collar, over-correction with TOT collar)

Mild to Moderate (20o tilt or less or

75% – 100% PROM)

Stretches:• supine

stretches• sitting side

flexion• carry stretch• sub-occipital• 2 person

stretch

Improving

Severe (20o or more tilt or

less than 75% PROM)

Positioning:• foam collar• snug n’ go

Torticollis Flow ChartOctober 12, 2012

Examples of Improvement:

• equal righting reactions• active rotation to both sides• increased time in midline

DDX:

• DDH• Clubfoot• Reflux• Strabismus/Occular

Problems• Chiari Malformation• Hemi-Vertebraes• Other syndromes

NO

NO

YES

YES

YES

NO

NO

NO

YES

YESYES

Improving

Discharge

Discharge

Discharge

YES

NO

Criteria for Discharge:

• < 5o tilt• > 85% of time in midline• equal righting reactions• full AROM rotation to both

sides

PresenterPresentation NotesTalk through this chart

Stretching

PresenterPresentation NotesMost common stretch is for SCM, done in 2 separate stretches especially in young kids Too difficult to maintain control of child and do both movements at the same timeMention that we have lots of other stretches depending on what muscle is effected, didn’t include them in this presentation due to time but if you’d like more please email Krystle

Stretching Parameters

Hold 15-20 seconds Repeat 3 times; 5 times per day Ensure close contact with baby Use whole hand

Strengthening

Righting Reactions

Strengthening Exercises

Other strengthening options:

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Treatment

Emphasize Neck and trunk strength and mobility Midline postural control Symmetry of postural responses Symmetry of weight-bearing and transitional movements Age-appropriate motor skill

development

Additional Treatment Options

TOT collar Alternative bracing Custom bracing Kinesiotape Craniosacral therapy Myofascial therapy Osteopathy Massage Acupuncture/Acupressure Surgery

PresenterPresentation NotesStudies suggest surgery seldom necessary when treatment initiated early

Treating Older Children with Torticollis

Follow same general assessment and treatment

Thorough assessment is vital

Postural exercises Recognition of midline Consider cognitive

development Custom brace options

PresenterPresentation NotesPostural exercises, use visual feedback, lights, mirrors, pt can participate and understandMidline training, very important to reestablishOcular retrainingVestibular retrainingTends to be a lengthy process, pt needs to be dedicated.

Indicators for Surgical Intervention

Persistence of an intramuscular tumour Thickening of SCM muscle at 6 months of age Plateau of improvement Increase in the deformity Persistence of the deformity beyond 12 months of age

PresenterPresentation NotesDespite consistant intervention by parents and therapistWe refer to our plastic surgeons Bipolar release. Typically followed by TOT collar and stretches

Indications for Discharge

Full, symmetrical PROM of neck and trunk Active symmetrical head rotation Active midline head to trunk alignment during static

and dynamic play Head righting reactions present bilaterally Less than 5 degree tilt

PresenterPresentation NotesRoation of at least 80 degrees from midline in both directions (without compensations)Head righting reactions may be delayed to one side

Check midline during play in all positions

Post-Discharge

Infants are at risk for regression during Growth spurts Illness TeethingAcquisition of new motor milestones

Regression should resolve in 10-14 days May require short period of stretching

Normal Skull of the Newborn

Mal-Development

Primary = Synostotic Secondary = Positional Deformation

Positional Deformation

CausesProlonged external pressuresPositioning In-UteroDeliveryAAP “Back to Sleep”

Campaign

PresenterPresentation NotesBack to sleep is now safe sleep campaignPositioning: car seats, baby swings, bouncy

Plagiocephaly

FeaturesOne side of back of head is flatResults in ipsilateralForehead bulgeEar forwardAppearance of Larger eye

Plagiocephaly

High risk of skull deformation with CMT Typically flattening is on opposite side of tilt Treat with reposition strategies Improves as the neck improves

PresenterPresentation NotesMod to severe torticollis and mod to severe head shape may need helmet if repositioning does not work, need to be seen by headshape clinic if querying helmetWorking against a tight muscle

Plagiocephaly

Brachycephaly

Features Flatness across entire back of headBiparietal widening Increased cranial vault heightProminent ears

PresenterPresentation NotesSubjective measurementNo magic number that means they should have a helmet

Treatment of Plagiocephaly/Brachycephaly

Aggressive Repositioning Remodeling Helmet

Remodeling Helmet

Redistribution of forces to direct cranial growth

4 month commitment Wearing time: 23 hours/day Done by community orthotist Follow up with orthotist every

1-3 weeks to adjust helmet $2500- $2700 cost

Craniosynostosis

Non-Syndromic No developmental or brain abnormalities May be corrected with surgical intervention

Syndromic Associated anomalies Crouzon’s or Apert’s SyndromesMuenke’s syndrome

PresenterPresentation NotesAperts: characterized by malformations of the skull, face, hands and feet Muenke: early synostosis of coronals often no intellectual delay but can be

Sagittal Synostosis

Clinical features Triangular shaped or closed anterior fontanellePalpable ridging Long narrow headBilateral frontal bossingProminent occiput

PresenterPresentation NotesMost common synostosisForehead wider than back of headSurgical intervention then helmet

Coronal Synostosis

Can be unilateral or bilateral (rare) Clinical features

Same side as synostosis Palpable ridging Eye appears wider Flattening of forehead

Prominent forehead on opposite side of synostosis

Bilateral Coronal

Clinical features Eyes are high Ears low setBilateral frontal height Flattened foreheadPalpable ridging

bilaterally Eyes appear large

Metopic Synostosis

Clinical featuresNoticeable ridge

mid-forehead Eyes narrow set Triangular shaped

head when viewed from top

PresenterPresentation NotesIf not severe often not corrected surgically

Lambdoid Synostosis

Clinical features Palpable ridge On same side as synostosis Ear is back and down Prominent mastoid process Flattening in the occipital region

Opposite side of synostosis Frontal bossingOccipital bossing

PresenterPresentation NotesOften mistaken for torticollisRemember that flattening should push ear forward

Questions?

TorticollisObjectivesDefinitionLet’s review: Anatomy of the NeckTypes of TorticollisCongenital Muscular Torticollis (CMT)CMT: A Three Dimensional Deformity�Congenital TorticollisNon-Congenital (Acquired) Torticollis Ocular TorticollisTorticollisAssessmentAssessment FormHemihypoplasiaHemihypoplasiaUsing a Goniometer!Muscle Function Scale for Infants�Cording vs. Tautness�Birthmarks and DimplesBirthmarks and DimplesNow on to…Slide Number 22Stretching�Stretching ParametersStrengtheningStrengthening ExercisesOther strengthening options:TreatmentAdditional Treatment OptionsTreating Older Children with TorticollisIndicators for Surgical Intervention�Indications for DischargePost-DischargeSlide Number 34Normal Skull of the NewbornMal-DevelopmentPositional DeformationPlagiocephalyPlagiocephalyPlagiocephalyBrachycephalySlide Number 42Treatment of Plagiocephaly/BrachycephalyRemodeling HelmetCraniosynostosisSagittal SynostosisCoronal SynostosisBilateral CoronalMetopic SynostosisLambdoid SynostosisQuestions?