Congenital torticollis: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:Nikki Rommers|Nikki Rommers]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>


== Introduction ==
 
== Introduction/ Description ==
[[File:Torticollis 1.jpg|alt=|right|frameless]]
[[File:Torticollis 1.jpg|alt=|right|frameless]]
Congenital torticollis is a postural, musculoskeletal deformity evident at, or shortly after, birth. It results from unilateral shortening and increased tone of the [[sternocleidomastoid]] (SCM) muscle and presents as lateral flexion of the head to the ipsilateral side with rotation to the contralateral side.  
[[Congenital and Acquired Neuromuscular and Genetic Disorders|Congenital]] torticollis (CMT) is a condition in infants commonly diagnosed at or soon after birth. The term torticollis is derived from the Latin word ''tortus'', meaning <nowiki>''twisted''</nowiki> and ''collum'' meaning <nowiki>''neck.''</nowiki> This condition is, therefore, also known as twisted neck or wry neck.  


* It is the third most common congenital musculoskeletal condition in newborns with an incidence ranging from 0.3 to 16%.  
CMT occurs when there is reduced length and increased tone of [[sternocleidomastoid]] (SCM) on one side. Infants present with lateral flexion on the ipsilateral side (i.e. the side where the SCM is affected) and contralateral rotation.<ref name=":2">Ellwood J, Draper-Rodi J, Carnes D. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288527/ The effectiveness and safety of conservative interventions for positional plagiocephaly and congenital muscular torticollis: a synthesis of systematic reviews and guidance]. Chiropractic & manual therapies. 2020 Dec;28(1):1-1.</ref>   
* Has been associated with dysfunction in the upper cervical spine and is sometimes referred to as kinetic imbalance due to subocciptal strain.  


Treatment approaches for CMT include manual therapy (including practitioner-led stretching exercises), repositioning therapy (including tummy time) and, in severe non-resolving cases, botulinum and surgery. CMT can lead to secondary changes such as cranial asymmetry ([[plagiocephaly]]), and also to functional problems, including breastfeeding problem<ref>Ellwood J, Draper-Rodi J, Carnes D. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288527/ The effectiveness and safety of conservative interventions for positional plagiocephaly and congenital muscular torticollis: a synthesis of systematic reviews and guidance]. Chiropractic & manual therapies. 2020 Dec;28(1):1-1.Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288527/ (accessed 10.8.2021)</ref>
Treatment approaches for CMT include:<ref name=":2" />
 
== Clinically Relevant Anatomy  ==


The [[Sternocleidomastoid|sternocleidomastoid muscle]] has a sternal and clavicular head. The sternal head is directed from the manubrium sterni superiorly, laterally and posteriorly and the clavicular from the medial third of the clavicle vertically upward. It runs to the mastoid process. It enables an ipsilateral lateral flexion and a contralateral rotation. The muscle extends the upper part of the cervical spine and flexes the lower part<ref name="p6">Middleditch A, Oliver J.Functional anatomy of the spine: second edition. Edinburgh; New York: Elsevier Butterworth-Heinemann; 2005. (Level of Evidence 5)</ref>.   
* manual therapy (e.g. therapist-led stretching exercises)
* repositioning therapy (e.g. tummy time)
* botulinum toxin (botox) / surgery may be necessary for more severe cases that do not resolve


  [[File:Grays 385.JPEG|center|Sternocleidomastoid muscle|frame]] 
Secondary changes associated with CMT can include:<ref name=":2" />
== Etiology ==
The etiology of congenital torticollis remains unknown, although there are several theories. However, there is no proof for any of them. The most cited are ischemia, trauma during childbirth, and intrauterine malposition (pelvic position).


The muscles of the neck form a complex system. Schematically, two levels are distinguished: superficial (long neck muscles) and deep (paravertebral muscle). The sternocleidomastoid is the most targeted muscle; it is in the anterior region of the neck, where it forms a visible and palpable mass. Its action: performs contralateral rotation, ipsilateral inclination, and flexion of the head. This motor activity results in the tilting of the head and neck toward the side of the affected muscle and rotation to the opposite side. The condition typically gets diagnosed during the neonatal period or infancy<ref name=":1">Gundrathi J, Cunha B, Mendez MD. [https://www.ncbi.nlm.nih.gov/books/NBK549778/ Congenital Torticollis].2021 Available:https://www.ncbi.nlm.nih.gov/books/NBK549778/ (accessed 8.10.2021)</ref>
* cranial asymmetry ([[plagiocephaly]])
* functional problems, such as difficulty breastfeeding


== Epidemiology ==
== Epidemiology ==
The worldwide incidence rate of congenital torticollis varies between 0.3% and 1.9 %; other studies indicate a ratio of 1 in 250 newborns being the third congenital orthopedic anomaly<ref name=":1" />. There is a preponderance to male sex and first pregnancy.  
* Torticollis in infants is most commonly caused by CMT<ref>Amaral DM, Cadilha RP, Rocha JA, Silva AI, Parada F. Congenital muscular torticollis: where are we today? A retrospective analysis at a tertiary hospital. Porto biomedical journal. 2019 May;4(3). </ref>
* CMT is the third most common congenital musculoskeletal condition in newborns - its incidence ranges from 0.3% to 19.7%<ref>Kuo AA, Tritasavit S, Graham JM. Congenital muscular torticollis and positional plagiocephaly. Pediatr Rev. 2014;35(2):79-87; quiz 87. </ref>
* It has been associated with upper [[Structure and Function of the Cervical Spine|cervical spine]] dysfunction and has been called a "kinetic imbalance due to suboccipital strain"<ref name=":2" />
== Clinically Relevant Anatomy  ==
[[File:Grays 385.JPEG|Sternocleidomastoid muscle|alt=|right|frameless|214x214px]]The [[Sternocleidomastoid|sternocleidomastoid muscle]] has a [[Sternum|sternal]] and [[Clavicula|clavicular]] head. The sternal head originates at the [[Sternum|manubrium sterni]]<ref>Gray H. [https://books.google.co.in/books?hl=en&lr=&id=9zBKAQAAMAAJ&oi=fnd&pg=PR30&dq=Gray%E2%80%99s+Anatomy+of+the+Human+Body&ots=XQbFp5nsga&sig=nfBceFQEHppdeFNtD4DGno09Hjs&redir_esc=y#v=onepage&q=Gray%E2%80%99s%20Anatomy%20of%20the%20Human%20Body&f=false Anatomy of the human body.] Lea & Febiger; 1878.</ref> moving superiorly, laterally and posteriorly. The clavicular head originates at the medial third of the clavicle and runs vertically upward. It inserts at the mastoid process and enables ipsilateral lateral flexion and contralateral rotation. SCM also extends the upper part of the cervical spine and flexes the lower part.<ref name="p6">Alison Middleditch MC, Jean Oliver MC. [https://books.google.co.in/books?hl=en&lr=&id=y5f_UYKL28UC&oi=fnd&pg=PR7&dq=Middleditch+A,+Oliver+J.+Functional+anatomy+of+the+spine:+second+edition.+Edinburgh%3B+New+York:+Elsevier&ots=pJziT5ywB7&sig=74BcHr3OJogFjpiaOjaDWmrg8S0&redir_esc=y#v=onepage&q=Middleditch%20A%2C%20Oliver%20J.%20Functional%20anatomy%20of%20the%20spine%3A%20second%20edition.%20Edinburgh%3B%20New%20York%3A%20Elsevier&f=false Functional anatomy of the spine]. Elsevier Health Sciences; 2005 Sep 30.</ref>  
== Aetiology ==
As mentioned, CMT is caused by an imbalance in the SCM, but its aetiology is still being explored. There are a number of suggested causes, including ischaemia, trauma during childbirth, intrauterine malposition.<ref name=":1">Gundrathi J, Cunha B, Mendez MD. Congenital Torticollis. 2023 Jan 31. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 31747185. </ref>


A 2% incidence of congenital torticollis in traumatic deliveries and 0.3% in non-traumatic deliveries.
CMT caused by intrauterine deformation may be associated with limited space in utero (e.g. in first pregnancies, multiple births), decreased amniotic fluid volume, or uterine compression syndrome.<ref name=":1" />


== Pathophysiology ==
== Pathophysiology ==
In congenital muscular torticollis, the palpable mass in the sternocleidomastoid muscle is mostly made up of fibrous tissue. This mass usually disappears during infancy and is replaced by a fibrous band. The muscle biopsies and MRI studies of the mass revealed that there could be a component of muscle injury, possibly due to compression and stretching of the muscle.
A fibrous band forms in the SCM muscle in infants with CMT. This may be due to muscle injury, i.e. prolonged compression and stretching of the muscle. Histological studies also found: oedema, muscle fibre degeneration, and fibrosis in babies with CMT (which suggests the presence of compartment syndrome).<ref name=":1" />


The venous neck compression during childbirth may also have contributed to the decreased blood supply and subsequent compartmental syndrome. Histological studies of material collected at delivery showed edema, muscle fiber degeneration, and fibrosis. These results corroborate the presence of compartment syndrome<ref name=":1" /><br>Characteristics/Clinical Presentation
== Clinical Presentation ==
* Unilateral contraction of the SCM causing a lateral flexion towards the affected side with slight rotation of the chin to the contralateral side.<ref name="p1">Haque S, Shafi BB, Kaleem M. [https://pubs.rsna.org/doi/full/10.1148/rg.322105143 Imaging of Torticollis in Children]. RadioGraphics. Mar 2012; 32(2): 558-571</ref><ref name="p7">Petronic I, Brdar R, Cirovic D, Nikolic D, Lukac M, Janic D, et al. [https://europepmc.org/article/med/20485220 Congenital muscular torticollis in children: distribution, treatment duration and out come]. European journal of physical and rehabilitation medicine. 2009 Dec 15;46(2):153-7.</ref><ref name="p8">Ta JH, Krishnan M. [https://www.sciencedirect.com/science/article/abs/pii/S0165587612004041 Management of congenital muscular torticollis in a child: a case report and review]. International journal of pediatric otorhinolaryngology. 2012 Nov 1;76(11):1543-6.</ref>
* Affected side may seem excessively stronger than the contralateral side
** this causes an imbalance in the neck muscles
** the lateral head righting on the contralateral side is weaker than the affected side<ref name="p3">Öhman A, Mårdbrink EL, Stensby J, Beckung E. [https://www.tandfonline.com/doi/abs/10.3109/09593985.2010.536305 Evaluation of treatment strategies for muscle function in infants with congenital muscular torticollis.] Physiotherapy Theory and Practice. 2011; 27(7): 463-470 (Level of Evidence 2)</ref>
* In some cases, the shoulder may be elevated on the affected side<ref name="p8" />
* Can be accompanied by [[plagiocephaly]]<ref name=":0">Kaplan SL, Coulter C, Fetters L. [https://journals.lww.com/pedpt/Fulltext/2018/10000/Physical_Therapy_Management_of_Congenital_Muscular.2.aspx Physical Therapy Management of Congenital Muscular Torticollis: An Evidence-Based Clinical Practice Guideline] FROM THE SECTION ON PEDIATRICS OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION. Pediatric Physical Therapy. 2013 Dec 1;25(4):348-94. </ref>


CMT is characterized by a unilateral contraction of the sternocleidomastoid muscle that forces the infant to hold the head tilted toward the affected side with slight rotation of the chin to the contralateral side<ref name="p1">Haque S, Shafi BB, Kaleem M. Imaging of Torticollis in Children. RadioGraphics. 2012;32(2): 558-571 https://doi.org/10.1148/rg.322105143 (Level of Evidence 2)</ref><ref name="p7">Petronic I, Brdar R, Cirovic D, Nikolic D, Lukac M, Janic D, et al. Congenital muscular torticollis in children: distribution, treatment duration and outcome. European Journal of Physical and Rehabilitation Medicine. 2010; 45(2): 153-158 (Level of Evidence 2)</ref><ref name="p8">Ta JH, Krishnan M. Management of congenital muscular torticollis in a child: A case report and review. International Journal of Pediatric Otorhinolaryngology. 2012;78(11): 1543–1546. (Level of Evidence 2)</ref>.The affected side seems to be excessively stronger than the contralateral side. This causes an imbalance in the neck muscles<ref name="p3">Öhman A, Mårdbrink EL, Stensby J, Beckung E. Evaluation of treatment strategies for muscle function in infants with congenital muscular torticollis. Physiotherapy Theory and Practice. 2011; 27(7): 463-470 (Level of Evidence 2)</ref>. In some cases the shoulder is elevated on the affected side<ref name="p8" />. It can be accompanied by [[plagiocephaly]], or develop as a result of [[plagiocephaly]] <ref name=":0">Kaplan S, Coulter C, Fetters L. Physical Therapy Management of Congenital Muscular Torticollis: An Evidence-Based Clinical Practice Guideline. Ped Phys There 2013;25(4):348-394. https://journals.lww.com/pedpt/Fulltext/2013/250 (accessed 21 June 2018) </ref>.
When CMT is left untreated, it can cause:


<br>When CMT is left untreated, it can cause fibrosis of the cervical musculature with progressive limitation of head movement, craniofacial asymmetry, and compensatory scoliosis that worsens with age<ref name="p8" />.
* fibrosis of the cervical musculature - this is associated with progressive limitations in head movements
* asymmetry of craniofacial structures
* compensatory [[scoliosis]] - this tends to get worse with age<ref name="p8" />


Congenital muscular torticollis categorizes into three types:
There are three types of congenital muscular torticollis:<ref name=":1" /><ref name=":0" />


# Postural (20%) – Infant has a postural preference but no muscle tightness or restriction to passive range of motion  
# Postural - occurs in 20% of cases - the infant will have a postural preference, but they do not have any muscle restrictions or reductions in passive range of motion  
# Muscular  (30%) – Tightness of the sternocleidomastoid muscle and limitation of passive range of motion
# Muscular - occurs in 30% of cases - the infant will have SCM tightness and a reduction in passive range of motion
# Sternocleidomastoid mass (50%) – Thickening of the sternocleidomastoid muscle and restricted passive range of motion<ref name=":1" />
# Sternocleidomastoid mass - occurs in 50% of cases - the infant will have thickening of SCM and restricted passive range of motion


Generally Postural CMT is the mildest form, with shorter treatment times compared with Sternocleidomastoid mass CMT which may require longer treatment times and more invasive management <ref name=":0" />.
Postural CMT is the mildest form of CMT. If identified early, postural CMT is associated with shorter treatment times. Infants with sternocleidomastoid mass and who are identified later (after 3-6 months) tend to require longer intervention and may need more invasive management.<ref name=":0" />


== Differential Diagnosis  ==
== Differential Diagnosis  ==


*[http://www.physio-pedia.com/Adult-onset_Idiopathic_Torticollis Acquired torticollis]<ref name="p1" />  
*[http://www.physio-pedia.com/Adult-onset_Idiopathic_Torticollis Acquired torticollis]<ref name="p1" />  
*Occipitoatlantal Fusion: characterized by partial or total fusion of the atlas to the occipital bone. The altered mechanics of the cervical spine predisposes the atlantoaxial joint to degeneration and potential instability, resulting in a dull, aching pain in the posterior neck with intermittent stiffness and torticollis. MRI and CT with 3D reconstruction are necessary for diagnosing<ref name="p1" />.
*Occipitoatlantal fusion<ref name="p1" />
*[http://www.physio-pedia.com/Klippel-Feil_syndrome Klippel-Feil syndrome]<ref name="p1" />  
*[http://www.physio-pedia.com/Klippel-Feil_syndrome Klippel-Feil syndrome]<ref name="p1" />  
*Sternomastoid tumor: there is a palpable mass on the sternocleidomastoid muscle, this must be conformed with ultrasonography<ref name="p4">Tatli B, Aydinli N, Caliskan M, Ozmen M, Bilir F, Acar G. Congenital muscular torticollis: evaluation and classification. Pediatric Neurology. 2006;34(1): 41-44 (Level of Evidence 2)</ref>
*Sternocleidomastoid tumour: palpable mass on the sternocleidomastoid muscle, this must be confirmed with ultrasonography<ref name="p4">Tatli B, Aydinli N, Caliskan M, Ozmen M, Bilir F, Acar G. [https://www.sciencedirect.com/science/article/abs/pii/S0887899405003437 Congenital muscular torticollis: evaluation and classification.] Pediatric Neurology. 2006;34(1): 41-44 (Level of Evidence 2)</ref>
*[http://www.physio-pedia.com/Scoliosis Scoliosis]<ref name="p8" />
*[http://www.physio-pedia.com/Scoliosis Scoliosis]<ref name="p8" />


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
Diagnosis of CMT can usually be made based on the clinical presentation. The following clinical features may be present:<ref name=":0" />


==== Observation, palpation and movement testing ====
* reduced neck range of motion
Infants presenting with observable neck/ head/ facial asymmetry should be screened for CMT. In cases of CMT, the sternocleidomastoid muscle may be shortened on the involved side, leading to an ipsilateral tilt of the head and a contralateral rotation of the face and chin<ref name="p1" /><ref name="p3" /><ref name="p4" /><ref name="p8" />. Reduced neck ROM, a palpable sternocleidomastoid mass, a head position preference and/or plagiocephaly may be present <ref name=":0" />.
* palpable SCM mass
* head position preference
* plagiocephaly


==== Ultrasound ====
However, some cases will require complementary diagnostic tests. In 50% of cases, infants are diagnosed before two months of age. Parents are often the ones to identify CMT.<ref name=":1" />  
Ultrasonography can clearly distinguish postural torticollis from sternomastoid tumor patients. Normally the sternocleidomastoid muscle (SCM) can be seen as an hypoechoic structure with short echogenic lines that represent normal perimysium. In sternomastoid tumor patients there is an enlargement of the sternocleidomastoid muscle, asymmetry of the sternocleidomastoid muscle, a heterogeneous internal pattern of echogenicity and overall echogenicity with surrounding tissue. In congenital muscular torticollis patients there is a visible alteration in the size and echogenicity of the SCM. <br>MRI is recommended when either the clinical symptoms do not resolve within 12 months or when there are atypical features of CMT at US. MRI can demonstrate changes in muscle shape and signal intensity.<ref name="p1" /><ref name="p4" />  


<br>Torticollis is a sign of an underlying disease process. It does not imply a specific diagnosis.<ref name="p1" />  
* Ultrasonography (US) is the most frequently used form of imaging, especially for neonates
** it is useful for assessing neck masses, pseudo-tumour
** useful for monitoring/evaluation post-treatment
* Magnetic resonance imaging (MRI) may be used to rule out non-muscular causes
== Outcome Measures ==


== Outcome Measures  ==
* Cervical range of movement testing
* Cervical range of movement testing
* Muscle Function Scale<ref>Öhman AM, Nilsson S, Beckung ER. [https://www.tandfonline.com/doi/abs/10.1080/09593980802686904 Validity and reliability of the muscle function scale, aimed to assess the lateral flexors of the neck in infants.] Physiotherapy theory and practice. 2009 Jan 1;25(2):129-37.</ref>


== Examination  ==
== Examination  ==
* Thorough history taking including birth history, developmental and medical history, family history.
The assessment for CMT includes:
* Observation of any asymmetries including facial, cranial, neck and positional preference and presence of plagiocephaly.
* Observation of skin creases.
* Observation of infant in developmentally appropriate positions to detect asymmetry and screen developmental milestones.
* Cervical active and passive range of movement testing.
* Upper and lower limb ROM screen, checking for hip dysplasia, which can be associated with CMT, and spine asymmetry.
* Pain at rest and during movements.
* Palpation of sternocleidomastoid for size and elasticity and presence of mass.
* Screen of visual tracking.
* Screen muscle tone.
* Identification of Red flags and appropriate onward referral:
** poor tracking
** abnormal muscle tone
** other features inconsistent with CMT
** poor progress with treatment<ref name=":0" />.
== Physical Therapy Management    ==


Manual stretching is the most common form of treatment for congenital muscular torticollis. A good stabilization and correct hand positions are necessary for the success of the stretch. However, every child/parent pair will have other preferences of stretching methods or positions.<ref name="p4" />  
* passive cervical range of motion with arthrodial goniometer
* active range of motion
* global assessment
* neurological, auditory and visual function assessments to rule out other conditions<ref name=":1" />


<br>An example of a stretching technique: Following stretch requires two persons. Person one stabilizes the shoulders. The other person does the stretching. For a torticollis on the right side, the left side of the face is cupped. The skull is supported with the right hand under the occipital. The left hand is placed on the chin. This hand placement is both for right rotation and left lateral flexion. Slight traction is given and then a right rotation is performed over the available ROM. The stretch is held for 10 seconds. The lateral flexion stretch is also initiated with a slight traction, followed by slight forward flexion and 10° of right rotation. Then the head is moved laterally, so that the left ear approached the left shoulder.<ref name="p3" />  
Identification of [[The Flag System|red flags]] is essential. These include: poor visual tracking; abnormal muscle tone; other features inconsistent with CMT; poor progress with treatment. If you identify these features, appropriate onward referral is necessary.<ref name=":0" />
== Treatment ==
There is no standardised treatment for CMT, but with appropriate interventions, it has been found that 90 to 95% of infants will improve before the age of 1 year. If treatment is commenced before 6 months, 97% of infants will improve.<ref name=":1" />


Another stretching technique can be really effective, this technique is using the gravity to assist in the passive stretch for the affected muscle. start the technique by carrying the baby where he/she is facing away from you. (For example if the child has left torticollis) carry the child with his/her head placed on your left shoulder and then place your right arm between his/her legs and reach his/her left shoulder, then gently depress their left shoulder &nbsp;(push it downward), and with your left hand gently lift his/her head up till the right ear is contacted with the right shoulder (or as higher as the baby can tolerate) then hold from 20 seconds up to one minute (the time could be increased according to the cooperation level of the baby). Advice the parents &nbsp;to play with their baby and distracting him/her from the pain.  
== Physiotherapy Management ==
Physiotherapy (stretching, strengthening and developmental facilitation) and aggressive repositioning are first-line treatments. Helmet therapy may be considered for infants with moderate to severe and persisting asymmetry.  


&nbsp; {{#ev:youtube|LxGenW5EHxU|600}}
=== '''Education''' ===
Education, guidance and support can reassure and help parents. It is important to educate parents/caregivers on positioning and handling skills to encourage active neck rotation towards the affected side and to discourage side flexion to the affected side<ref name="p3" /><ref name="p4" /> (e.g. during feeding).<ref name=":3">Eskay K. Torticollis and Plagiocephaly Course. Plus, 2023.</ref> 


<br>Conservative management also includes educating the parents/caregivers about positioning and handling skills that promote active neck rotation toward the affected side and discouraging children from tilting their head toward the affected side.<ref name="p3" /><ref name="p4" /><br>
=== '''Manual Stretching''' ===
Manual stretches are an important part of treatment. Manual stretches include side flexion and lateral rotation. It is necessary to show the caregiver how to stabilise and correctly position their hands for each stretch. Please note that stretching techniques are contraindicated in infants diagnosed with Klippel-Feil syndrome.


[http://www.physio-pedia.com/Taping Kinesio Taping] is a possible addition to the physical therapy management. Powell (2010) concluded from three case studies that kinesio taping might decrease treatment duration due to longer lasting efficacy with Kinesio application.<ref name="p6" />&nbsp;Öhman (2012) concluded kinesio-taping had an immediate effect on muscular imbalance in children with congenital torticollis.<ref>Öhman AM. The immediate effect of kinesiology taping on muscular imbalance for infants with congenital muscular torticollis. Phys Med and Rehabilitation Journal. 2012;4(7):504-8 (Level of Evidence 3)</ref><br>Kinesio Taping of Sternocleidomastoid muscle: on the affected side from insertion to origin with 5-10% tension, on the unaffected side from origin to insertion with 10-15% tension.<ref name="p6" />  
==== Passive ROM Lateral Neck Flexion ====
The following stretch is useful to encourage lateral flexion of the neck:
* hold infant's shoulder
* perform side tilt until you feel a gentle stretch
* never force the stretch
* infant should not be crying, but might be fussy, so try to keep them distracted
* can perform supine, or lying on your lap
* hold stretch for 30 seconds
* perform this 3-6 times a day (e.g. every diaper change)<ref name=":3" />


Mean treatment duration and predictive factors were studied by C. Emery (1994). The mean treatment of children with congenital muscular torticollis was 4.7 months. Children with palpable masses in the sternocleidomastoid muscle are generally younger and have more severe restrictions in ROM. They were treated longer (6.9 months) than children with no palpable mass (3.9 months). <br>Children received a tubular orthosis for torticollis (TOT) when at the 4.5 months of age or older there was a head tilt of more than 6°. The TOT was essentially a collar made of soft tubing, which the child wore while awake as an active correcting device. Their treatment time was longer (7.2 months) than the time needed in children who didn’t need the orthosis (3.6 months).<br>The severity of restriction of neck rotation was seen as a significant predictor in children with no palpable intramuscular fibrotic sternocleidomastoid muscle mass.
==== Passive ROM Cervical Rotation ====
The following stretch is useful to encourage cervical rotation:
* rotate to the infant's non-preferred side
* place your hand on their cheek
* block their opposite shoulder and rotate them
* the goal is to get their chin over the top of their shoulder
* can be performed supine or while being held<ref name=":3" />


<br>Age at initial assessment, side of involvement and gender were no significant predictors of treatment duration.<ref name="p3" />


<br>Most of the children under one year of age can be treated conservatively.<ref name="p4" />


<nowiki>**</nowiki> This short video by Baby Movement Tips shows stretching techniques.{{#ev:youtube|LxGenW5EHxU|600}}<ref>Baby Movement Tips. Congenital Torticollis Stretches. Available from:https://www.youtube.com/watch?v=LxGenW5EHxU&t=5s [last accessed 11/28/2021]</ref>
=== Kinesio Taping ===
Kinesio taping is an alternative intervention for CMT. It has been suggested that kinesio taping might decrease treatment duration for CMT<ref name="p6" /> and that it can have an immediate effect on muscular imbalance in children with CMT.<ref>Öhman AM. [https://www.sciencedirect.com/science/article/abs/pii/S1934148212001980 The immediate effect of kinesiology taping on muscular imbalance for infants with congenital muscular torticollis.] PM&R. 2012 Jul 1;4(7):504-8.</ref><br>To apply kinesio tape to the SCM: on the affected side, place tape from insertion to origin of SCM with 5-10% tension; on the unaffected side place tape from origin to insertion with 10-15% tension.<ref name="p6" />
=== '''Home Programme''' ===
There are certain measures that caregivers can take at home to help their child with CMT:
* place toys/decorations to encourage infant to turn to other side
* position the crib or changing table, so the infant must turn to the other side to see / interact with caregivers
* Tubular Orthosis for Torticollis (T.O.T) collar<ref>Russo KJ, Fragala MA. [https://journals.lww.com/pedpt/citation/2001/13040/use_of_the_tot_collar_in_conjunction_with.45.aspx USE OF THE TOT COLLAR IN CONJUNCTION WITH TRADITIONAL INTERVENTION FOR A CHILD WITH TORTICOLLIS]. Pediatric Physical Therapy. 2001 Dec 1;13(4):204.</ref>
This video below shows how to use a T.O.T collar.{{#ev:youtube|uLTv1_j1eMQ|600}}<ref>My Torticollis Baby. How to Apply TOT Collar (used for Torticollis). Available from: https://www.youtube.com/watch?v=uLTv1_j1eMQ&t=1s [last accessed 11/28/2021]</ref>
==  Medical Management ==
==  Medical Management ==
If conservative treatment is not successful botox<ref name=":0" /> or surgical options may be considered. These include subcutaneous tenotomy, open tenotomy, bipolar tenotomy, and radical resection of a sternomastoid tumour or the sternocleidomastoid muscle.
If conservative treatment is not successful, botox<ref name=":0" /> or surgical options may be considered.  
 
Surgical may be indicated for the following:<ref name=":1" />
 
* no improvement after six months of manual stretching
* there is a deficit of more than 15 degrees in passive rotation and lateral bending
* tight muscular band is present
* there is a tumour in SCM


Traditionally, the operative treatment of congenital muscular torticollis has been largely determined by the age of the patient. Although some authors<ref name="p9">Ling CM. The influence of age on the results of open sternomastoid tenotomy in muscular torticollis. Clin Orthop. 1976;116:142-8. (Level of Evidence 2)</ref> have suggested that operations should be performed within a few weeks of birth, later reports<ref name="p0">Cheng JC, Tang SP. Outcome of surgical treatment of congenital muscular torticollis. Clin Orthop 1999;362:190-200. (Level of Evidence 2)</ref> have shown spontaneous resolution of symptoms within a year of birth, or there were satisfactory results with conservative treatment, such as bracing, exercise and massage. <br>An operation performed too early, particularly before one year of age creates problems in post-operative wound management owing to easier formation of haematomas and increased prevalence of infection. Therefore, some authors have reported that the optimal time for operation is between one and four years of age. Coventry and Harris<ref name="p1" /> reported that operation up to 12 years of age produced good results. <br>Latest studies<ref name="p2">Lee Y, Yoon K, Kim YB, Chung PW, Hwang JH, Park YS, et al. Clinical features and outcome of physiotherapy in early presenting congenital muscular torticollis with severe fibrosis on ultrasonography: a prospective study. Journal of Pediatric Surgery. 2011; 46(8): 1526-1531 (Level of Evidence 2)</ref> suggest that age is not the most important factor when determining the optimal time for operation, and that compliance with a post-operative rehabilitation program is the most important consideration. They suggest that operative treatment of congenital muscular torticollis should be delayed until such compliance is possible.
Surgical options for torticollis include: unipolar/ bipolar sternocleidomastoids muscle lengthening; "Z" lengthening, and radical resection of SCM.<ref name=":1" />
== Resources   ==
== Resources ==


For a comprehensive look at CMT and evidence-based physiotherapy management:
For a comprehensive look at CMT and evidence-based physiotherapy management:


[https://journals.lww.com/pedpt/Fulltext/2013/250 Physical Therapy Management of Congenital Muscular Torticollis: An Evidence-Based Clinical Practice Guideline]
[https://journals.lww.com/pedpt/Fulltext/2018/10000/Physical_Therapy_Management_of_Congenital_Muscular.2.aspx Physical Therapy Management of Congenital Muscular Torticollis: An Evidence-Based Clinical Practice Guideline]
== References  ==
== References  ==


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[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Paediatrics - Conditions]]
[[Category:Paediatrics - Conditions]]
[[Category:Congenital Conditions]]
[[Category:Course Pages]]

Latest revision as of 02:43, 19 April 2023

Original Editor - Nikki Rommers Top Contributors - Grace Barla, Nikki Rommers, Lucinda hampton, Jess Bell, Asma Alshehri, Admin, Lauren Kwant, Robin Tacchetti, Ahmed M Diab, Ceulemans Lisa, Kim Jackson, WikiSysop, Uchechukwu Chukwuemeka, Rucha Gadgil, Mila Andreew, 127.0.0.1 and Gaelle De Coster


Introduction/ Description[edit | edit source]

Congenital torticollis (CMT) is a condition in infants commonly diagnosed at or soon after birth. The term torticollis is derived from the Latin word tortus, meaning ''twisted'' and collum meaning ''neck.'' This condition is, therefore, also known as twisted neck or wry neck.

CMT occurs when there is reduced length and increased tone of sternocleidomastoid (SCM) on one side. Infants present with lateral flexion on the ipsilateral side (i.e. the side where the SCM is affected) and contralateral rotation.[1]

Treatment approaches for CMT include:[1]

  • manual therapy (e.g. therapist-led stretching exercises)
  • repositioning therapy (e.g. tummy time)
  • botulinum toxin (botox) / surgery may be necessary for more severe cases that do not resolve

Secondary changes associated with CMT can include:[1]

  • cranial asymmetry (plagiocephaly)
  • functional problems, such as difficulty breastfeeding

Epidemiology[edit | edit source]

  • Torticollis in infants is most commonly caused by CMT[2]
  • CMT is the third most common congenital musculoskeletal condition in newborns - its incidence ranges from 0.3% to 19.7%[3]
  • It has been associated with upper cervical spine dysfunction and has been called a "kinetic imbalance due to suboccipital strain"[1]

Clinically Relevant Anatomy[edit | edit source]

The sternocleidomastoid muscle has a sternal and clavicular head. The sternal head originates at the manubrium sterni[4] moving superiorly, laterally and posteriorly. The clavicular head originates at the medial third of the clavicle and runs vertically upward. It inserts at the mastoid process and enables ipsilateral lateral flexion and contralateral rotation. SCM also extends the upper part of the cervical spine and flexes the lower part.[5]

Aetiology[edit | edit source]

As mentioned, CMT is caused by an imbalance in the SCM, but its aetiology is still being explored. There are a number of suggested causes, including ischaemia, trauma during childbirth, intrauterine malposition.[6]

CMT caused by intrauterine deformation may be associated with limited space in utero (e.g. in first pregnancies, multiple births), decreased amniotic fluid volume, or uterine compression syndrome.[6]

Pathophysiology[edit | edit source]

A fibrous band forms in the SCM muscle in infants with CMT. This may be due to muscle injury, i.e. prolonged compression and stretching of the muscle. Histological studies also found: oedema, muscle fibre degeneration, and fibrosis in babies with CMT (which suggests the presence of compartment syndrome).[6]

Clinical Presentation[edit | edit source]

  • Unilateral contraction of the SCM causing a lateral flexion towards the affected side with slight rotation of the chin to the contralateral side.[7][8][9]
  • Affected side may seem excessively stronger than the contralateral side
    • this causes an imbalance in the neck muscles
    • the lateral head righting on the contralateral side is weaker than the affected side[10]
  • In some cases, the shoulder may be elevated on the affected side[9]
  • Can be accompanied by plagiocephaly[11]

When CMT is left untreated, it can cause:

  • fibrosis of the cervical musculature - this is associated with progressive limitations in head movements
  • asymmetry of craniofacial structures
  • compensatory scoliosis - this tends to get worse with age[9]

There are three types of congenital muscular torticollis:[6][11]

  1. Postural - occurs in 20% of cases - the infant will have a postural preference, but they do not have any muscle restrictions or reductions in passive range of motion
  2. Muscular - occurs in 30% of cases - the infant will have SCM tightness and a reduction in passive range of motion
  3. Sternocleidomastoid mass - occurs in 50% of cases - the infant will have thickening of SCM and restricted passive range of motion

Postural CMT is the mildest form of CMT. If identified early, postural CMT is associated with shorter treatment times. Infants with sternocleidomastoid mass and who are identified later (after 3-6 months) tend to require longer intervention and may need more invasive management.[11]

Differential Diagnosis[edit | edit source]

Diagnostic Procedures[edit | edit source]

Diagnosis of CMT can usually be made based on the clinical presentation. The following clinical features may be present:[11]

  • reduced neck range of motion
  • palpable SCM mass
  • head position preference
  • plagiocephaly

However, some cases will require complementary diagnostic tests. In 50% of cases, infants are diagnosed before two months of age. Parents are often the ones to identify CMT.[6]

  • Ultrasonography (US) is the most frequently used form of imaging, especially for neonates
    • it is useful for assessing neck masses, pseudo-tumour
    • useful for monitoring/evaluation post-treatment
  • Magnetic resonance imaging (MRI) may be used to rule out non-muscular causes

Outcome Measures[edit | edit source]

  • Cervical range of movement testing
  • Muscle Function Scale[13]

Examination[edit | edit source]

The assessment for CMT includes:

  • passive cervical range of motion with arthrodial goniometer
  • active range of motion
  • global assessment
  • neurological, auditory and visual function assessments to rule out other conditions[6]

Identification of red flags is essential. These include: poor visual tracking; abnormal muscle tone; other features inconsistent with CMT; poor progress with treatment. If you identify these features, appropriate onward referral is necessary.[11]

Treatment[edit | edit source]

There is no standardised treatment for CMT, but with appropriate interventions, it has been found that 90 to 95% of infants will improve before the age of 1 year. If treatment is commenced before 6 months, 97% of infants will improve.[6]

Physiotherapy Management[edit | edit source]

Physiotherapy (stretching, strengthening and developmental facilitation) and aggressive repositioning are first-line treatments. Helmet therapy may be considered for infants with moderate to severe and persisting asymmetry.

Education[edit | edit source]

Education, guidance and support can reassure and help parents. It is important to educate parents/caregivers on positioning and handling skills to encourage active neck rotation towards the affected side and to discourage side flexion to the affected side[10][12] (e.g. during feeding).[14]

Manual Stretching[edit | edit source]

Manual stretches are an important part of treatment. Manual stretches include side flexion and lateral rotation. It is necessary to show the caregiver how to stabilise and correctly position their hands for each stretch. Please note that stretching techniques are contraindicated in infants diagnosed with Klippel-Feil syndrome.

Passive ROM Lateral Neck Flexion[edit | edit source]

The following stretch is useful to encourage lateral flexion of the neck:

  • hold infant's shoulder
  • perform side tilt until you feel a gentle stretch
  • never force the stretch
  • infant should not be crying, but might be fussy, so try to keep them distracted
  • can perform supine, or lying on your lap
  • hold stretch for 30 seconds
  • perform this 3-6 times a day (e.g. every diaper change)[14]

Passive ROM Cervical Rotation[edit | edit source]

The following stretch is useful to encourage cervical rotation:

  • rotate to the infant's non-preferred side
  • place your hand on their cheek
  • block their opposite shoulder and rotate them
  • the goal is to get their chin over the top of their shoulder
  • can be performed supine or while being held[14]


** This short video by Baby Movement Tips shows stretching techniques.

[15]

Kinesio Taping[edit | edit source]

Kinesio taping is an alternative intervention for CMT. It has been suggested that kinesio taping might decrease treatment duration for CMT[5] and that it can have an immediate effect on muscular imbalance in children with CMT.[16]
To apply kinesio tape to the SCM: on the affected side, place tape from insertion to origin of SCM with 5-10% tension; on the unaffected side place tape from origin to insertion with 10-15% tension.[5]

Home Programme[edit | edit source]

There are certain measures that caregivers can take at home to help their child with CMT:

  • place toys/decorations to encourage infant to turn to other side
  • position the crib or changing table, so the infant must turn to the other side to see / interact with caregivers
  • Tubular Orthosis for Torticollis (T.O.T) collar[17]

This video below shows how to use a T.O.T collar.

[18]

Medical Management[edit | edit source]

If conservative treatment is not successful, botox[11] or surgical options may be considered.

Surgical may be indicated for the following:[6]

  • no improvement after six months of manual stretching
  • there is a deficit of more than 15 degrees in passive rotation and lateral bending
  • tight muscular band is present
  • there is a tumour in SCM

Surgical options for torticollis include: unipolar/ bipolar sternocleidomastoids muscle lengthening; "Z" lengthening, and radical resection of SCM.[6]

Resources[edit | edit source]

For a comprehensive look at CMT and evidence-based physiotherapy management:

Physical Therapy Management of Congenital Muscular Torticollis: An Evidence-Based Clinical Practice Guideline

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Ellwood J, Draper-Rodi J, Carnes D. The effectiveness and safety of conservative interventions for positional plagiocephaly and congenital muscular torticollis: a synthesis of systematic reviews and guidance. Chiropractic & manual therapies. 2020 Dec;28(1):1-1.
  2. ↑ Amaral DM, Cadilha RP, Rocha JA, Silva AI, Parada F. Congenital muscular torticollis: where are we today? A retrospective analysis at a tertiary hospital. Porto biomedical journal. 2019 May;4(3).
  3. ↑ Kuo AA, Tritasavit S, Graham JM. Congenital muscular torticollis and positional plagiocephaly. Pediatr Rev. 2014;35(2):79-87; quiz 87.
  4. ↑ Gray H. Anatomy of the human body. Lea & Febiger; 1878.
  5. ↑ 5.0 5.1 5.2 Alison Middleditch MC, Jean Oliver MC. Functional anatomy of the spine. Elsevier Health Sciences; 2005 Sep 30.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Gundrathi J, Cunha B, Mendez MD. Congenital Torticollis. 2023 Jan 31. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 31747185.
  7. ↑ 7.0 7.1 7.2 7.3 Haque S, Shafi BB, Kaleem M. Imaging of Torticollis in Children. RadioGraphics. Mar 2012; 32(2): 558-571
  8. ↑ Petronic I, Brdar R, Cirovic D, Nikolic D, Lukac M, Janic D, et al. Congenital muscular torticollis in children: distribution, treatment duration and out come. European journal of physical and rehabilitation medicine. 2009 Dec 15;46(2):153-7.
  9. ↑ 9.0 9.1 9.2 9.3 Ta JH, Krishnan M. Management of congenital muscular torticollis in a child: a case report and review. International journal of pediatric otorhinolaryngology. 2012 Nov 1;76(11):1543-6.
  10. ↑ 10.0 10.1 Öhman A, Mårdbrink EL, Stensby J, Beckung E. Evaluation of treatment strategies for muscle function in infants with congenital muscular torticollis. Physiotherapy Theory and Practice. 2011; 27(7): 463-470 (Level of Evidence 2)
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 Kaplan SL, Coulter C, Fetters L. Physical Therapy Management of Congenital Muscular Torticollis: An Evidence-Based Clinical Practice Guideline FROM THE SECTION ON PEDIATRICS OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION. Pediatric Physical Therapy. 2013 Dec 1;25(4):348-94.
  12. ↑ 12.0 12.1 Tatli B, Aydinli N, Caliskan M, Ozmen M, Bilir F, Acar G. Congenital muscular torticollis: evaluation and classification. Pediatric Neurology. 2006;34(1): 41-44 (Level of Evidence 2)
  13. ↑ Öhman AM, Nilsson S, Beckung ER. Validity and reliability of the muscle function scale, aimed to assess the lateral flexors of the neck in infants. Physiotherapy theory and practice. 2009 Jan 1;25(2):129-37.
  14. ↑ 14.0 14.1 14.2 Eskay K. Torticollis and Plagiocephaly Course. Plus, 2023.
  15. ↑ Baby Movement Tips. Congenital Torticollis Stretches. Available from:https://www.youtube.com/watch?v=LxGenW5EHxU&t=5s [last accessed 11/28/2021]
  16. ↑ Öhman AM. The immediate effect of kinesiology taping on muscular imbalance for infants with congenital muscular torticollis. PM&R. 2012 Jul 1;4(7):504-8.
  17. ↑ Russo KJ, Fragala MA. USE OF THE TOT COLLAR IN CONJUNCTION WITH TRADITIONAL INTERVENTION FOR A CHILD WITH TORTICOLLIS. Pediatric Physical Therapy. 2001 Dec 1;13(4):204.
  18. ↑ My Torticollis Baby. How to Apply TOT Collar (used for Torticollis). Available from: https://www.youtube.com/watch?v=uLTv1_j1eMQ&t=1s [last accessed 11/28/2021]
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