Congenital torticollis: Difference between revisions

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== Introduction/ Description ==
== Introduction/ Description ==
[[File:Torticollis 1.jpg|alt=|right|frameless]]
[[File:Torticollis 1.jpg|alt=|right|frameless]]
[[Congenital and Acquired Neuromuscular and Genetic Disorders|Congenital]] torticollis (CMT) also known as twisted neck or wry neck 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.     


The term torticollis is derived from the Latin word ''tortus'', meaning <nowiki>''twisted''</nowiki> and ''collum'' meaning <nowiki>''neck.''</nowiki> The infant holds their head tilted to unaffected side and has difficulty in turning the head to the opposite side. 
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>    


* It is the third most common congenital musculoskeletal condition in new-borns with an incidence ranging from 0.3 to 16%.
Treatment approaches for CMT include:<ref name=":2" />
* Has been associated with dysfunction in the upper [[Structure and Function of the Cervical Spine|cervical spine]] and is sometimes referred to as kinetic imbalance due to subocciptal strain.
* Congenital muscular torticollis is the most common cause of torticollis in the infants.<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>


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 [[The Relationship Between Posture and Swallowing|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.</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


== Clinically Relevant Anatomy  ==
Secondary changes associated with CMT can include:<ref name=":2" />
[[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 is directed from 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> 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">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>.   
== 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).
* cranial asymmetry ([[plagiocephaly]])
 
* functional problems, such as difficulty breastfeeding
The sternocleidomastoid is the most targeted muscle. The motor activity of SCM 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.] </ref>


== 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 orthopaedic 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 Scans|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" />
== 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>


== Presentation ==
When CMT is left untreated, it can cause:
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. [https://pubs.rsna.org/doi/full/10.1148/rg.322105143 Imaging of Torticollis in Children]. RadioGraphics. Mar2012; 32(2): 558-571</ref><ref name="p7">Petronic I, Brdar R, Cirovic D, Nikolic D, Lukac M, Janic D, Pavicevic P, Golubovic Z, Knezevic T. [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>.
* fibrosis of the cervical musculature - this is associated with progressive limitations in head movements
* The affected side seems to be excessively stronger than the contralateral side. This causes an imbalance in the neck muscles The lateral head righting on contralateral side is weak as compared to 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>.
* asymmetry of craniofacial structures
* 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 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>.
* compensatory [[scoliosis]] - this tends to get worse with age<ref name="p8" />


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


When CMT is left untreated it can cause-
# 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 - occurs in 30% of cases - the infant will have SCM tightness and a reduction in passive range of motion
# Sternocleidomastoid mass - occurs in 50% of cases - the infant will have thickening of SCM and restricted passive range of motion


* Fibrosis of the cervical musculature with progressive limitation of head movement
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" />
* Craniofacial asymmetry<ref>Cheng JC, Tang SP, Chen TM, Wong MW, Wong EM. [https://www.sciencedirect.com/science/article/abs/pii/S0022346800492249 The clinical presentation and outcome of treatment of congenital muscular torticollis in infants—a study of 1,086 cases]. Journal of pediatric surgery. 2000 Jul 1;35(7):1091-6.</ref>
* Compensatory [[scoliosis]] that worsens with age<ref name="p8" />.
 
 
Congenital muscular torticollis categorizes into three types:
 
# Postural (20%) – Infant has a postural preference but no muscle tightness or restriction to passive range of motion
# Muscular  (30%) – Tightness of the sternocleidomastoid muscle and limitation of passive range of motion
# Sternocleidomastoid mass (50%) – Thickening of the sternocleidomastoid muscle and restricted passive range of motion<ref name=":1" />
 
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" />.


== 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<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 tumour: 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. [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>
*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 is usually made clinically, with few cases diagnosed through the use of complementary diagnostic tests. Diagnosis is generally before two months in 50% of cases; parents identify most cases and may correlate with plagiocephaly.
Diagnosis of CMT can usually be made based on the clinical presentation. The following clinical features may be present:<ref name=":0" />
 
* reduced neck range of motion
* palpable SCM mass
* head position preference
* plagiocephaly


* The most common imaging modality is ultrasonography, especially in the neonatal period. Magnetic resonance imaging (MRI) can be useful to rule out nonmuscular causes of torticollis.
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" />  
* Ultrasound is advantageous in assessing neck mass / pseudo-tumor, as well as long-term monitoring and post-treatment evaluation<ref name=":1" />.


Reduced neck ROM, a palpable sternocleidomastoid mass, a head position preference and/or plagiocephaly may be present <ref name=":0" />.
* 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 Motion|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>
* 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  ==
Physical examination is the easiest and most effective means of diagnosis. The most representative assessment methods for assessing congenital torticollis include an assessment of the passive cervical range of motion using an arthrodial goniometer (can be done by physical therapists), as well as an active range of motion, and global assessment. Neurological assessment, as well as auditory assessment, are fundamental to exclude other differential diagnoses<ref name=":1" />.
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<ref name=":1" />


Identification of [[The Flag System|Red flags]] and appropriate onward referral: poor tracking; abnormal muscle tone; other features inconsistent with CMT; poor progress with treatment<ref name=":0" />.
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 ==
== Treatment ==
There are several ways to approach congenital torticollis, and there is no therapeutic standardization. Professionals in various fields, including physiotherapy and osteopathy, recommend techniques for the treatment of infant torticollis.
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" />
 
With proper treatment, 90% to 95%  of children improve before the first year of life, and 97% of patients improve if treatment starts before the first six months<ref name=":1" />.


== Physical Therapy Management ==
== Physiotherapy Management ==
Both physical therapy and repositioning as first line treatment are recommended followed by helmet therapy as a second line of treatment for infants with moderate to severe and persisting asymmetry. [[Physiotherapy / Physical Therapy|Physical therapy]] is better than positioning pillows due to the risk of Sudden Infant Death Syndrome when sleeping on stomach.
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.  
 
There are a large number of protocol studies in the literature demonstrating the effectiveness of physical therapy.
 
Little data on the frequency and types of exercise exists
 
* In many studies, the initial frequency was 2 times per week in the 1st month, progressing to once per week
* Some authors refer 3 times a week initially.
 
The duration of congenital torticollis physiotherapy treatment depends on the date on which rehabilitation began.  The sooner it starts, the faster the normal cervical biomechanics become established, as well as achieving better


=== '''Education''' ===
=== '''Education''' ===
Education, guidance and support is likely to reassure and help parents.   
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>  


* Educate 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" />
=== '''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.


=== '''Manual stretching''' ===
==== Passive ROM Lateral Neck Flexion ====
Initial treatment focus on passive range stretching and close follow up. Parents are advised to perform positioning at schedules such as during feeds; this includes rotation of the chin towards the affected side shoulder. Infants can be placed on their stomach when awake and under supervision to develop motor skills in the prone position. Manual stretches such as flexion, extension, the lateral rotation. Good stabilization and correct hand positions are necessary for the success of the stretch. Every child/parent pair will have other preferences of [[stretching]] methods or positions.<ref name="p4" />
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" />


Examples of stretching techniques
==== 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" />


* 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" />


Another stretching technique.


* Can be really effective, this technique is using the gravity to assist in the passive stretch for the affected muscle.
<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>
* 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)
* 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.&nbsp;
This 1.45 minute video shows the above technique. {{#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 ===
It is a possible addition to the physical therapy management. Powell (2010) concluded from three case studies that [[Taping|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. [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>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" />
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 program''' ===
=== '''Home Programme''' ===
There are certain measures that parents can take:
There are certain measures that caregivers can take at home to help their child with CMT:


* Place the toys in the direction where the baby must turn their head to see it
* place toys/decorations to encourage infant to turn to other side
* Position the crib or changing table in direction away from the affected side to see you
* 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>
* 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 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>
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 ==
If conservative treatment is not successful, botox<ref name=":0" /> or surgical options may be considered.


==  Medical Management ==
Surgical may be indicated for the following:<ref name=":1" />
If conservative treatment is not successful botox<ref name=":0" /> or surgical options may be considered.


Surgical indications include cases where there is no improvement after six months of manual stretching if there are more than 15-degree defects in passive rotation and lateral bending, the presence of a tight muscular band, or a tumour in sternocleidomastoid. The procedure includes unipolar/ bipolar sternocleidomastoids muscle lengthening, "Z" lengthening, or radical resection of the sternocleidomastoid<ref name=":1" />.
* no improvement after six months of manual stretching
== Last Words ==
* there is a deficit of more than 15 degrees in passive rotation and lateral bending
Early diagnosis results in the initiation of prompt non-invasive correction, which prevents long-term disfiguring complications. Parents should receive education regarding the condition, their participation in its management, and prognosis of the condition. Healthcare providers should be aware of the relationship between congenital torticollis, its impact on the child's gross motor development and that most children resolve any motor delays associated with the condition by 3 to 5 years. A paediatric nurse should follow the child until there is a complete resolution of the congenital torticollis. With proper therapy from a collaborative interprofessional team, most children have a good outcome.<ref name=":1" />
* 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.<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:Paediatrics - Conditions]]
[[Category:Paediatrics - Conditions]]
[[Category:Congenital 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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