Congenital torticollis: Difference between revisions

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Traditionally, the operative treatment of congenital muscular torticollis has been largely determined by the age of the patient. Although some authors<ref name="9">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="10">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="11">Coventry MB, Harris LE. Congenital muscular torticollis in infancy: some observation regarding treatment. J Bone Joint Surg [Am] 1999;41-A:815-22. (Level of Evidence 2)</ref> reported that operation up to 12 years of age produced good results. <br>Latest studies<ref name="12">J. S. Shim and H. P. Jang. Operative treatment of congenital torticollis. J Bone Joint Surg Br July 2008 90-B:934-939. (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.<br><br>  
Traditionally, the operative treatment of congenital muscular torticollis has been largely determined by the age of the patient. Although some authors<ref name="9">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="10">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="11">Coventry MB, Harris LE. Congenital muscular torticollis in infancy: some observation regarding treatment. J Bone Joint Surg [Am] 1999;41-A:815-22. (Level of Evidence 2)</ref> reported that operation up to 12 years of age produced good results. <br>Latest studies<ref name="12">J. S. Shim and H. P. Jang. Operative treatment of congenital torticollis. J Bone Joint Surg Br July 2008 90-B:934-939. (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.<br><br>  


== Physical Therapy Management <br>  ==
<h2> Physical Therapy Management <br /</h2>
 
<p>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.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="14">A. Matin et al. Management of Congenital Muscular Torticollis Under One Year of Age. Journal of Shaheed Suhrawardy Medical College 2009; vol.1, no.2. (Level of Evidence 4)</span>  
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="14">A. Matin et al. Management of Congenital Muscular Torticollis Under One Year of Age. Journal of Shaheed Suhrawardy Medical College 2009; vol.1, no.2. (Level of Evidence 4)</ref>  
</p><p><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.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="13">C. Emery. The Determinants of Treatment Duration of Congenital Muscular Torticollis. Phys. Ther. 1994; 74:921-929. (Level of Evidence 2)</span>  
 
</p><p><br />Conservative management also includes informing the parents 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.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="13" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="14" /><br />  
<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="13">C. Emery. The Determinants of Treatment Duration of Congenital Muscular Torticollis. Phys. Ther. 1994; 74:921-929. (Level of Evidence 2)</ref>  
</p><p><a href="http://www.physio-pedia.com/Taping">Kinesio Taping</a> 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.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="16">F. Powell. The effects of kinesio taping method in treatment of congenital torticollis case studies. 2010. (Level of Evidence 4)</span>&nbsp;Öhman (2012) concluded kinesiotaping had an immediate effect on muscular imbalance in children with congenital torticollis.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="17">A.M. Öhman. The immediate effect of kinesiology taping on muscular imbalance for infants with congenital muscular torticollis. Phys Med and Rehabilitation Journal. 2012. (Level of Evidence 3)</span><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.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="16" />  
 
</p><p>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 orthesis (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.  
<br>Conservative management also includes informing the parents 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="13" /><ref name="14" /><br>  
</p><p><br />Age at initial assessment, side of involvement and gender were no significant predictors of treatment duration.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="13" />  
 
</p><p><br />Most of the children under one year of age can be treated conservatively.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="14" /> <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="15">S. Lal et al. Response of primary Torticollis to Physiotherapy. Journal of Surgery Pakistan (International). 2011; 16 (4).  (Level of Evidence 4)</span><br /><br />
[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="16">F. Powell. The effects of kinesio taping method in treatment of congenital torticollis case studies. 2010. (Level of Evidence 4)</ref>&nbsp;Öhman (2012) concluded kinesiotaping had an immediate effect on muscular imbalance in children with congenital torticollis.<ref name="17">A.M. Öhman. The immediate effect of kinesiology taping on muscular imbalance for infants with congenital muscular torticollis. Phys Med and Rehabilitation Journal. 2012. (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="16" />  
</p>
 
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 orthesis (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.  
 
<br>Age at initial assessment, side of involvement and gender were no significant predictors of treatment duration.<ref name="13" />  
 
<br>Most of the children under one year of age can be treated conservatively.<ref name="14" /> <ref name="15">S. Lal et al. Response of primary Torticollis to Physiotherapy. Journal of Surgery Pakistan (International). 2011; 16 (4).  (Level of Evidence 4)</ref><br><br>  


== Key Research  ==
== Key Research  ==

Revision as of 09:38, 19 June 2013

 

Welcome to Vrije Universiteit Brussel's Evidence-based Practice project. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Search Strategy[edit | edit source]

Keywords: Congenital torticollis, wry neck AND infants,  torticollis AND diagnosis 

Definition/Description[edit | edit source]

Congenital torticollis or wry neck is a condition in infants detected at birth or shortly afterCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. It is characterized by rotational deformity of the cervical spine with secondary tilting of the head Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. There is a lateral head tilt to one side and contralateral rotationCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. It is most commonly the result of unilateral shortening and thickening or excessive contraction of the sternocleidomastoid muscle Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. The basic abnormality is known as endomysial fibrosis with deposition of collagen and migration of fibroblasts around individual muscle fibersCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. It leads to a limitation of the head mobility in both rotation and lateral flexion and progressive degrees of neck contractureCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

Clinically Relevant Anatomy[edit | edit source]

The normal physiologic range of rotation of the atlas on the axis is 25o-53o degrees to either side. The transverse ligament is the primary stabilizer of the atlantoaxial joint and prevents excessive anterior motion of the atlas on the axis. It extends behind the dens, between the medial portions of the lateral masses of C1Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. The paired alar ligaments act as secondary stabilizers to prevent anterior shift. The alar ligaments extend from the lateral aspect of the dens tip to the medial aspect of the occipital condyles, with a lower portion attaching to the medial aspect of the lateral masses of C1Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.


The 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 partCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.


Etiology/Epidemiology[edit | edit source]

Congenital torticollis occurs in 0.4 to 3.94% of births according to different sourcesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. It is the third most common musculoskeletal abnormality in infantsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.


The true etiology remains controversialCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. So far more than 80 entities have been described that can cause torticollisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. We can differentiate several frequent causes of congenital torticollis:

  • Muscular in more than 80% of the casesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. Types muscular torticollis
              - Fibromatosis colli: torticollis with palpable mass in the SCM;
              - Tightness of the SCM without an apparent mass;
  • Postural torticollis with neither mass or tightnessCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
  • Birth trauma: facet dislocation, tears in the sternocleidomastoid muscle
  • Congenital anomalies of the craniovertebral junction: occipitoatlantal fusion or Klippel-Feil syndromeCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
  • Sternocleidomastoid tumour Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Ocular abnormalitiesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Intrauterine mechanical factorsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

A common hypothesis of muscular torticollis is that intrauterine constraint limits head mobility and leads to progressive degrees of neck contracture. The severity depends on the duration of prenatal immobilityCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. There is no difference in clinical severity based on the method of child birthCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

Characteristics/Clinical Presentation[edit | edit source]

Congenital muscular torticollis is characterized by an 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 contra¬lateral sideCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.The affected side seems to be excessively stronger than the contralateral side. This causes an imbalance in the neck musclesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. In some cases the shoulder is elevated on the affected sideCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
When congenital muscular torticollis 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 ageCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

Differential Diagnosis[edit | edit source]

  • Acquired torticollisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • 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 diagnosingCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
  • Klippel-Feil syndromeCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Sternomastoid tumor: there is a palpable mass on the sternocleidomastoid muscle, this must be conformed with ultrasonographyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • ScoliosisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Diagnostic Procedures[edit | edit source]

Torticollis is a sign of an underlying disease process. It does not imply a specific diagnosis.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


At inspection you see that, in case of congenital muscular torticollis, the sternocleidomastoid muscle is shortened on the involved side, leading to an ipsilateral tilt of the head and a contralateral rotation of the face and chin.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


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.
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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Outcome Measures[edit | edit source]

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Examination[edit | edit source]

add text here related to physical examination and assessment

Medical Management
[edit | edit source]

Treatment of congenital torticollis includes observation, the use of braces, exercise programs, traction, and various operations. These include subcutaneous tenotomy, open tenotomy, bipolar tenotomy, and radical resection of a sternomastoid tumour or the sternocleidomastoid muscle.

Traditionally, the operative treatment of congenital muscular torticollis has been largely determined by the age of the patient. Although some authorsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title have suggested that operations should be performed within a few weeks of birth, later reportsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 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.
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 HarrisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title reported that operation up to 12 years of age produced good results.
Latest studiesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 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.

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.A. Matin et al. Management of Congenital Muscular Torticollis Under One Year of Age. Journal of Shaheed Suhrawardy Medical College 2009; vol.1, no.2. (Level of Evidence 4)


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.C. Emery. The Determinants of Treatment Duration of Congenital Muscular Torticollis. Phys. Ther. 1994; 74:921-929. (Level of Evidence 2)


Conservative management also includes informing the parents 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.

<a href="http://www.physio-pedia.com/Taping">Kinesio Taping</a> 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.F. Powell. The effects of kinesio taping method in treatment of congenital torticollis case studies. 2010. (Level of Evidence 4) Öhman (2012) concluded kinesiotaping had an immediate effect on muscular imbalance in children with congenital torticollis.A.M. Öhman. The immediate effect of kinesiology taping on muscular imbalance for infants with congenital muscular torticollis. Phys Med and Rehabilitation Journal. 2012. (Level of Evidence 3)
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.

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).
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 orthesis (3.6 months).
The severity of restriction of neck rotation was seen as a significant predictor in children with no palpable intramuscular fibrotic sternocleidomastoid muscle mass.


Age at initial assessment, side of involvement and gender were no significant predictors of treatment duration.


Most of the children under one year of age can be treated conservatively. S. Lal et al. Response of primary Torticollis to Physiotherapy. Journal of Surgery Pakistan (International). 2011; 16 (4). (Level of Evidence 4)

Key Research[edit | edit source]

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Resources
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Clinical Bottom Line[edit | edit source]

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Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

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