Neuro Peds - 03 - Torticollis

Question 1

What does Torticollis mean?

Answer 1

twisted neck

Question 2

What is the physical manifestation of Torticollis?

Answer 2

abnormal neck posture

• lateral head tilt
• neck rotation

Question 3

What are the 2 primary planes of motion involved with Torticollis?

Answer 3

rotation - to the opposite side

lateral flexion to the same side

Question 4

What muscles are primarily involved with Torticollis?

Answer 4

SCM - for the rotation
Scalenes
Upper traps

Question 5

which muscles are tight and which are weak (stretched) in Left Torticollis?

Answer 5

tight - Left SCM, Scalenes, Upper Traps

weak (stretched) - Right SCM, scalenes, upper traps

Question 6

what are the 2 types of Torticollis?

Answer 6

Muscular, aka Congential Muscular Torticollis, aka CMT

Non-muscular - Sprengel’s Deformity, Klepper-Feil Syndrome

Question 7

What is the etiology of Muscular Torticollis?

Answer 7

Birth trauma
Fetal mal-position
Uterine compression
Inflammatory condition
Difficult delivery –clavicular fractures, brachial plexus injury

Question 8

What is the etiology of Non-muscular Torticollis?

Answer 8

Cervical skeletal malformation
Visual impairment
Gastroesophageal reflux
Sprengel’s Deformity
Klepper-Feil Syndrome (or Klippel-Feil)

can happen in utero
visual impairment can contribute

Question 9

describe Sprengel’s Deformity:

Answer 9

one (usually left) or both scapulae fail to descend during early fetal development
75% girls.
Peri-scapular muscles may be fibrotic.
Shoulder motion restricted

– formation – and distending of the scapular – genetic deformity

Question 10

describe Klippel-Feil syndrome:

Answer 10

Any 2 of 7 cervical vertebrae fused.
Worse if C1-C2.
(Case study with Noah – more apparent with growth, PT did not help).

If no progress, don’t crank.
Might have fused vertebra.
If no response to treatment, stop and look again. Monitor

Question 11

how does the PT evaluate for Torticollis?

Answer 11

Palpation for fibrous mass
Cervical x-rays
R/O hip dysplasia 
Cranial and facial asymmetries
Visual tracking
Posture
Gross motor screen

Question 12

What condition is commonly associated with Torticollis?

Answer 12

Plagiocephaly

Question 13

What else might the PT see with Torticollis?

Answer 13

(plagiocephaly)
Hip Dysplasia
Postural Asymmetry

Question 14

Who else is on the team to resolve the Torticollis?

Answer 14

pediatrician
neurosurgeon
physical therapist
orthotist (some OTs) for cranial band
sometimes plastic surgeon

Question 15

name 3 types of abnormal head shapes

Answer 15

plagiocephaly - asymmetrical
brachycephaly - flat head (wide)
scaphocephaly - cone head (long and narrow)

seen best when viewed from the top

Question 16

what does the PTA do when the parent wants to know if a helmet is needed?

Answer 16

suggest evaluation

tell MD to make referral

Question 17

how does the cranial helmet work?

Answer 17

Cranial helmet puts pressure on areas to round out head

Question 18

what is critical to maintain head shape?

Answer 18

Stretching/elongation of tight muscles is critical to maintain head shape. Must avoid pressure on skull using a combination of positioning and molded cast.

Question 19

when is the best time for Cranial Band Intervention?

Answer 19

between 3 months and 12 months when rate of growth of cranial circumference is accelerated.

Question 20

when does ossification start (so you hope you are done with cranial band)?

Answer 20

18 months

Question 21

What is the

Cranial Vault Asymmetry Index?

Answer 21

CVAI –Cranial Vault Asymmetry Index: Measure diagonally top of head and difference between two expressed as a percentage.
Calipers can be used but very difficult in wiggly infant and if off even a millimeter is inaccurate – now orthotist can scan cranial topography using a digital image.

Question 22

describe the 5 levels of involvement on the Plagiocephaly Severity Scale

Answer 22

1 - normal - symmetrical - no helmet - CVAI < 3.5%
2 - mild - minimal asymmetry in one posterior quadrant - repositioning program for 2 months - CVAI 3.5 - 6.25 %
3 - moderate - two quadrants, mod-severe posterior quad flat, min ear shift/anterior involvment - reposition or cranial remolding - CVAI 6.25 - 8.75%
4 - severe - 2-3 quads, severe posterior quad flat, mod ear shift, anterior involvement, CVAI 8.75 - 11.0%
5 - very severe - 3-4 quad involved, severe posterior quad flat, severe ear shift, anterior involvement (orbit and cheek asymmetry), CVAI > 11.0%

Question 23

When might a child with plagiocephaly not need the helmet?

Answer 23

when the case is mild
some cases so mild that the child grows out of it.
Level 2 PT probably the same as level 1 PT, if there is any level 1 PT

Question 24

What is recommended for normal to mild cases of plagiocephaly?

Answer 24

positioning

and at all levels, positioning documented for insurance

Question 25

What are the PT goals for Torticollis?

Answer 25

Achieve neutral head/neck alignment in all postures. Cervical ROM WNL. Strength WNL and equal bilaterally of cervical or other muscle weakness noted. Balance and postural reactions WNL. Patient EDUCATION Good muscle balance Both active and passive Address other mm – trunk, etc Head in odd position will interfere with reactions and such – More persistent will affect more, of course

Question 26

What are the PT interventions for Torticollis ? How long?

Answer 26

``` ROM Strengthening Balance and postural reactions Positioning Parent education/HEP ``` Duration: 2 to 6 wks - RX duration for CMT is dependent on degree of restriction and involvement of other systems, such as motor, visual.

Question 27

What are the PT treament principles for Torticollis?

Answer 27

HEP is absolutely key - big parent challenge is adhering to program, understand technique Usual Ther Ex principles - Progress from AROM to gravity resisted as appropriate - Strengthen in positions that are developmentally appropriate - Inhibition techniques - rocking, oscillation... Prevent substitutions Avoid painful stretching Use AROM, simple routine activities, parent/child natural interaction, positioning.

Question 28

describe Tummy Time for | birth to 2 months

Answer 28

If cannot lift head: 1) Place hand on baby’s bottom 2) Start on incline to shift weight caudally away from head. 3) Place towel roll under chest ---------------- Basically helping to shift weight caudally if able to lift head off flat surface If horizontal is too hard, then raise it up a bit. – parent chest, maybe. – chest especially nice because bonding with parent. Comforting to baby. And baby can’t see much else anyway.

Question 29

describe Tummy Time for | 3 to 5 months

Answer 29

Use toys and mirrors to encourage reaching and weight shifting. Eyes at horizon now. _________ More – strength, weight shift. Reaching Put toys in front for reaching Some don’t like the floor if there’s nothing to see. Boppy is helpful but she prefers a more firm surface for arms When a baby is reaching, when they reach with the “good” arm it’s a good challenge for the bad side. Remember “demo” that made no sense.

Question 30

describe Tummy Time for | 6 to 9 months

Answer 30

airplane | Crawling, rolling at this age will help develop symmetrical strength.

Question 31

Parent Education

Answer 31

teach them them muscles or just have them do same exercises on both sides. remember, don't talk down to parents.

Question 32

describe seated positioning for Torticollis

Answer 32

Car seat, high chair, infant seat, other devices Towel rolls or stuffed animals using 3 point system for symmetrical posture hips, trunk head. Place toys on appropriate (tighter) side to increase AROM cervical rotation. When head is off center, the hips will be off center in opposite direction 1st, fix hips. 2nd, fix head.

Question 33

describe the Three-Point System in posititoning

Answer 33

looking for symmetry counter force at hips nothing near face a single force is placed at the area of deformity or angulation; two additional counterforces act in the opposing direction

Question 34

why is it important to keep doing PT exercises while wearing the cranial helmet?

Answer 34

Muscles help remodel bone. | Muscles need to work to help remodel bone.

Question 35

quick - if it is left torticollis, which way to stretch the tight SCM?

Answer 35

rotate left

Question 36

some tips for doing Lateral Neck Stretches

Answer 36

Just by putting the head on your arm, you are stabilizing head. Hold shoulder other hand and can pull a bit Also works from in the lap. Crook of arm – be careful about grading force. Or supine – hold head and pull body So, pull the body instead of the head, actually. Be careful.

Question 37

Taping? Why?

Answer 37

Yes, taping on babies. Because is like "hands on" the patient all the time. will keep the shoulder down will activate neck muscles

Question 38

Name gross motor activities helpful for torticollis at 0-2 months

Answer 38

Supine visual tracking faces or rattle Feeding positioning Sleeping positioning on side with wedges Tummy time - head lift/rotate to auditory or visual stimulation (near-sighted) Pull to sit for symmetrical cervical flexor strength Pretty much just getting them to look at you Primarily they are eating and sleeping. So things that will be done in these positions

Question 39

Name gross motor activities helpful for torticollis at 3-4 months

Answer 39

Supine reach in midline orientation Held upright with trunk support -Vertical suspension for optical righting – suspend vertically when eyes focus on mirror, turn body to rotate neck - Stabilize trunk for ROM exs Tummy time – encourage weight shift/reach Reach prone – head righting more difficult to the uninvolved side Rolling with L torticollis (head rotated r) – place on L side, stabilize head and roll body R from side to supine

Question 40

Name gross motor activities helpful for torticollis at 5-6 months

Answer 40

Rolling to promote lateral neck flexion to the uninvolved side Side propping for lateral neck and shoulder strength Tummy time Supported head/trunk righting on lap or ball Head righting in sit -------------- Less time supine by 6 months. Ball – work on lateral and posterior displacement in sitting. More lateral flexion Rolling – which does use head and neck

Question 41

Name gross motor activities helpful for torticollis at 7-9 months

Answer 41

Increasing strength head, neck and trunk Balance and equilibrium reactions on ball Reaching/head righting in quadruped and standing ------------------------------------------------- Starting to get the balance and equilibrium reactions The therapy ball is pretty great The reactions are good for activating neck muscles.

Question 42

Torticollis Outcomes are what? Which type of torticollis will have these outcomes?

Answer 42

``` Good-Excellent outcomes have been reported with conservative PT intervention. Long term studies show Persistent craniofacial asymmetry Intermittent head tilt with fatigue Small percent with scoliosis No evidence of TMJ or cervical pain --------------- muscular torticollis ```