Lecture 11: Torticollis and Plagiocephaly

Question 1

What is a fontanelle?

Answer 1

Soft spot

Question 2

When does the anterior fontanelle close?

Answer 2

12-18 months

Question 3

When does the psoterior fontanelle close?

Answer 3

2-3 months

this is a big one. This is where you can see the kid breathing through that soft spot

Question 4

KNOW: once everything closes you can’t change the head shape. However before that you can

When doing the intial examinination:
* Look at craniofacial symmetry
Eye position and tracking
Facial muscular symmetry

Question 5

Etiolog and pathophysiology of cranial deformation

Etiology:
* Intrauterine deformation that worsens post-natally - can be in a position that puts pressure on it
* Postnatal positioning - think lying on one side of head (not getting tummy time)
* cervical muscular imbalance

About 75% of infants wht cranial deformation have SCM imbalance of or congenital msucular torticollis

Incidence of cranial deformation
* Increases until roughly 4 months of age, when infants independently can maintain their head upright - so think, if they’re lying it all day its going to get worse. That prone on elbows 90 degrees of head contorl = 4 months
* decreasing incidence by 2 beacuas someone should’ve found it and corrected it

Question 6

What is plagiocephaly and what pathology / condition causes it?

Answer 6

Comes w/ torticollis

Posterior flatenning on one side, and anterior bossing (head comes out) on the opposite side
* so if it has flattening on R posterior, than theres bossing on L anterior side

Question 7

What is brachycephaly?

Answer 7

When head is shortened and out wider

Thinking more some kind of genetic syndrome
* when tis more symmetrical we start thinking some genetic syndrome

Question 8

What is Dolichocephaly / Scaphocephaly

Answer 8

ears closer head longer

Thinking some kind of genetic syndrome caused
* when its more symmetrical is when we start thinking more genetic syndromes

Question 9

Plagiocephaly

Clinical Presentations:
* Parallelogram shape of the skill
* Ipsilatearl occipital flattening
* Contraltaeral occipital bossing or bulging
* Facial abnormaltities including uneven - think one eye / ears higher. cheekbones, eye sockets, or lower jaw - we don’t measure this as PT’s
* Commonly ssociated w/ Congential msucular torticollis
* Flattened occiput is typically contraltaeral to the tight SCM

So if its a left tight SCM the right side is flattened

Question 10

pt has plagiocephaly. You observe an flattened occiput on the R side. What is likely going on?

Answer 10

L SCM tightness

Flattened occiput is typically contralateral to the tight SCM
* because it does contraltaeral rotation

Question 11

Explain what the cranial vault asymmetry index is and how it’s used
* If its uneven what pathology is likely?

Answer 11

Checks for facial symmetry

Measure in millimeters at 30 degrees from center of nose (outer edge of eyebrow)

Will not need to know formula

Draw that X and see if those lines are equal and make an X. If not equal were thinking the have plagiocephaly (because the other 2 are symmetrical due to having gentic origins)

Question 12

Cranial vault assymetry idnex

If the index is <3.5 everythings within normal limits

Question 13

Cranial remolding orthosis = helmit

Question 14

Probs dont memorize

Question 15

NOTE: when using the cephalic index to measure head size it should be pretty much the same from medial lateral and anterior posterior

Question 16

What would someones cephalic index look like who has brachycephalic?

Answer 16

Would be much longer anterior posterior than medial latearl (remember, the should both be even)

Question 17

How is Brachycephalic treated?

Answer 17

Cranial remolding orthosis

Question 18

Bracycephalic presentation
* Bilatearl forehead bossing or flattening?
* Bilatearl posterior bossing or flattening?

Answer 18

Bilatearl forehead bossing (makes sense their head is longer)

Posterior flattening (so since their forehead protrudes it needs to compensate in the back)

NOTE: Bilatearl protrusion of parietal bone above ears

Question 19

What is a cranial remodeling orthosis?

Answer 19

A non-invasive device used to correct the symmetry of an infants skull

High temperature thermoplastic matearials

Lined w/ high-density, hypoallergenic medical grade foam

Question 20

The FDA requires fitting of the cranial remodeling orthosis within how many days of the initial scan?

Answer 20

14

Question 21

How many hours per day should the cranial remodeling orthosis be worn?
* how often are they adjusted?
* HOw long does treatment last?

Answer 21

23.5

off for bathing and cleaning

Adjusted every 1-2 weeks

Typical treatment time = 2-6 months

You put the helmit on and the head grows into anywhere there is open space

Question 22

What is Craniosynostosis?

Answer 22

The sutures in the head fuse to early
* it makes the helmit not worth wearing unless they go and do surgery to open the sutures back up
* This is a contraidination/precaution

Question 23

Can a baby get a cranial remodeling helmit if they have hydrocephaly?

Answer 23

No, this is a red flag

Must be cleared by doctor

makes sense there is swelling on brain

can do a brain shunt to get rid of fluid and cleared by doctor they can get this

Question 24

Cranial remodeling is contraindicated under _ months old?

Answer 24

under 3 months old = don’t do cranial remodeling
* all more conservative internvetions

Question 25

At what age can the child no longer get cranial remodeling and why?

Answer 25

Can no longer get it over 24 months old becuase the skull is fully fused and no longer pliable

Question 26

NOTE: skin breakdown / lack of sensation are also precautions / contraidincaitions for cranial remodeling

Question 27

notice how the skull will grow toward the direction there is still space

Question 28

Found that the best choice for these kids if there is significant head deformity is the helmit w/ PT If you can't do that than changing their position alone will still help. Meaning that they won't be lying on one side of their head all day.

Question 29

Helmits coereved when they are determined medically necessairy A 2-month trial of conservative therapy consisting of re-positioning the child's head such that the child lies opposite to the preferred position, has failed to improve the deformity and is judhed to be unlikely to do so, and CVAI or CR moderate to severe * so have to not be getting better If only cosmetic it is not covered Medically necessary for infants to correct continued assymmetry following surgery * if their ears are not symmetrical they can't wear glasses = medically necessairy

Question 30

For Medicaid specifically to cover head shit remodeling must start between 4-12 months to be covered

Question 31

Prognosis following for fucked up head shape Full resolution of CD * 77% after parent education in repositioning (for mild cases) * 94-96% after cranial remolding therapy (moderate to severe) Risk factors poor prognosis: * Poor adherence to positioning schedule * Poor adherence to therapy program (home or clinic) * Initiating positioning/therapy intervention after 3 months of age * Persistence of CMT beyond 6 months of age * Developmental delay * Abnormality of tone * Severity of inital CD * Poor adherence with helmet wear * Initiating remodeling intervention after 6 months

Question 32

Associated changes w/ cranial deformation: * An apparent change in the atlas and axis * Progressive anatomical cahnges affecting the upper cervical vertebrae-develop. Around 8 months become more evident in older children * Rotational and bending deformitites most likely - think driving ability * Changes decreased gardually until C7, which appeared to be normal in most * Affects mainly the superior articular facet, the lamina, and the body * Long-standing, untreated congenital muscular torticollis (CMT) can lead to permanent craniofacial deformitites and asymmetry

Question 33

Congenital muscular torticollis = twisted neck Congenital or Acquired characterized by lateral inclination of the head to shoulder and torsion of the neck and deviation of face

Question 34

Right SCM is tight. How is someone w/ torticollis lying

Answer 34

Rotation = left Ipsilatearl flexion to right So they would have difficly w/ right rotation, and difficulty w/ contralateral left flexion **NOTE: Torticollis is named for the side that the SCM is tight on. So this would be defined as right torticollis**

Question 35

Causes of torticollis: - undefined origin Multiple Hypothesis: * Brith trauma/difficult delivery - often impacting first born babies for obvious reasons * Venous compression * Myopathy of the SCM * Fetal Malpositioning * Intrauterine Crowding * Prematurity * Breech - head down curled up Much more common in vaginal deliveries than C sections However, they really don't know why it happens

Question 36

Differential Diagnosis for general msucular Torticollis: * GERD: Sandifer's Syndrome - turn their head when they swallow because it hurts to eat. Ask if the baby spits up loads etc... to rule this out. * Malformation Atlas - fractures here can cause that head position * Inflammitory conditions * Cervical/Clavicular fractures * Ocular Disorders - if baby is not visually tracking - that torticollis can be because they're turning their head to see something ebcause their eyes don't move great * C1/C2 Rotatory Subluxation - would cause that rotary issue sideways Risk factors: * First born x 6 * Multiple Births * Forceps and birth trauma * Long body length * Breech * Hip dislocation - if they have torticollis were gonna check this out as well

Question 37

SCM: Origin: Manubrium and medial portion of the clavicle Insertion: Mastoid proess of the temporal bone, superior nuchal line

Question 38

Clinical Practice Guideline for CMT Congenital muscular torticollis is a postural deformity evident shortly after birth, typically characterized by latearl flexion/side bending of the head to one side and cervical rotation/head turning to the opposite side due to unilatearl shortening of the SCM

Question 39

Question 40

Clinical present of CMT Head tilt to one side * Latearl flexion: head tilt to ear close to shoulder Neck rotation: * Face rotated toward opposite side ROM deficit Age diagnosed * Birth - 12 months

Question 41

CMT is the third most common pediatric diagnosis in infancy * Up to 16% of neonates Early PT is an effective and non-invasive treatment

Question 42

Were getting increased torticollis Hypothesis of why this is true is due to back to sleep campaign * They're missing out on that tummy time

Question 43

Torticollis Impact on Motor Contorl If you don't have symmetrical movement pattern, you're not going to have symmetry down the spine. You need symmetry in order to have stability

Question 44

Infants need prone time to help avoid this condition (not just back to sleep) * Infants learns from experience and practice to content w/ grabity * Practice increases strength and contorl * Consistent sensory input face and oral motor area * Sensory input, practice, experience and environment circumstances lead to the progression of icnreased motor contorl and delicate balance between flexors and extensors * Critical for upright development and postural control

Question 45

so incooportating that tummy time in within everydayactivities. nobody has 2 hours to spend just playing with the baby

Question 46

CPG torticollis * Faster we start the less PT needed * More severe = means it takes longer to fix * #1 thing is to educate on positioning - should happen within 2 days of birth (prone play) - doesnt happen because there are a lot of other things going on * Refer infants with asymmetries in CMT to PT * Document the history of development (think age, age of onset symptoms etc...) * Screen infants for non-muscular causes of asymmetry and conditions associated w/ CMT (think screening for vision, Gi hx, postural preference, structural / movement symmetry) - anything that could be causing that baby to go into that position that isnt actually that tight SCM (because that stuff is treated very differently) - remember reflexes should be symmetrical * Refer infants from PT to physician if indicated by screen (think poor visual tracking, abnormal muscle tone, extra muscular masses, cranial deformation, asymmetry non-consistent w/ CMT, over 7 months of age and SCM mass present) * Requies images and reports (arent great imaging for this) #8 Examine body structure: * cervical PROM/AROM (Arthoridal Protactor) * Active PROM UE/LE * Palpation of SCM (fibrotic mass present, tissue mobility, skin integrity) * Pain * Craniofacial asymmetries * Muscle strength/Function (muscle function scale) * Bilatearl Hip Assessment (barlow / ortalani manuver) * Resting head posture (prone, supine, sitting, standing - if it goes all the way down their spine its proably not torticollis Prone: * Asymmetry of spine/presence of scoliosis * Head and trunk * Use of asymmetrical patterns * Tolerance to position Sitting * Supported/unsupported * Compensations in shoulders, trunk, and hip

Question 47

Line up w/ chink and nose

Question 48

Very specific to torticollis you're going to let go of their head (SLOWLY) and see what happens always check bilatearlly 0 = worst. Won't be able to have contraltaerral head flexion because its held down by the tight SCM

Question 49

What is 0 on the muscle function scale?

Answer 49

Head below horizonral line

Question 50

What is 1 on the muscle function scale?

Answer 50

Head on horizontal line

Question 51

what is a 2 on the muscle function scale?

Answer 51

Slightly over horizontal line

Question 52

What is a 3 on the muscle function scale?

Answer 52

High over horizontal line

Question 53

What is a 4 the muscle function scale?

Answer 53

High above hoirzontal line

Question 54

What is a 5 on the muscle function scale

Answer 54

Very high above horizontal line almost vertical position

Question 55

This is that SCM mass thats common w/ torticollis Looks like a little pea

Question 56

What grade is this: Early mild 0-6 months * postural, muscle tightness * <15 degrees lacking of passive cervical rotation

Answer 56

grade 1

Question 57

What grade is this. Early moderate 0-6 months. * muscle tightness * 15-30 degrees of cervical rotation lacking

Answer 57

Grade 2

Question 58

What grade is this. Early severe 0-6 months * muscle tightness * SCM mass * > 30 degrees of cervical rotation lacking

Answer 58

grade 3

Question 59

What grade is this. Late Mild 7-9 months * Postural, muscle tightness * < 15 degrees of cervical rotation lacking total

Answer 59

Grade 4

Question 60

What grade is this: late moderate 10-12 months * Postural, muscle tightness * < 15 defrees cervical rotation (total)

Answer 60

Grade 5

Question 61

What grade is this: Late severe 7-12 months * muscle tightness * > 15 degrees cervical rotation

Answer 61

Grade 6

Question 62

What grade is this: Late extreme after 7 months * **SCM mass** * > 30 degrees of cervical ROM lacking

Answer 62

Grade 7

Question 63

What grade is this: Very Late: after 12 months * Muscle tightness * > 30 degrees of cervical rotation lacking * Postural muscle tightness or SCM mass

Answer 63

Grade 8 (proposed)

Question 64

How often you're seeing the pt depends on the below

Question 65

part of CPG

Question 66

Question 67

Something w/ torticollis is that they might score higher on standarized test because that tightness makes it look like they have head control when they really dont.

Question 68

Prone positioning while awake for grater than 1 cumulative hour per day, with no minimum amount of time per opportunity, appears to offset the transient effects of supine sleep positions on motor skill acquisition * **So they need an hour of tummy time per day** - does not have to be straight PT should document the amount of time the infant spends in positioning equipment as reported by parents (i.e., positioningseating decives, strollers, car etc...)

Question 69

#12 of CPG Prognoses for the extent of symptom resolution * Age of intiation of treatment * Classification of severity * Intensity of intervention * Presence of comorbidities * Rate of change * Adherence to HEP

Question 70

#13 of CPG: Five components of first choice internvetions (what you should do first) Environmental adaptations * Crib position * Caregiver position - don't always put them in the same position in the crib * Changing Table Position - how to hold your child - don't always hold them on your L side, switch back and forth Parent/Caregiver Education * Print out * Hands on demonstration * Teach back method - explain to parent and amke them repeat back Neck PROM * Myofascial work - soft tissue * Calm tissue elongation - doesnt take much * Mannual soft tissue work Neck and Trunk AROM * Prone play * Supported sitting * Isolated Chin Tucks Development of Symmetrical Movement * Use a mirror * Concentrate on midline positions **Stretching 1 rep x 30 seconds, 4x/day, 7 days/week** * however more stretching is ALWAYS better, so can go above this

Question 71

#14 on CPG - Supplemental Interventions Microcurrent * Improved tilt, neck rotation immediately Kinesiological taping * no good evidence No evidence w/ * cervical manipulation * Craniosacral * Topcollars * Fledenkaris

Question 72

#15 on CPG - refer consultation when outcomes are not fully achievd * Rehabiliation Medicine * Oral maxio Fascial Specialist * Neurosurgery * Plastic Surgery * Botox interventions * * Assess plagiocephaly * Differentaite diagnosis * Surgery

Question 73

#16 of CPG - discontinue direct services when these 5 criteria are achieved 1) The CMT has resolved within accepted ranges of measurement error 2) There is no lignering seconary compensations of developmental delys 3) The parent/cargivers know how to assess for regression as the infant grows and when to contact their infants physician and/or the PT for reassessment 4) Discontinuation documentation reflects the expected outcomes for the episode of care, realtive to the baseline measures taken at the initial examination

Question 74