Torticollis

Question 1

What is CMT?

Answer 1

Congenital Muscular torticollis. Postural deformity evident shortly after birth.

Question 2

What causes CMT?

Answer 2

Unilateral shortening of the SCM characterized by IL side flexion, and opp rotation

Question 3

What side is the CMT name by?

Answer 3

For the side of the tightness.

Question 4

What is the prevalence of CMT?

Answer 4

3rd most common congenital MSK condition.

Male > Female

Question 5

What do children with CMT have trouble developing?

Answer 5

Vision and midline motor activities.

Question 6

What is CMT associated with 80-90% of the time?

Answer 6

Plagiocephaly

Question 7

What is plagiocephaly?

Answer 7

Defined as slanting/flattening of the head. Occipital asymmetry.

Question 8

What are some other skull characteristics you may see with plagiocephaly?

Answer 8

IL ear positioned anterior or inferior
Frontal bossing
Facial asymmetry
Temporal bossing
Posterior vertical cranial growth

Question 9

Causes of plagiocephaly

Answer 9

Uterine constraint due to multiple births
Assisted delivery with forceps or vacuum
Premature birth
Prolonged Labor
Inadequate tummy time
Nonvarying nursing/bottle feeding habits
Developmental Delay
Torticollis

Question 10

Resolution of Plagiocephaly

Answer 10

Many head deformities resolve during the first few months of life if the infants head is frequently repositioned.
Can get worse over time
If significant at 4 mo helmeting may be needed

Question 11

Concepts for positioning for play

Answer 11

Limit time in devices where head is resting on hard devices
Alternate infant position in the crib with head at either end
Promote tummy time!

Question 12

What does helmet therapy do?

Answer 12

Redirect growth

Improve symmetry of cranial vault cranial base and face.

Question 13

Etiology of CMT at birth

Answer 13

Due to constraint during last few weeks of gestation

Question 14

What is fibroma in CMT?

Answer 14

Pseudotumor of infancy. Develops at 2-3 weeks of life resolves by 4-6 mo. Painless and in middle to lower 1/3 of the sternal portion of SCM.

Question 15

What are the two categories of torticollis?

Answer 15

Acquired and Congenital (Acquired is subdivided into traumatic and atraumatic)

Question 16

What disorders/conditions are associates with acquired non-traumatic torticollis?

Answer 16

Occular conditions, orthopedic abnormalities, sandifer syndrome, klippel-feil syndrome, Benign paroxysmal torticollis, infections conditions, neurologic syndromes.

Question 17

Occular torticollis

Answer 17

Infant may tilt head to correct vision d/t visual impairment.

Question 18

Potential impairments causing occular torticollis

Answer 18

Strabismus
Nystagmus
Inconsistent visual tracking
Gaze aversion
Typically due to unilateral superior oblique muscle weakness

Question 19

What orthopedic abnormalities can it result in?

Answer 19

Can result in scoliosis

Question 20

Sandifer syndrome

Answer 20

Onset in infancy/early childhood (18-36 mo peak)
Spasmodic neck dystonia with arching of the back and posturing of the neck back and UE.
May look like a seizure
GER or hiatal hernia
Severe hypotonia may be noted

Question 21

Klippel-Feil Syndrome

Answer 21

Genetic
congenital fusion of C2-C7
Webbed short neck, low hairline
abnormalities of head/face/sex organs, muscles extremities and heart

Question 22

Benign paroxysmal torticollis

Answer 22

Tort posture but involved side switches. Resolves around 2-3 y.o. Can be assoc with nausea vomiting ataxia, irritability and drowsiness. Migranes.

Question 23

Comorbid conditions.

Answer 23

Hip dysplasia (+ on side of torticollis)
Club foot
Metatarsus adductus
Brachial plexus injury

Question 24

Types of torticollis

Answer 24

SCM tumor/fibrotic nodule
Muscular torticollis (tightness/thickening of muscle may have fibrotic band)
Postural torticollis (without tumor or tightness)

Question 25

Normal CROM to 12 mo

Answer 25

``` Rot: 100 deg Lateral Flex: 70 deg Extension: 45 Cervical Flex: 45 Capital Flex: 10 ```

Question 26

How many severities of torticollis are there?

Answer 26

Seven

Question 27

Stratification of CMT

Answer 27

Age at initiation of Tx, type, amount of PROM tightness

Question 28

What is early tort? late?

Answer 28

Early: 0-6 mo Late: 7-12

Question 29

what are the rotation limitation severities?

Answer 29

mild: 30

Question 30

deficits on UE IL side

Answer 30

decreased reaching toward midline with forearm supination shoulder ER, and or flexion, decreased crossing midline during reaching, decreased development of protective extension reaction

Question 31

Trunk/LE asymmetry

Answer 31

``` c surve or s curve in spine, with IL leg: decreased kicking/hands to feet Asym LE position in sitting Tripod position during creeping Asym in supported standing and sitting ```

Question 32

Sequela of postural abnormalities

Answer 32

Neglect of IL hand, decreased awareness of IL visual field Decrease symmetry in development of head righting, uneven WB, delayed gross motor skills, incomplete devel of automatic balance reactions

Question 33

Other muscle involvement in tort

Answer 33

``` SCM Upper trap Scalenes Platysma Lev Scap Suboccipitals Neck extensors Muscles of mastication, UE, Trunk LE ```

Question 34

CMT evaluation: general history

Answer 34

Pregnancy: complications/bed rest/decreased amniotic fluid Delivery: full term?, method, length/weight at birth, presence os skull or facial asymmetry at birth, birth order Current health: prone play tolerance, preferred sleep position, feeding/GI, refulx ,feeding pos. Devices: how long, which ones

Question 35

CMT evaluation: torticollis history

Answer 35

``` When was tort first noticed? Has it changed since initially noticed? Sudden onset? Testing? Hx of treatment to date ```

Question 36

CMT systems review

Answer 36

Vision screen (midline visual focus, tracking, eyes moving together) Hearing Screen Neuro Screen (ATNR should be int. by 4-5 mo), presence of sustained clonus, muscle tone Pain Screen: NIPS, FLACC Integument screen: folds, redness

Question 37

Muscle function scale for lateral righting

Answer 37

infants of 2 mo had med score of 1 inc to 3-4 by 10 mo. Don't use in infants

Question 38

Tests for hip dysplasia

Answer 38

Barlow/Ortilani Galleazi: (+) leg/knee lower on side of dislocation (hooklying) Thigh/gluteal folds: asymmetry on side of dislocation Hip Abduction

Question 39

FIrst choice of treatment

Answer 39

``` Neck PROM Neck and Trunk AROM (strengthening) Development of symmetrical movement Environmental adaptations/positioning Parent/caregiver education ```

Question 40

Positioning techniques

Answer 40

Nesting & Prone towel rolls with functional activities.

Question 41

Stretching protocol for torticollis

Answer 41

``` Daily basis (at least 3x/day up to 6-8x/day) Low load sustained stretches recommended 10-30 sec up to 2 min Hand placement is important (stabilize shoulder/trunk, support infant & prevent compensations) ```

Question 42

Strengthening techniques

Answer 42

``` tummy time active rotation prone and sitting active flexion (work on symmetry) Rolling Lateral flexion head righting ```

Question 43

When is medical management recommended

Answer 43

lack of progress after 6 mo conservative treatment or child begins PT after i eyar of age and has significant restrictions or mass. (Botox, surgical release)

Question 44

Surgery indications

Answer 44

Not responding after 6 mo Approaching 1 yr with no resolution Deficits of PROM rotation and lateral flexion > 15 degrees Tight fibrotic muscular band or tumor