Congenital muscular torticollis (CMT)
is a congenital deformity of the neck, seen in
a baby as head being turned and / or tilted to one side. There have been 3 sub types of torticollis:
- Tumor in the sternocleidomastoid (SCM) in terms of a
discrete mass palpable in the muscle.
- Muscular torticollis where there is only
tightness of the SCM. but no palpable mass.
- Postural torticollis when there is neither SCM
tightness nor palpable mass.
X-ray will be normal in all 3 subtypes, however,
ultrasound should detect dimensions of
a palpable
mass when present.
Postural torticollis maybe due to one of several reasons
including positioning, congenital absence of a cervical muscle, or tightness of
other neck muscles.
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| Stretching of Right SCM with Gentle Neck Traction |
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| Stretching of Right SCM on a Therapy Ball |
This blog will discuss 4 children with torticollis who were
treated in my clinic in the last couple years.
- A baby boy of 10 weeks presented with a palpable
mass in the right SCM. The mass was detected during the second week after birth
and PT intervention was initiated in the form of neck range of motion (ROM) and positioning. However, parents were concerned about lack of
progress or rather worsening of the neck posture as weeks elapsed. Hence they
approached me for a second opinion.
Treatment was provided in the form of
stretching with gentle neck traction and positioning in the initial few
sessions. Very soon, prone positioning was introduced and parents were provided ongoing instructions
about correct handling of the baby.
Parents started observing changes, the baby
started feeding on both breasts, and neck posture was improved.
- A newborn of 10 days old presented with a small
palpable mass that was resolved within the next 3 weeks of treatment and full
ROM was achieved.
- A 6-months old baby with a
diagnosis of developmental delays presented with asymmetrical posture. He would
only look and turn towards his right. When passively turned towards the left,
he would scream despite apparent full ROM. On visual observation, there seemed
to be hemiparesis of the left side. However, on careful examination, tightness
of the left upper trapezius was revealed. This baby had a postural torticollis
with concordant plagiocephaly.
Again, intervention resolved most of the asymmetry within 10 sessions,
and further treatment was geared towards achieving developmental milestones.
- Another 8-months old baby girl presented with
tilting of the head to the left. The
persistent head tilt was first observed at 4-months of age; mom remembered that
the baby preferred feeding on the right breast during early infancy. Ultrasound
had revealed neither mass nor tightness of the SCM. Developmental milestones were age-appropriate,
inclusive of bringing hands to midline and reaching with the left hand.
On
examination, there was tightness of left upper trapezius and surrounding soft
tissues. Hence a diagnosis of postural torticollis was provided. There was
insignificant plagiocephaly.
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| Active
reaching to the right. |
- The
common factor central to treatment of all these infants was stretching of the
tight neck muscles after gentle manual traction of the neck.
- As
treatment progressed, other treatment components such as prone
positioning, crawling, reaching, and
many other activities were included to develop midline head control and
righting responses on the involved side.
- These
activities were also targeted to prevent neglect of the visual field and the involved
side of the body.
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| Crawling
up a slope while encouraged to rotate head to right. |
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| Encouraging
head control on unstable surface. |
Research
has demonstrated a correlation between severity of restriction in ROM and
treatment duration towards achieving full ROM. Only one of these babies had to
undergo surgical SCM release at 2 years of age since contralateral head tilt
was minimally achieved and the SCM presented as a restricted band despite 5
months of conservative management. Otherwise conservative treatment was
successful for the other 3 children.
The key to success of conservative treatment is
to commence treatment as early as possible. Generally, ROM is achieved fairly
well if treatment begins within 4 months of age. If left untreated, CMT can
result into ipsilateral neglect, disuse of the involved side, cervical
scoliosis, and pelvic obliquity.
Reference:
Campbell , Linden, Palisano (2006);
Physical Therapy for Children, Saunders Elsevier
