Torticollis

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:

1. Tumor in the sternocleidomastoid (SCM) in terms of a discrete mass  palpable in the muscle.
2. Muscular torticollis where there is only tightness of the SCM. but no palpable mass.
3. 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.

Stretching of Right SCM with Gentle Neck Traction

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.

1. 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. 
2. 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.
3. 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.
4. 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.

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.

Crawling up a slope while encouraged to rotate head to right.

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