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

 

Diagnosis—is it essential?

Parents are the first observers of any atypical behavior in their child such as delayed speech, delayed walking, clumsiness, poor feeding, and many more symptoms. In kindergarten or grade school, difficulties are observed in reading and writing abilities. Or simply there is a gut feeling that all is not well with their child. That probably begins their journey with medical examinations, internet searches, and exploring treatment options. 

And they either get puzzled when the child is not provided with a proper diagnosis,  or there is a sigh of relief that there is no diagnosis. Either way, the problem still remains as to why is the child displaying atypical behaviors or struggling in school. 

A qualified physiotherapist, occupational therapist, or a speech therapist would do a detailed assessment of the child in terms of assessing muscle tone, strength, flexibility, motor skills, sensory systems, balance, communication, language, visual-motor skills etc. to detect any deficits that would lead to difficulties that the child is experiencing. Therapy is targeted to reduce these identified difficulties and improve functional abilities. 

Rather than arguing about whether the child is diagnosed or not, getting the symptoms addressed is an option. And earlier the better, since issues can be treated at a better and faster rate until age 7 when the brain is most adaptable to learning.

Peddler in Pediatric Therapy

While working in the sub acute rehabilitation centers in the United States, I had used the peddler for the geriatric population as a means to strengthen the lower extremities. Occupational therapists also used it for upper extremity exercises with the patient in either sitting or standing position. We had separate peddlers for upper and lower extremities for hygiene purposes. (I can still remember when I got yelled at by an occupational therapist because I had taken the UE-marked peddler for LE use, albeit in a rush of time!

Personally, despite the benefits of cycling on a peddler, I viewed it as boring equipment, which I used for my patients on hectic days.  I did not like it much since it needed to be stabilized with weights so that it would not glide while being used. To make it interesting and justify its objectivity, I would tie cuff weights to the patient’s ankles as well as time the minutes of peddling.

Little did I know then, that it would become crucial equipment in my private pediatric practice in India. I purchased peddlers for adult treatments, and ended up using them mostly for children!

During the past 3 years, I came across many preschool children who had difficulty with propelling a tricycle. Not only did they have strength deficits in the lower body, teaching them to pedal at home was a daunting and frustrating task for parents.  All of these children were aged 3 to 5 years with various diagnoses such as autism, sensory processing dysfunction, traumatic brain injury, spastic diplegia and hemiplegia. One child, at the age of 9, was struggling unsuccessfully to pedal his bike through full revolutions. The demands of strength, balance, and coordination of two sides of the body were too overwhelming for these children. Moreover, any effort to pedal caused the bike to move, which further instilled fear in some of the children who were oversensitive to movement. 

That is when I realized that the peddler would be a perfect, stationary solution to start learning alternate and reciprocal movements of the extremities. I had the child sit on a small chair or a regular chair with pillows for support for pedaling with lower extremities. The child would sit cross-legged on the floor or stand while using the peddler with upper extremities.  Doing so, I had to initially help them push, and it did take a number of sessions before the child would be able to propel themselves. Soon I started introducing cuff weights on ankles or arms to provide them with increased proprioceptive input. And most children soon started riding the bike at home.

For children who were still non-ambulatory, the peddler became a useful tool for practicing stepping movements of the lower extremities. The functional changes in strength and balance led to better stance and consequently faster ambulation. For some others, peddling helped correct the in-toeing gait by strengthening the hip external rotators.

The peddler is static, light-weight, easy to move as well as store, and economical to purchase. By practicing on the peddler, I was teaching the children the sensation of alternate-reciprocal movement of the upper / lower extremities that is so crucial for body awareness, bilateral coordination, and facilitating better communication across cerebral hemispheres. Ultimately it led to the skill of cycling that is so essential for any child’s movement, play repertoire, confidence, and self-esteem. 

As a clinician, I learnt another lesson as to how a simple equipment can become valuable in skill attainment for our clients. This is a reminder that we may easily miss out simple strategies already available to us in our quest for sophisticated solutions.

#pedaling #cycling #bilateral coordination #bilateral integration #body awareness #hand cycle