1: Congenital Muscular Torticollis

What is congenital muscular torticollis (CMT)?

postural neck deformity at/after birth → head tilt ipsilateral, rotation contralateral due to unilateral SCM shortening or fibrosis

what settings most commonly sees CMT?

outpatient, community-based, hospitals

incidence of CMT

3.9% (29,30) to 16% of newborns

3rd most common congenital musculoskeletal anomaly after hip dislocation and club foot

CMT

Common comorbidities with CMT?

Cranial deformation, hip dysplasia, brachial plexus injury, club foot/LE abnormalities

what co-morbidities of CMT occur from inter-uterine crowding or positioning?

hip dysplasia or foot/LE abnormalities

Three main types of CMT?

Postural preference: without muscle or PROM restriction

Muscular: tightness and PROM restriction

SCM mass: presence of fibrotic thickening, PROM impairment

How is CMT severity classified?

8 levels based on age, type, and presence/absence of mass

• 1 mild

• 7 severe

• 8 = late treatment > 12mo

Prenatal risk factors for CMT?

High birth length/weight, breech, first pregnancy, multiples

Perinatal risk factors for CMT?

Prolonged/complicated delivery, forceps use

Postnatal/environmental risk factors for CMT?

• supine sleep

• poor tolerance/lack of tummy time

• time in containment devices

• reflux

prognosis of CMT varies based on…

• age of starting intervention

• type

• parent/caregiver compliance

when should you start treatment for CMT? (best prognosis)

< 3-4 months

92-100% achieve full PROM

<1% surgical intervention

Outcomes if CMT treated < 1 month?

99% = excellent clinical outcomes

avg duration = 1.5 months

no head tilt and full ROM rotation bilaterally

Outcomes if CMT treated 1-3 months?

62%

avg duration= 7.2 months

decreasing percentage, increasing average treatment time

Outcomes if CMT treated 6-12 months?

19%

avg duration = 8.9 months

how does CMT affect developmental delays?

in infancy but with follow up testing found to be developmentally on target by preschool

What % of asymmetric head postures may be non-muscular?

18

Serious differential diagnoses for CMT?

Klippel-Feil syndrome, neurologic disorders, brachial plexus injury/clavicle fracture, spinal abnormalities, SCM neoplasms

what is Klippel-Feil syndrome?

infants born with abnormal fusion of at least 2 cervical bones

short neck, low hairline back of neck, restricted movement of upper spine

RARE!!

why is DDX important in CMT?

if not making progress in therapy or sxs don’t exactly fit with CMT diagnosis

components of CMT eval

• Birth, developmental, medical history

• Gastrointestinal screen

• Neurological screen

• Musculoskeletal assessment

• Integumentary screen

• Developmental assessment

• Standardized developmental testing

what do we want to know about birth history?

• Premature, on time, late

• Vaginal delivery vs c-section

• Complications during or after birth?

what do we want to know about medical history?

• other diagnosed issues

• currently being worked up for other medical issues

what do we want to know about developmental history?

• Timeline for meeting developmental milestones

• Parent observation of development

• Parent concerns

what do we want to know about gastrointestinal history?

• parental report of GERD

• how frequently

• is infant distressed after with increased posturing

• if present, refer to PCP for assistance with management

Why is reflux relevant in CMT eval?

Infants may side bend/rotate to close esophagus → mimics or worsens CMT

Key integument finding in CMT?

palpate for presence of a fibrous band or mass in the SCM muscle

assess for skin breakdown and/or irritation on the affected side

mass involving _____ is associated with a greater severity of CMT

> distal 1/3 of the SCM

Neurological screening in CMT should rule out what?

oculomotor deficits (CN IV palsy), hearing screen, coordination, abnormal tone, social-emotional

if a child has a hearing deficit, they are more likely to turn head to one side to improve hearing from _____ ear

NON-AFFECTED

What postural asymmetries may be seen in CMT?

Facial flattening, shoulder elevation, trunk lateral flexion, pelvic rotation

what structures should we focus on during posture screen?

head, face, spine/rib cage, shoulder and hip girdles

what are the Barlow and Ortolani maneuvers?

special tests to identify hip dysplasia

CMT and ____ frequently go together

plagiocephaly

How is cervical rotation ROM measured < 3 months?

test in supine only

use arthrodial protractor, bubble inclinometer, or anatomical landmarks

How is cervical rotation ROM measured > 3 months?

option to repeat measurement in supine

rotating stool test

what is the rotating stool test?

measure cervical rotation in sitting

body supported with visual focus on object maintained while parent/caregiver rotates on stool and observe amount of cervical rotation

How is cervical lateral flexion ROM measured?

SUPINE using protractor/inclinometer, compare head/shoulder alignment

how is resting posture measured?

supine with forward visual focus

how is lateral flexion resting position measured?

Line drawn thru the acromial processes and thru midpoints of both eyes → allows you to measure the angle of side bending

Measure ankle at intersection of the 2 lines

What tool is used for cervical lateral flexion strength in CMT?

Muscle Function Scale (MFS) > 2 months

• Strength of SB/lateral flexion against gravity and hold

• Scale of 0-5

what do we want to test for developmental screening?

Posture, movement, and endurance in all age-appropriate developmental positions and participation in age-appropriate functional mobility

document symmetrical alignment, and preferred positioning or posturing

Standardized CMT test: Through 4 months of age (adjusted)

Test of Infant Motor Proficiency (TIMP)

Standardized CMT test: 1-18 months of age (adjusted) or until ambulatory

Alberta Infant Motor Skills (AIMS)

Standardized CMT test: 1 to 72 months of age

Peabody Developmental Motor Scales 2 (PDMS-2): gross motor section

Standardized CMT test: 3 - 24 months of age

Hammersmith Neurological Examination (HINE)

PT plan of care frequency for CMT?

1:1 weekly/biweekly sessions until the child meets discharge criteria

Discharge criteria for CMT? (5)

• < 5° rotation difference

• no lateral flexion

• symmetrical movement

• age-appropriate developmental skills

• parent understanding of monitoring

When should infants with CMT be re-evaluated after discharge?

3-12 months post-discharge, onset of ambulation, or if torticollis returns, after new gross motor acquisition until 12 months old

Key CMT treatment interventions?

• parent/caregiver education

• stretching (AROM/PROM)

• functional strengthening and stretching in developmentally appropriate positions

• therapeutic activities to facilitate symmetric achievement of motor developmental milestones (play positions)

• environmental adaptations