Lecture 10 (CMT & Plagio)

What is torticollis?

• How does it present?

• A Posture, Not A Diagnosis

  • IPSI LAT FLX & CONT ROT

How many torticollis patients are non-muscular?

• 1 in 5 Children

What are the types of torticollis?

• Acquired

  • Traumatic (3)

  • Non-Traumatic (6)

• Congenital (CMT)

  • Postural (1)

  • Muscular (1)

  • SCM Nodule (1)

What are the 3 Traumatic Acquired Torticollis?

1. Soft Tissue Injury

2. Cervical or Clavicle Fx

3. C1-C2 Rotary Subluxation

What are the 6 Non-Traumatic Acquired Torticollis?

• Which of these will tend to resolve on its own?

1. Inflammatory MSK Conditions

   1. Juvenile RA, Tonsilitis, & Mastoiditis

2. Oculomotor Weakness / Ocular Lesions

   1. Superior Oblique Palsy, Congenital Nystagmus, & Diplopia

3. Neurologic Cases (10% Of Non-Muscular)

   1. Tumors, Chiari, & Syringomyelia

4. Bony Deformities

   1. C/S Fusion & Hemivertebrae

5. “Sandifer Syndrome” - GI Linked

   1. Paired w/ Hiatal Hernia & Gastric Reflux

6. Benign Paroxysmal Torticollis

   1. Paired w/ Vomiting, Ataxia, & Seizures

   2. Resolved In 3-5 Days w/o Tx

What is Postural CMT?

• How does it present?

• How severe is this?

• Unilateral SCM Tightness

  • AROM Tight, PROM Not

    • Mild Severity

What is Muscular CMT?

• How does it present?

• How severe is this?

• Unilateral SCM Fibrosis

  • AROM & PROM Tight

    • Moderate Severity

What is SCM Nodule CMT?

• How does it present?

• How severe is this?

• Unilateral SCM Fibrotic Node

  • AROM & PROM Tight

    • Highest Severity

How is SCM Nodule CMT classified?

• When does it typically appear by?

• Classified Using US

  • By: 2-3 Weeks Old

What is the incidence of CMT?

• 0.3 - 16% of Live Births in USA

  • 3rd Most Common Congenital Anomaly

What are the causes of CMT?

• Prenatal

  • Icshemic Injuries To SCM

  • Intrauterine Cramping

  • Muscle Rupture

• Perinatal

  • Birth Trauma (Breech?)

What are common accompanying diagnoses of CMT?

• Congenital Hip Dysplasia

• Clubfoot

• Metatarsus Adductus

• Brachial Plexus Injuries

What are the 8 CMT Severity Classifications?

• At what age do they typically present?

• How does muscle tightness present?

1. Early Mild

   • Postural Preference (<6 Months)

   • OR Ms Tightness <15º (<6 Months)

2. Early Moderate

   • Ms Tightness 15-30º (<6 Months)

3. Early Severe

   • SCM Mass (<6 Months)

   • OR Ms Tightness >30º (<6 Months)

4. Late Mild

   • Postural Preference (7-9 Months)

   • OR <15º Ms Tightness (7-9 Months)

5. Late Moderate

   • Postural Preference (10-12 Months)

   • OR <15º Ms Tightness (10-12 Months)

6. Late Severe

   • >15º Ms Tightness (7-12 Months)

   • AND 15-30º Ms Tightness (10-12 Months)

7. Late Extreme

   • SCM Mass (7-12 Months)

   • AND >30º Ms Tightness (10-12 Months)

8. Very Late

   • ANY Of The Above (> 1 Year)

What is the standard duration of CMT intervention?

• Minimum → 1.5 Months

• Maximum → 4-6 Monnths

What can occur if CMT is failed to be treated?

• Persistent Neck Tilt (Eyes Not Level)

• C/S v T/S Scoliosis (Eyes Now Level)

• Structural Deformities:

  • “CD” - Skull Flattening

  • Mandibular Asymmetry

  • Orbital Fissure Asymmetry

  • Feeding Problems

• Motor Skill Impairments

  • Ex) Head & Body Must Turn Together

What are recommended GM Tests for CMT?

• If <4 Months → Use TIMP

• If 4-12 Months → Use AIMS

• If >12 Months → Use PDMS

What are recommended Strength Tests for CMT?

• <2 Months → Not Indicated

• >2 Months → MFS

What are recommended PROM Tests for CMT?

• Any Age → Arthrodial Protractor

• Any Age → Goniometer / Inclo

What are recommended AROM Tests for CMT?

• <3 Months → Arthrodial Protractor

• >3 Months → Seated Swivel Test

What positions are recommended for CMT ROM?

• <4 Months → Supine

• >4 Months → Seated

What is normal PROM for those <1 year?

• LAT FLX - 70º

• ROT - 110º

Using visual estimates for resting lateral flexion, what do different landmarks indicate?

• Chin to Nipple → 40º

• Chin To Armpit → 70º

• Chin To Shoulder → 90º

• Chin Over Shoulder → 100º

What is MFS Testing Protocol?

• Infant’s Held Horizontally → No Head Support

  • Grading Per Position: Must Be >5 Seconds

What are MFS Grades?

0. Head Below Horizontal

1. Head At Horizontal

2. Head Slightly Above Horizontal

3. Head Far Above Horizontal, But <45º

4. Head Far Above Horizontal, And >45º

5. Head Very Far Above Horizontal, Near Vertical

What are MFS Norms?

• At 2 Months → MFS 1

• At 10 Months → MFS 3-4

What MFS scores are seen in CMT?

• 2-3 Point Difference Between Sides

  • Involved Side Should Be Higher

How do postural reactions change with CMT?

• Decreased: Righting Rxns

• Decreased: Protective Rxns

• Diminished: Equilibrium Rxns

What is average tx time for CMT?

• If <3 Months At Start OR Mild CMT:

  • Tx: 1.5 - 3 Months

• If >3 Months At Start OR Mod-Sev CMT:

  • Tx: 3 - 6 Months

• If >6 Months At Start (Any Severity):

  • Tx: >6 Months

What determines “good” vs “excellent” prognosis for CMT?

• Assuming PT Starts In <1 Year:

  • “Good” → < 50º PROM Asymmetry

  • “Excellent” → < 10º PROM Asymmetry

During CMT tx, what is considered to be a “natural” pattern?

• What can this phenomenon be attributed to?

• Alternating Progression / Regression

  • Due To: Growth Spurts, Teething, v Illness

What does the CPG suggest for CMT tx?

1. Neck & Trunk AROM / PROM (When Limited)

2. Motor Control (Midline Symmetry & Milestones)

3. Environmental Adaptations

4. Patient / Caregiver Education

What are the 3 Steps for effective CMT tx?

• What are main tips for each one?

1. Stretching (HEP)

   • Low Intensity, Sustained, & Pain Free

   • Desensitize Neck w/ Heat & Massage

   • Generally: Stretch Every Diaper Change

2. Position & Strength

   • Could Do Tummy Time / Crawling

   • Examine & Adjust Seat Positions

   • Use Theratogs For Symmetry

3. Posture & Motor

   • Begin Upright Control At 4 Months

   • Focus On Age-Based Milestones

What are contraindications for CMT stretching?

• Down Syndrome

• Spina Bifida

• Spinal Cord Abnormalities

• Circulatory Abnormalities

When are we allowed to discontinue tx for CMT?

• Only When All Are Met:

  • C/S PROM <5º Difference

  • Symmetrical Active Mvmt

  • Age-Appropriate Motor Skills

  • No Visible Head Tilt

  • CG Understands What To Monitor

When are we allowed to discharge tx for CMT?

• 3-12 Months After Discontinuation v When Walking

When is any non-conservative tx for CMT indicated?

• Infants Not Progressing After 6 Months Of Conservative PT

OR

• Children > 1 Year & Grade 7 Severity

When is surgical SCM lengthening indicated?

• How long does PT take afterwards?

• General Rules & >15º Residual Tightness

  • Post-PT: 4 Weeks - 10 Months

What is Craniosynostosis vs Cranial Deformation (CD)?

• What is frequency associated with each?

• Craniosynostosis - Rare

  • Premature Closure Of ≥1 Cranial Sutures

• Cranial Deformation - 1 in 3

  • Shape Changes Due To External Stressors

What are common risk factors of CD?

• CMT

• Intrauterine Contraints (Commonly 1st Born)

• Males (3x) > Females

• Supine Sleeping w/ Unilateral Pressure

What are the three types of CD?

• Plagiocephaly (Asymmetry)

• Brachycephaly (Wide Head)

• Scaphocephaly (Long Head)

How is CI Deformation measured?

• What is the average value of it?

• Cephalic Index = (Head Breadth / Head Length) x 100

  • Mean CI (Depending On Age & Gender) → 79% - 84%

What are the Plagiocephaly Grades?

Argenta Classification

• 1 - Normal Head Shape

  • 1 Quadrant Impacted

  • Mild Posterior Flattening

• 2 - Mild Deformity

  • 2 Quadrants Impacted

  • “1” + IPSI Anterior Ear Shift

• 3 - Moderate Deformity

  • 2 Quadrants Impacted

  • “2” + IPSI Forehead Prominence

• 4 - Severe Deformity

  • 2 Quadrants Impacted

  • “3” + Face-Jaw Asymmetry

• 5 - Very Severe Deformity

  • ≥ 3 Quadrants Impacted

  • “4” + Vertical / Temporal

What are the Brachycephaly grades?

Argenta Classification

• 1 - Mild Deformity

  • Central Posterior Flattening

• 2 - Moderate Deformity

  • “1” + Posterior Widening

• 3 - Severe Deformity

  • “3” + Vertical / Temporal

What are Scaphocephaly risk factors?

• Premature <32 Weeks

• After NICU Malpositioning

• Paired w/ Craniosynostosis

What are possible adverse effects of non-resolved plagiocephaly?

• Permanent Cranial-Facial Asymmetry

• Auditory & Visual Processing Disorders

• Neurodevelopmental Delays

What are preferred tx options for CD deformities?

• If < 4 Months AND Min-Mod →

  • Parent Education

  • Repositioning

  • Exercises

• If > 4 Months OR Mod-Sev →

  • Cranial Banding

  • Helmets

• If Craniosynostosis OR >2 Yrs Old →

  • Surgery

What does parent education entail for CD deformities?

• Increase Supervised Tummy Time

• Shifting Infant Off Of Flattened Areas

• Alternate Head Position During Sleep

• Avoid Excess Use Of Car Seats & Swings

When are Cranial Banding / Helmets recommended for referral?

• 4 Months → If Severe

• 6 Months → If Moderate

When are Cranial Banding / Helmets indicated?

• Babies 4-18 Months w/ Mod-Sev Deformity

• No / Poor Response To Repositioning

• Persistent v Secondary Changes

When are Cranial Banding / Helmets contraindicated?

• Babies <4 Months

• Babies >18 Months

• Concurrent Hydrocephalus

• Concurrent Craniosynostosis

What is the difference between cranial banding and helmets?

• Banding → Mild Corrective Postures

• Helmets → Severe Corrective Postures

How are cranial bands and helmets properly fitted?

• Using Digital Surface Imaging

When picking out cranial bands and helmets, what criteria must it hit?

• FDA Approved

• Can Work Well w/ Kids

• Can Demonstrate Safety / Success

What are DOC Band benefits (compared to others)?

• Very Lightweight (6 oz)

• Custom Fitting

What are DOC Band tx protocols?

• Worn 23 Hours / Day Over 2 - 4 Months

What measurements are taken before and after DOC Band use?

• Anthropometric Measurements

• Clinical Photography