Chapter 27 Congenital Muscular Torticollis
Differential Diagnosis
• Medical differential diagnosis is important to rule out other causative factors of positional head/neck asymmetry.
• Other causative factors, such as viral infection, muscular strain, postnatal trauma (clavicular fracture), congenital anomalies of the base of the skull, congenital anomalies of the upper cervical spine, ocular pathology, imbalance of the extraocular muscles, rotary subluxation of the atlantoaxial joints (following URI), tumor of the posterior fossa, brain stem, or cervical spinal cord, all need to be ruled out as the cause of the presenting neck asymmetry.
• Neurologic evaluation may be required to rule out an underlying neurological cause, especially in the event of sudden onset torticollis in the infant.
• Evidence shows that a thorough clinical examination is necessary to assist in differential diagnosis as it relates to CMT.
Rehabilitation Overview
Primary Impairments
• The baby postures with a lateral tilt toward the involved side and rotation away from the tight SCM.
• There is limited passive range of motion (PROM) into lateral flexion toward the uninvolved side and decreased rotation toward the involved side.
Secondary Impairments
• Plagiocephaly and facial deformity are also encountered in babies with CMT. This involves flattening on the posterior lateral portion of the skull on the uninvolved side because of the child’s positioning in supine; associated facial deformities include posterior displacement of the ear on the same side of the involved SCM, posterior recession of the same side eyebrow and forehead, and the tip of the chin skewed toward the involved side.
• Muscle shortening, which includes tightness in secondary muscle(s) such as the platysma, scalene muscles, trapezius muscles, cervical extensors, pectoral muscles, as well as limitation of scapulohumeral ROM and trunk flexibility may exist. Shoulder elevation and protraction on the involved side may also be present.
• Developmental delays can also be found in babies with CMT.
2 Weakness in the ipsilateral trunk and scapular musculature due to the decreased active and controlled weight-bearing to and on that side may also be present.
3 Delays or asymmetrical movement patterns can develop, which include delayed rolling or rolling toward/over the unaffected side only, decreased weight-bearing and/or use of the arm on the involved side (prone prop and reaching), in sitting asymmetrical weight-bearing that fosters lateral flexion to the involved side, delayed creeping, pull to stand, and ambulation.
Treatment Guidelines
• At HSS, infants are seen for physical therapy intervention two to three times per week for 30 to 45 minute-sessions, depending on the severity of the CMT and the child’s tolerance to therapeutic intervention.
• A HEP is recommended to be performed a minimum of four to five times per day or at every diaper change.
• During the initial evaluation, the parent and/or caregiver should be instructed in a home stretching program of lateral flexion toward the uninvolved side and rotation toward the involved side, to be performed at a minimum of four to five times per day.
• Positioning is also an important adjunct to therapy, and family/caregivers should be educated in ways to position the infant, hold/carry the infant, and play/stimulate the infant in ways that encourage rotation toward the involved side and lateral flexion away from the involved side as well as midline orientation.
• Supervised time spent in prone is important for the development of symmetrical neck extension and upper extremity weight-bearing.
• Active neck ROM can also be encouraged through positioning of toys, positioning during feeding, and varying the carrying position.
Precautions
• Infants cry to express themselves; they will cry if they are experiencing negative symptoms associated with stretching, such as pain, numbness, or burning; they will also cry if they are afraid, tired, or hungry.
• The therapist should develop a sense of the infant’s personality and his or her tolerance for stretching and exercise. Performing gentle stretching and constantly monitoring the baby for signs of discomfort or distress throughout the treatment session are extremely important.
• While passively stretching the SCM into lateral flexion, the neck must be kept in a neutral position within both the sagittal and transverse planes.
Recommendations
• The therapist should take time to develop a rapport with the infant and to gain the infant’s trust through interaction and play before initiating stretching.
• Stretching can typically be accomplished without eliciting crying if the therapist is gentle and can develop strategies to distract the infant, such as using singing and/or sensory stimulating and age-appropriate toys during treatment.
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