Congenital

Muscular
Torticollis
CMT
B Y : D R . Z A K I R U K ( D P T, MS P T, K M U )
E D I T E D B Y: S A B A R J A M I L A & S A B A R M I N A
What is torticollis?
Word is derived from Latin
Tortuous means twisted + collis means
neck or collar
Abnormal turning or bending of the
neck
 Congenital Muscular Torticollis
CMT
DEFINATION:
Congenital muscular torticollis (CMT) describes How to name
the posture of head and neck from shortening of the side of neck
SCM muscle causing the head to tilt toward and involve?
rotate away from the affected SCM. It is named for
the side of the
In addition to rotation and tilting, the infant involved SCM
may exhibit asymmetric neck extension and a muscle
forward head posture due to upper cervical
extension
Characteristics
of torticollis
head
It is characterized by a
lateral head tilt toward and
chin rotation away from the
involved side.
Fig. illustrates a right CMT
with head tilt to the right
and rotation of the chin to
the left secondary to a tight
right SCM
 Normal Anatomy
of SCM
Origin Manubrium and medial portion of
the clavicle

Insertion Mastoid process of the temporal

bone, superior nuchal line

Artery Occipital artery and the superior

thyroid artery

Nerve Motor: spinal accessory nerve ·

sensory: cervical plexus · C2-3 provides
sensation

Actions Unilaterally: contralateral cervical

rotation, ipsilateral cervical flexion
Bilaterally: cervical flexion, elevation of
sternum and assists in forced inhalation
 Other complications
There are many other developmental conditions that are
associated with CMT.
Plagiocephaly is the most common (90% occurrence rate with
CMT) followed by hip dysplasia, club foot deformity, cervical
scoliosis, bowed legs, visual disturbances, unlevel pelvis and
retained primitive reflexes
 DDH has a varied coexistence rate with CMT of 0-20% and is
also observed with plagiocephaly
What is CD?
CD stands for Cranial deformation
CD is a distortion of the shape of the skull resulting from
mechanical forces that occur pre- or postnatally.
It is defined as cranial asymmetry resulting from
premature closure of one or more of the cranial sutures.
CD is a coexisting impairment in up to 90.1%26 of
infants with CMT and increases the risk of facial, ear,
and mandibular asymmetry.
 Prevalence
Reports of CMT incidence vary from 0.3% to 16% of newborns.
 It is the third most common congenital musculoskeletal condition after hip
dislocation and clubfoot.
Synonyms
for CMT
include
bromatosis
colli, wry
neck, or
twisted neck
 Etiology
Direct injury to muscle
Ischemic injury based on abnormal vascular patterns
Rupture of muscle
Infective myositis
Neurogenic injury
Hereditary factors
Intrauterine malpositioning
Birth trauma: position of the head and neck in uterus or during labour and delivery of forward
flexion, lat bending and rotation may cause a compression injury of ipsilateral SCM muscle and
brachial plexus, resulting in ischemia, reperfusion & edema)
 Pathophysiology
Infants with CMT present with unilateral tightness of the SCM, a possible mass or
nodule in the muscle and may also have ipsilateral restrictions or tightness of the
upper trapezius muscle.
The trapezius is a synergist of the ipsilateral SCM muscle for lateral head tilt, and it
elevates the scapula.
Histologic tissue changes of the SCM in infants with CMT include excessive fibrosis,
hyperplasia, and atrophy
In some infants a palpable nodule may be present in the SCM as early as 2–3 weeks
both the degree of fibrotic changes and the location of the nodule are associated with
the prognosis for resolution.
Do You Know?
Nodules in the lower one third of the SCM are most likely to
resolve with conservative stretching as compared to nodules that
occupy the middle one third or both the lower and middle one
third, and those that occupy the length of the SCM are the most
recalcitrant
 Potential Body Structure and Function, Activity, and
Participation Limitations of CMT
Body Structure and Function Activity Limitations Participation Restrictions
Limitations
Presence of tight band or nodule in Restricted neck motion Prefers bottle feeding to one side
SCM Positional preference and or difficulty breast feeding
SCM, cervical, or upper trapezius decreased tolerance to prone equally on both sides
ROM tightness positioning
SCM, cervical, or upper trapezius Asymmetrical propping on upper Reduced tolerance of prone
weakness extremities positions for play
Asymmetrical postures in all symmetrical movements and Possible delays in development
positions transitions: rolling, sitting,
quadruped, kneel, one-half kneel,
and standing
Possible hip dysplasia, Red and Resistance to stretching that Difficulty cleaning infant’s neck
irritated skinfolds increases with head control
Cervical and thoracic scoliosis
 Grades of CMT severity
Grade Defination

Grade 1: Early Mild These infants present between 0 and 6 months of age with only postural
preference or muscle tightness of less than 15° of cervical rotation.
Grade 2: Early These infants present between 0 and 6 months of age with muscle tightness of
Moderate 15° to 30° of cervical rotation.
Grade 3: Early These infants present between 0 and 6 months of age with muscle tightness of
Severe more than 30° of cervical rotation or an SCM nodule.
Grade 4: Late Mild These infants present between 7 and 9 months of age with only postural
preference or muscle tightness of less than 15° of cervical rotation
Grade 5: Late These infants present between 10 and 12 months of age with only postural or
Moderate muscle tightness of less than 15° of cervical rotation.
Grade 6: Late These infants present between 7 and 12 months of age with muscle tightness of
Severe more than 15° of cervical rotation.
Grade 7: Late These infants present after 7 months of age with an SCM nodule or after 12
Extreme months of age with muscle tightness of more than 30° of cervical rotation.
 Physical therapy examination
The nine health history factors include items that are known to be associated with CMT
and/or are typically included in a physical therapy history. They are:
1. Age at initial visit because this assists with assigning a severity grade and determining
a prognosis for the episode of care.
2. Age of onset of symptoms because this assists with distinguishing between acquired
torticollis and CMT and with determining a prognosis for the episode of care.
3. Pregnancy history, including maternal sense of whether the infant was “stuck” in one
position during the final 6 weeks of pregnancy because this assists with identifying
factors associated with CMT and CD
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4) Delivery history including birth presentation (cephalic or breech) or multiple births because
this assists with understanding possible causes of CMT
5) Use of assistance during delivery such as forceps or vacuum suction because these methods
may be a cause of CMT if the SCM was strained during delivery.
6) Head posture/preference and changes in the head/face because these asymmetries are classic
presentations of CMT and possible CD.
7) Family history of torticollis or any other congenital or developmental conditions because
there may be a genetic component to the condition.
8) Other known or suspected medical conditions because they may be a cause of asymmetries.
9) Developmental milestones appropriate for age because delays may signal other contributing
factors to asymmetries or may be a consequence of CMT
 Screening and Differential Diagnosis for
CMT
Infants with suspected CMT require a thorough history and screening for neurologic,
musculoskeletal, visual, gastrointestinal, integumentary, and cardiopulmonary integrity
Neurologic cause:
Neurologic causes of asymmetrical posturing include brachial plexus injuries, central
nervous system (CNS) lesions, astrocytoma's, brain stem or cerebellar gliomas, agenesis
of CNS structures, and hearing deficits.
Screen for the red Flags: abnormal or asymmetrical tone, retention of primitive reflexes,
resistance to movement, cranial nerve integrity, brachial plexus injury, and pain signals
during movement; a neurologic consult may be appropriate
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Musculoskeletal conditions
Musculoskeletal conditions that mimic CMT include Klippel-Feil syndrome (fusion of
cervical vertebrae), clavicle fracture, congenital scoliosis, or C1-C2 rotary subluxation.
Screen for the asymmetry of the face, neck, spine, and hips, asymmetrical passive neck
rotation, the presence of masses in the SCM
Red Flags include: atypical positions, such as right cervical rotation with a right lateral
Flexion, asymmetrical cervical vertebrae on palpation, acute pain responses on cervical
movement, tissue masses outside of the SCM or in other areas of the body, children with
Down syndrome, C1-C2 cervical spine instability, and late onset of a head tilt with known
symmetry for the first few months of life;
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Visual conditions
It may cause asymmetrical posturing as the infant attempts to
stabilize his or her focus and include ocular apraxia, strabismus,
ocular muscle imbalances, and nystagmus.
Screen for the asymmetrical and discoordinated visual tracking in any
direction or clinician inability to distinguish between limitations due
to ocular control versus neck rotation
Continue…
Gastrointestinal conditions
Gastrointestinal conditions include Sandifer syndrome, a hiatal hernia with
gastroesophageal reflux that typically causes trunk arching and neck flexion to the
right following eating, a history of reflux or constipation, and easier or preferred
feeding to one side.
screen for the following red ag: curvature or arching of the trunk and head turning as
a means of extending away from the esophagus, usually accompanied by crying; a
gastrointestinal consult may be appropriate
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Integumentary conditions
Integumentary conditions include redness or irritation in the folds of the neck,
asymmetry of the skinfolds about the neck, asymmetry of the skinfolds of the
hips as a sign of hip dysplasia, and color of the skin that might suggest trauma
as a cause of asymmetry.
Screen for the red Flags by inspecting the skin and ROM with clothing removed:
asymmetrical skinfolds, bruising, raw skin breakdown, or purulent exudate
 Continue..
Cardiopulmonary conditions
Cardiopulmonary conditions include asymmetric expansion and appearance of the rib
cage and respiratory distress.
Screen by observation of the chest wall during breathing at rest and when active or
crying.
Red flags include: stridor, wheezing, shortness of breath, cyanotic lips
Acquired torticollis, in contrast to congenital torticollis, may occur in older babies and
children
caused by ocular lesions, benign paroxysmal torticollis, dystonic syndromes, infections,
Arnold-Chiari malformation, syringomyelia, posterior fossa tumors, and trauma.
 Key Examination Tools for CMT
Limitation PT Measurement

Cervical PROM Arthrodial protractor measurement of PROM

Cervical AROM Arthrodial protractor or seated swivel test
Prone tolerance Time per episode and episodes per day in prone
Gross motor function TIMP for < 4 months old; AIMS for > 4 months to 1 year

Pain FLACC
Cervical strength Muscle Function Scale
AIMS, Alberta Infant Motor Scale; FLACC, Face, Legs, Activity, Cry,
Consolability scale; TIMP, Test of Infant Motor Performance
Measuring with an arthrodial
protractor.
(A)Position of the arthrodial
protractor for measuring
neck rotation.
(B)Placement of the protractor
for measuring lateral neck
flexion
 Physical therapy interventions
Goals:
1. Restore full joint and muscle ROM
2. Prevention of contractures
3. To restore muscle strength
4. Promote motor development
Intervention is directed toward resolving each impairment or activity limitation
identified in physical therapy examination
Continue…
This conservative management consist of:
Passive neck ROM exercises
Active assistive ROM
Strengthening and postural control exercises
Instruction to care givers how to carry and position the infant to promote
elongation of muscle
Correct postural alignment and education about maintaining correct postural
environment
Duration and outcomes of physical therapy interventions depend on cause and
age
 Physical therapy interventions and outcomes
Interventions Treatment outcomes

STW Reduce tightness and increase flexibility

PROM Open joint space, aloe free movement of head and improve ROM

Shoulder depression exercise Decrease elevation of shoulder, reduced tightness of muscles

Trunk rolling Promote transitional movement, encourage symmetry in rolling of both sides

Therapy ball exercise Promote trunk strength and stability, promote rotation to upward seated posture.

Prone position on pillow or Encourage neck extension and rotation, facilitates upper body weight bearing
Ramp
Sideling on involve side Encourage side lying so that head and neck turns aways from restricted side

Side lying carry Facilitates streatch and encourage to look away from limitated/restricted view
 Orthotic devices
Assistive devices are used to help obtain, maintain motion
Tubular orthosis collar for torticollis:
it is advised for children of 4 months of age or older
Head tilt of 5 degree or greater
They should have adequate passive ROM
Possible complications include shoulder depression on involved
side, lat shift of cervical spine, vital signs should be observed and
visual torticollis should be ruled out, skin integrity should be
checked for every 2 hours
 Other management
Surgery

Surgical options range from tendon lengthening to unipolar

or bipolar release of the SCM
Indications : persistent residual tightness of > 15° or progressing
ROM limitations even after PT
Goals :The goals of surgery are to normalize neck ROM and to
improve or prevent additional craniofacial asymmetry resulting
from persistent asymmetrical posturing.
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Botox
Botulinum toxin (BOTOX) is also being used as an intervention to
assist with stretching of the tight SCM muscle.
Indication: If there is no response to stretching over a month or 2
months then BOTOX is considered an option for intervention
Goals: presumed to either relax the tight muscle by inhibiting
acetylcholine release or by causing muscle atrophy that allows for
easier stretching
Any Question??
Thank You 