Congenital Muscular Torticollis

Congenital Muscular Torticollis (CMT) is characterized by an abnormal posture of a child’s head, with their head laterally flexing to one direction and then rotating to the opposite direction (pic?). This is due to shortening in the muscle known as the sternocleidomastoid (SCM). There are 2 of these muscles in a person’s neck (one on each side). With this condition, there may be muscle shortening of one of these muscles that would result in the deficits mentioned above. CMT is categorized by 3 types:

1. Postural CMT: a child has a head preference without muscular or passive range of motion restrictions. This means that upon examination, there are no difference in side bending or lateral flexion on both sides. This is typically the mildest presentation.
2. Muscular CMT: a child has a head preference and it is accompanied with range of motion deficits, specifically side bending on the affected side and head rotation to the opposite side.
3.  SCM Mass CMT: this is typically the most severe form of CMT. Upon examination, there is a presence of a fibrotic mass on the SCM as well as range of motion limitations as described with muscular CMT.

How To Assess
Neck asymmetries may be identified by a parent or pediatrician during a wellness examination. If a child has SCM mass CMT, this fibrotic mass may be identified during palpation. CMT is named by the side that is affected, so if the right SCM is shortened, then the child is said to have Ride sided CMT.

Important of Early Detection
When this condition is noticed in infants, it is imperative to initiate physical therapy immediately to ensure full recovery by age 2 (fact check that) to prevent long term complications or permanent head shape deformities. If a child with CMT at 1 month of age initiates physical therapy upon identification, their average bout of physical therapy care is about 1.5 months. If a child is identified to have CMT after 1 month of age, their bout of care prolongs to 6 months of physical therapy. If CMT is detected in a child greater than 6 months of age, the bout of physical therapy may last between 9-10 months.

Physical Therapy Intervention
Physical therapy management consists of 5 important components:

1. Neck passive range of motion: this would be consider “stretching” of your infant’s tight SCM. PTs will educate parents and caregivers once the side with deficits has been identified on stretching techniques they can perform during play and sleep.
2. Neck and trunk active range of motion: this is when your infant will be encouraged to play to promote strengthening on the side of weakness. In infants with a head preference from CMT, they experience one-sided weakness of their neck and trunk muscles. As they start to acquire their milestones, you may notice preference to leaning of one side in sitting and imbalances in their core strength.
3. Development of symmetrical movements: Torticollis can lead to developmental asymmetries that can lead to one-sided weakness, curvature in the spine (C-shape), and impaired awareness of midline. It is important to encourage strengthening of both sides and develop symmetrical head rage of motion to allow for acquisition of developmental milestones and to prevent further postural asymmetries as they grow older. 
4. Environmental adaptations: sometimes in CMT, environment has a large influence to why infants develop a head preference. Take a look at the positioning of your infant’s crib. Does the position of where the door is coordinate with their head preference? Are there more of their toys on one side of the crib compared to the other? It might require making these, what seem small, modification to make bigger strides towards correcting their CMT.
5. Parent/ caregiver education: Throughout all of these components of their physical therapy care, it is important to educate parents on the importance of parents and caregivers on performing physical therapy exercises and home and how frequency can impact the correction of torticollis.

Below you will find some exercises that have been effective in help to correct torticollis and are widely used by physical therapist when developing a plan of care.

Examples of Therapeutic Exercises
Football Carry
The football carry is a useful position for stretched the tightened SCM muscle of your baby’s neck. To perform, carry your baby with their back against the front of your body. Make sure that the side their torticollis is on is face up (towards your face). Support the baby’s head with one and support the baby’s lower body with the other arm. Use this position frequently throughout the day. Engage in play by using a mirror and playing peek-a-boo games.

Tummy Time
Place your baby on their tummy and place their most desired toys opposite from the direction your baby is facing. You may also want to position yourself away from the direction your baby is facing to encourage active range of motion to the opposite side to help strengthen their weaker neck muscles. For infants who tired easily with tummy time, you may want to utilize a boppy or rolled up towel to help support under their chest.  

Side Bending Stretch
While your baby is laying on their back, place one hand on their shoulder to hold in place and use other hand to guide your baby’s head into a side bending position AWAY from the side of their torticollis. You can sing to your baby or have a desired toy, so they maintain their gaze forward to get the full benefits of this stretch. Hold this stretch for at least 30-60 seconds and perform multiple times throughout the day.

If you are concerned that your baby may be developing a head preference or notice asymmetries of their neck, consult your pediatrician at your baby’s next visit and ask about physical therapy services to help to meet your baby’s needs. Schedule your free screening with Triumph Pediatrics today!

References

1. Kaplan, S. L., Coulter, C., & Fetters, L. (2013). Physical Therapy Management of Congenital Muscular Torticollis: An Evidence-Based Clinical Practice Guideline FROM THE SECTION ON PEDIATRICS OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION. Pediatric Physical Therapy, 25(4), 348-394.
2. https://pathways.org/watch/torticollis-and-the-importance-of-tummy-time-meet-jonathan/
3. https://kidshealth.org/en/parents/torticollis.html
4. http://www.cmnrp.ca/uploads/documents/Torticollis_and_Plagiocephaly___handouts.pdf