Congenital muscular torticollis

DEFINATION:
Congenital muscular torticollis(CMT) describes the
posture of head and neck from shortening of SCM
muscle causing the head to tilt toward and rotate
away from the affected SCM.
In addition to rotation and tilting, the infant may
exhibit asymmetric neck extension and a forward
head posture due to upper cervical extension
It is named for the side of involved SCM muscle
 Etiology and Pathophysiology
1. Direct injury to muscle
2. Ischemic injury based on abnormal vascular
patterns
3. Rupture of muscle
4. Infective myositis
5. Neurogenic injury
6. Hereditary factors
7. Intrauterine malpositioning
8. Birth trauma: position of the head and neck in utero
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, & edema)
Postural torticollis
Congenital absence of one or several cervical
muscles or of transverse ligament or contracture of
other neck muscles
DIFFERENTIAL DIAGNOSIS:
 1 in 5 children has a nonmuscular etiology that may
include skeletal abnormalities or neurologic causes
as brachial plexus injury
 So initial examination should be detailed history
and thorough physical examination to determine if
the lesion is congenital or acquired
 Changes in body structure and function

 In infants with CMT, neck ROM is decreased for

contralateral rotation, ipsi lateral lat flexion, and
contra lateral asymmetric flexion and extension.
 Infant is not able to maintain midline alignment of the
head in static postures as well during movements
bcoz of the neck muscle imbalance and muscle
contracture
 Prolonged uncorrected head tilt caused by underlying
mechanism of imbalanced muscle pull acting on
growing spinal and craniofacial skeleton, may cause
scoliosis, skull and facial asymmetry, and influence
compensatory movement patterns affecting motor
control development
Facial and cranial characteristics include:
 Asymmetry of craniofacial skeletal structures

 Asymmetry of masticator and tongue muscles

 Underdevelopment of ipsilateral jaw, elevation of

TMJ,dental occlusion problems
 Inferiorly positioned ipsilateral ear, asymmetry of the ear
(cupped or bat ears)
 Asymmetry of the eyes with ipsilateral eye smaller

 Deviation of the chin point and nasal tip

 Other musculoskeletal asymmetries include trunk

curvature toward affected SCM, persistence of
asymmetric tonic neck reflex
 hip joints abducted on facial side and adducted on
occipital side causing pelvis to tilt when legs are
together
 When infant acquire the ability to sit, a double spinal
curve may develop to compensate the head tilt and to
bring centre of gravity over base of support and to
compensate for contracture of hip and pelvic tilt
 Some children elevate the shoulder to allow the head
to be in midline
 Some may present with level shoulders but with a
head tilt, which produces a lateral shift of the cervical
spine leading to cervical spinal scoliosis
 Typical activity limitations
 The young infant with CMT is unable to have
purposeful symmetric movement of the head bcoz of neck
muscle contracture and neck muscle strength imbalances
 Impaired immobility may lead to persistent asymmetry of
early reflexes and reinforcement of an asymmetric posture
which cause neglect of ipsilateral hand, decreased visual
awareness of ipsilateral visual field, interference of
symmetric development of head and neck righting
reactions, delayed propping and rolling over the involved
side and limited vestibular,proprioceptive and
sensorimotor development
 In older child it may result in asymmetric weight
bearing in sitting at neck flexion, crawling, walking,
and transitional movement skills as well as
incomplete development of automatic postural
reactions
 These persistent asymmetries result in structural
deformities such as pelvic obliquity and scoliosis
 Inability to turn the head and neck will cause the
child to rotate the body to compensate and inability to
recruit lat neck flexion with automatic reactions will
cause the child to compensate with overuse of
muscles
 Activity limitations include difficulty in sustaining
midline head posture in an upright position, regaining
head midline posture in vertical, prone, or supine with
 weight shifts and maintaining midline head posture during
movement
 Both the child and infant will have difficulty with upper
extremity weight bearing on involved side, reaching
toward midline with forearm supination, shoulder ext rot
and flexion, and full expression of upper extremity
protective and equilibrium reactions
 The infant will use compensatory manoeuvres to be able to
perform a task such as hand clapping by crossing midline
to bring the uninvolved side upper extremity toward the
involved arm
 Infant with CMT respond to restrictions with self initiated
movements that include pattern of head tilting to ipsilateral
side and rotation to contra lateral
side of SCM involvement so young infant is unable
to adapt appropriately to the supporting surface and
has limited kinaesthetic feedback which affects the
development of sensorimotor systems, postural
organizations, orientation and body schema and
motor milestones may develop atypically bcoz
various subsystems are developing asymmetrically
and infant is not experiencing normal interactions of
each system as growth and development occur
 Physical therapy examination
It should include:
 both prenatal and birth history

 Sex of infant

 Side of SCM muscle involvement

 Other congenital anomalies

 X rays or other diagnostic testing

 Reports of previous subspecialists consulted

 age at diagnosis

Questions should be asked about :

 Time spent in prone and supine position

 Sleeping position and head rotations

 Findings in congenital muscular torticollis
 MSK should be examined for restriction in joint
range of motion and muscle length with particular
attention paid to ipsilateral neck rotation, contra
lateral neck flexion, contra lateral asymmetric neck
flexion and extension, muscle and soft tissue
extensibility and skin creases about neck
 Passive ROM of head and neck to determine
available ROM
 Gentle traction of cervical spine is used to assess the
ability to align the cervical vertebrae in neutral and
eliminate the lateral glide position induced by
shortened SCM muscle
 Gentle traction between shoulder complex and
occiput combined with specific head and neck
motions is used to assess the tightness of upper
trapezius, scaleni, and post neck muscles of ipsilateral
side
 Active and passive ROM should be assessed in prone
with head and neck free of supporting surface
because infant may not have enough ROM or strength
to extend the head off the supporting surface and
clear the airway
 Ipsilateral shoulder girdle and upper extremity should
be assessed to see active movement toward midline
with horizontal adduction and flexion
 Movement of forearm into supination and reach and
grasp is examined
 The trunk should be assessed for ability to elongate
with weight shifting
 The pelvis and lower extremity on ipsilateral side
should be examined for ability to accept a weight
bearing load with proper biomechanical alignment
 Spinal motion should be assessed for restriction in
flexion, extension, lat flexion, and rotation
 Resting head posture and passive and active ROM
should be assessed in supine, prone and sitting posture
 Hip asymmetry is assessed by leg length, thighs skin
folds, and measuring hip abduction
 Examination include palpation of muscle for tone or
any tumour
 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
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
 Biomechanics of stretching and stretching
protocols
 To properly stretch the SCM muscle by stabilizing the
origin and tnsertion,move the muscle into its
elongated position
 This can be attained with ipsilateral rotation,
contralatertal lat flexion, and contra lateral
asymmetric extension from a starting point of neutral
cervical spine alignment
 Infant should be positioned supine with head and
neck free of supporting surfaces, with both shoulders
stabilized and held parallel to a stable pelvis
 There are different protocols of stretching:
1.Neck stretching two times a day, each stretch for 5
minutes with a 10 second hold
2.Manual stretching 3 times a week consisting of 3
repetitions of 15 manual stretches held for 1 second
with a 10 second rest period combined with a prone
sleeping home programme
3.Stretching carried out 4 to 5 times daily with at least
40 repetitions in each set
Contraindications and precautionary measures should
be considered before stretching
 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, skin integrity should be checked
for every 2 hours
 Instructions to care givers
They should be taught:
1. How to carry and hold the infant
2. How to position the infant during sleep to create a
prolonged stretch and midline development
3. How to present toys to involved side to facilitate
reaching in
4. How to approach and feed the infant to promote
looking toward the involved SCM muscle
5. Once strength is obtained task specific exercises
should be done which will promote development of
movements as lifting head, rolling, coming to sit
1.what are outcomes of physical therapy intervention?
2.describe contraindications and precautionary measures
for stretching of SCM and neck muscles?