CONGENITAL MUSCULAR TORTICOLLIS (CMT)AND

CRANIAL DEFORMATION (CD):CURRENT TRENDS IN TREATMENT,

MANAGEMENT,& DIFFERENTIAL DIAGNOSIS THROUGH EVIDENCE-BASED PRACTICE

T.R. Goins, P.T.Abilitations Children’s Therapy

Methodist University Doctor of Physical Therapy

DIAGNOSIS, EVALUATION,& TREATMENT

COURSE OBJECTIVES

1. Recognize the use of the American Physical Therapy (APTA) Clinical Practice Guideline (CPG)for CMT for identifying severity of CMT.

2. Identify the eight classifications of CMT as outlined by the APTA CPG for CMT3. Identify red flags for referral to outside specialists.

4. Adding evidence-based data to the pediatric P.T. CMT evaluation 📋

5. Identify the four types of cranial deformation.6. Identify the Argenta Classification scale for cranial deformation7. Recognize techniques used to measure A/PROM in CMT.8. Identify developmental milestones most impacted in CMT.9. Identify the two primary cervical spine motions impacted by CMT and muscles impacted.

10. Recognize secondary complications due to CMT.11. Recognize first choice treatment used in addressing CMT.12. Identify when to refer for a helmet for CD based on clinical findings and the Argenta Scale13. Identify discharge criteria for CMT.

SELF ASSESSMENTBEFORE WE BEGIN…… TEST TIME

Use of the Academy of Pediatric Physical Therapy Clinician Self-Assessment of the APTA Clinical Practice Guideline (CPG) for Congenital Muscular Torticollis (CMT)

DEFINING TORTICOLLISCongenital Muscular Torticollis (CMT): A condition in which the infant’s head is tilted to one side and rotated to the opposite side, resulting in loss of ROM of ipsilateral cervical rotation and contralateral lateral flexion. Can occur at birth, in utero, or following birth.1 Defined by direction of lateral flexion positioned in.

Incidence:Ranges from 3.9%2,3 to 16%.4 Slightly more frequent in males5,6 and infants who are exposed in utero to opioids.7

ORIGINS & CAUSES Concurrent theories related to the origin of SCM muscle impairment in CMT include intrauterine crowding, muscle trauma during a difficult delivery, soft-tissue compression leading to compartment syndrome and congenital abnormalities of soft-tissue differentiation within the SCM muscle.8,9 SCM mass can be present due to trauma from the pull on muscle.

Clinical review of 48 children with CMT showed a relation between birth position and the side affected by the contracture.8

CMT is the third most common pediatric diagnosis.10

MEET JACOB..Do you really understand CMT?AGE: 6 months

DEFINING CMTDefined by the direction of the tilt : Left Torticollis

Left lateral tilt

Right cervical rotation

CMT is typically categorized as 3 types:11

1. Postural2. Muscular3. Sternocleidomastoid (SCM) Mass

WHAT MUSCLES AND BONES ARE INVOLVED?

Muscles: By definition the sternocleidomastoid(SCM) is the primary muscle involved but experience proves the upper trapezius is a major player in the game.

UPPER TRAP VS SCMUpper Trapezius:The trapezius muscle is a postural and active movement muscle, used to tilt and turn the head and neck, shrug, steady the shoulders, aide with upward rotation of the scapula (in combo with lower traps), and twist the arms. The trapezius elevates, depresses, rotates, and retracts the scapula, or shoulder blade.

SCM: The primary actions of the muscle are rotation of the head to the opposite side and ipsilateral lateral flexion of the neck.

INFANTS ARE IN CONSTANT DEVELOPMENT→crawling,reaching,pulling to stand

📋Erythema and deeper skin folds along the anterior lateral side of the neck are indicative of SCM tightness.

Erythema and deeper posterior neck skin folds are more indicative of tightness in the trapezius muscle.12

CLASSIFICATION SCALE FOR CMT

The APTA adopted a CPG for classification and treatment of CMT, with the latest update in 2018.11

Determined by three factors:11,12

1. Age at which infant was referred/evaluated by P.T.2. Limits of cervical rotation3. Presence of or absence of SCM nodule

1 +2+3=Classification

📋 APTA CMT CPG CLASSIFICATION 11

Classification Definition

Grade 1~Early Mild Infants between 0 and 6 months of age with only postural preference or a difference between sides in passive cervical rotation of less than 15°

Grade 2~Early Moderate Infants between 0 and 6 months of age with a difference between sides in passive cervical rotation of 15° to 30°

Grade 3~Early Severe Infants between 0 and 6 months of age with a difference between sides in passive cervical rotation of more than 30° or an SCM mass.

Classification Definition

Grade 4~ Later Mild Infants between 7 and 9 months of age with only postural preference or a difference between sides in passive cervical rotation of less than 15°

Grade 5~Later Moderate Infants between 10 and 12 months of age with only postural preference or a difference between sides in passive cervical rotation of less than 15°.

Grade 6~Later Severe Infants between 7 and 9 months of age with a difference between sides in passive cervical rotation of more than 15° or between 10 and 12 months of age with a difference of 15° to 30°.

Classification Definition

Grade 7~Later Extreme Infants between 7 and 12 months with an SCM mass or between 10 and 12 months of age with a difference between sides in passive cervical rotation of more than 30°

Grade 8~ Very Late Infants and children older than 12 months of age with any asymmetry, including postural preference, any difference between sides in passive cervical rotation, or an SCM mass

📋

To add to the validity of our field it is important to include the Grade of the CMT on your evaluation for physicians. The more we educate our referral source on the evidence-based data for CMT the stronger we advocate for the patients and early referral. See CMT Evaluation Template

Referral age Avg Tx time % recovery Outcomes Surgical

< 1 mo old 1.5 mos 99 % No lateral tilt, full c-spine rotation

N/A

1-3 mo old 5.9 mos 89% No lateral tilt, full c-spine rotation

N/A

Before 3-4 mos 92-100% Full passive c-spine rotation and lateral tilt

0-1 % cases

Between 3-6 mos 7.2 mos 62 % As above, plus active ROM

N/A

Btwn 6-12 mos 8.9 mos 19% “Excellent outcomes” N/A

PROGNOSIS OF CMT11,13,14

Five factors have been associated with full or more complete symptom resolution including the infant’s:

(1) Participation in physical therapy intervention 15

(2) Younger age at initiation of treatment 13,16-20

(3) Decreased difference in cervical rotation PROM between sides 21

(4) Decreased difference in SCM muscle thickness between sides 22

(5) The caregiver’s ability to frequently implement a home program of active positioning and passive stretching.20

PROGNOSIS OF CMT

Per the APTA CPG, recent studies show that the “parent only stretching” until 2 months of age,often suggested by the PCP, is not effective.14,20

Refer back to prognosis chart, referral before 1 month of age is the most effective with the best outcome and least amount of treatment time=$ vs $$$$$

Moving forward as clinicians it is imperative we advocate for early referral by educating both insurance companies and referral sources.

PROGNOSIS OF CMT COMORBIDITIES ASSOCIATED WITH CMTReflux: Correlation was established with a retrospective study, spanning five years of 2159 patients.23 The study found a higher prevalence in children with CMT and reflux who had a history of breech presentation.23

Balance Challenges, preferred rolling in one direction, visual-spatial deficits: Impact on timely acquisition of gross motor milestones such as rolling prone<->supine, sitting, crawling

Feeding problems:Associated w/ CMT and/or plagiocephaly as asymmetrical jaw positioning,24 nursing preference side,25,26 as well as side of bottle feeding.26,27 “As many as 44% of infants with CMT may demonstrate a feeding preference to one side,24 and as many as 2.4% are described as having additional feeding problems.”11,28 Advise mothers to breastfeed from both sides.11

Hip dysplasia:There is a correlation between CMT and hip dysplasia. Data shows 8 % of infants with CMT have hip dysplasia=hip dislocation and shallowing of the acetabulum.29

📋NORM-REFERENCED GUIDELINES FOR CERVICAL STRENGTH

Scores of Muscle Function Scale (Measure of C spine Lateral Flexion)

The Muscle Function Scale

0=Head below Horizontal Line

1=Head on Horizontal Line (norm for 2 months of age or less)

2=Head slightly over horizontal line

3=Head over horizontal line (by 3 months of age)

4=head very high over horizontal line, approaching vertical

Test both sides and note asymmetries

NORM-REFERENCED GUIDELINESReference values for typically developing infants:18

ROM Reference:30

Rotation mean ROM is 100-110 degrees

Lateral flexion is 65-70 degrees.

Muscle Function Score Standard Norms:30 Active Lateral Flexion (strength and ROM assessment)

Infants of 2 months of age had a median muscle function score of 1 (interquartile range, 1-2). This is due to head control not fully emerging until 3 months.

Muscle function increased to score 3 to 4 by 10 months

USE OF THE CMT CLASSIFICATION SCALE

WHAT ABOUT JACOB? What do we know?

● Referred to P.T. at 6 months● Caregiver was working on

stretches at home that PCP suggested.

● DATA OBTAINED? YES

First step toward finding his classification scale

CRANIAL DEFORMATION (CD)“The etiology of CD can be attributed to intrauterine deformation that worsens postnatally” 12,31,32

Three Types of Cranial Deformation, note ALL due to uneven distribution of pressure on cranium due to positioning.33

● Plagiocephaly● Brachycephaly● Dolichocephaly/Scaphocephaly

Bossing

Type of Cranial Deformation12,31-33 Definition

Plagiocephaly Flattening on one side of the back of the head with a bulging in the forehead of the same side as the flattening. Flattening is typically on same side as rotation as that where more weight is being distributed.

Brachycephaly Symmetrical flattening on the back of the head. This flattening causes the head to appear wide above the ears and short from front to back. From a side view, the back of the head appears taller than the front

Brachycephaly with Asymmetry Combination of Plagiocephaly and Brachycephaly.

Dolichocephaly/Scaphocephaly Head shape that is long from front to back and very narrow from side to side

CRANIAL DEFORMATION 📋 ARGENTA CLASSIFICATION SCALE FOR CDCRANIAL DEFORMATION

Plagiocephaly and torticollis are closely connected based on the longevity of torticollis and intrauterine conditions (multiple births, intrauterine fibroids).

# of cases of torticollis and plagiocephaly: 1 in every live 60 births.34

Prognosis

Prognosis for full resolution of CD has been shown to be 77% after parent/caregiver education in repositioning techniques and 94-96 % after cranial remolding therapy (more to come) independent of being combined with parent education in repositioning.35

Plagiocephaly, what we typically see with CMT is on the side of dominant rotation. Jacob has a left lateral tilt preference with right rotation and thus right plagiocephaly

No bossing per my clinical assessmentForehead bossing?Ear displacement/shift?Flattening, even, one-side, temporal?

THE CMT and CD P.T. EVALUATION“The Physical Therapy evaluation should evaluate and document across the ICF domains of body

structure, function, activities, and participation.” 11

Body Structure and Function Limitations

Activity Limitations Participation Restrictions

Presence of tight band or nodule in the SCM36

SCM, upper trapezius, or cervical tightness37 & weakness38

Asymmetrical postures in all positions39

Pain during stretches17

Red, irritated skin folds40

Hip dysplasia41

Cervical and thoracic scoliosis17

Limited cervical motion42

↓tolerance to prone and positional preference 43,44

Asymmetrical movements and transitions45

Resistance to stretching

Asymmetrical standing and sitting postures

Limitation with rolling, visual-spatial work

Preference of bottle feeding or breastfeeding to one side46

↓ tolerance to prone positions 47 & potential developmental delays of certain milestones47,48

Challenges cleaning infant’s neck

Domain Areas of Assessment

Body structure & function11

Recommended areas to assess as

outlined by the 2018 APTA CPG for

CMT

1. Infant posture and tolerance to positioning in supine, prone, sitting, standing for body symmetry, with or without support as appropriate for age

2. Bilateral passive C-spine rotation and lateral flexion3. Bilateral active C-spine rotation and lateral flexion4. A/PROM of Bilateral UE, LE, and inclusive screening

for possible hip dysplasia or spine/vertebrae asymmetry

5. Pain or discomfort at rest and during active/passive ROM

6. Skin integrity, symmetry, of neck and hip skinfolds, presence and location of an SCM mass, size of mass, shape, and elasticity of the SCM mass and secondary muscles (trapezius)

7. Craniofacial asymmetries and head shape/skull shape

Diagnostic Imaging Purpose

Sonoelastography49 To quantify the size, shape, organization, and location of fibrous bands or masses36,50-52

Cervical spine X-ray Per studies and the CPG the current standard of care does not include routine imaging of infants younger than 1 year with suspected or diagnosed CMT.53 Clinicians should refer if they see red flags to indicate further examination such as lateral tilt without progress

THE CMT AND CD P.T. EVALUATIONTHE CMT AND CD P.T. EVALUATION

Observation: Take a minute to observe, as these are topics that can reveal underlying concerns or limitations to discharge.

● Neck Position in supine, sitting, side lying, prone, standing. All important positions to assess in.✔

● Visual Gaze: At rest what are the eyes doing? Strabismus, nystagmus, convergence?

● Cranial Shape:Note shape of cranium● Facial Symmetry: eye position, nose,

cheeks ✔● Muscle Tone: hypotonia, normal tone,

spasticity

3 postures to observe

CLINICAL ASSESSMENT~Range of Motion (ROM)

Active and Passive: Lateral Flexion of C-Spine

Active and Passive: Rotation of C-spine

What is harder measuring the cervical ROM of a giraffe or a toddler?

Cervical Spine ROM guidelinesCervical Spine Rotation

☑ ACTIVE ROTATION (2 months and up)

☑ PASSIVE ROTATION (All AGES)

● Arthrodial Goniometer12

● Clinical Observation

Cervical Spine Lateral Flexion

☑ Active Lateral Flexion (2 months and up)~Righting Reaction

☑ Passive Lateral Flexion (All AGES)

● Arthrodial Goniometer12

● Muscle Function Scale12

ARTHRODIAL GONIOMETER

Lateral FlexionNorm= 65-70 deg

RotationNorm=100-110 degrees

Muscle Function Scale~ Active Lateral Flexion AssessmentStrength and Active ROM

Technique: Hold infant vertically in front of mirror and tip child horizontally to 90 degrees in each direction, observing for the amount of neck righting reaction from horizontal line.

The Muscle Function Scale is reliable for assessing lateral flexion in the CMT population12

Scores of Muscle Function Scale (Measure of C spine Lateral Flexion & Strength)12

0=Head below Horizontal Line

1=Head on Horizontal Line (norm for 2 months of age or less)

2=Head slightly over horizontal line

3=Head over horizontal line (by 3 months of age)

4=head very high over horizontal line, approaching vertical

Muscle Function Score Standard Norms:

Infants of 2 months of age= 1

By 10 months of age= 3 to 4

Muscle Function Scale

Looking for a head righting

reaction~bring it back to

midline!

ACTIVE MOVEMENT ASSESSMENT

Cervical Movement Age Techniques

Cervical Rotation ~2.5 months-5 months~5 months and up

~Following toys to initiate rolling~Stool test, sitting/standing and stabilizing trunk while child looks for a toy (suction balls on mirror, ipad).

Cervical Lateral Flexion ~2.5 months (closer to 3) and up

~Tilting sideways and looking for a return to midline=Muscle Function Scale

ACTIVE MOVEMENT ASSESSMENT

Looking for active rotation ~ therapist remains stationary on the stool. With music and/or noise toys encourage child to rotate

Can be useful in treatment with the therapist rotating the stool in the opposite direction.

EVALUATION: SUBJECTIVE, CAREGIVER INTERVIEW

Area of Concern Pertinent Questions for the Caregiver

Birth History Complications with pregnancy or delivery (breech?)Gestational length?Gestational diabetes?

Infant/Child’s history When did you first notice a tilt or rotational preference?Hx of reflux?Any of other medical complications?Hx of hip dysplasia? clicking/popping/gait issues?

Sleeping and Positioning Preferences

Time spent in prone, supine, in car seat, other seats?Direction the child prefers to look? Preference of tilt?

Prior treatments If had therapy prior, at what age referred?What treatments were effective? Ineffective? (e.g. taping, stretches)Diagnostic images taken?

EVALUATION: OBJECTIVE ASSESSMENT Area of Concern Assessment/Outcome Measure

Cervical ROM GoniometerStool Test~ rotationMuscle Function Scale

Cervical Strength Muscle Function Scale (Lateral flexion)Extension (prone)Head control~all positions

Motor Milestones Test of Infant Motor Performance: 34 weeks post-conception to 4 months posternAlberta Infant Motor Scale: 0-18 monthsPDMS-2: birth through 5 years

UE ROM Active: Motor milestones, overhead reaching, observation and documentationPassive: goniometer

LE ROM Active: Motor milestonesPassive: goniometerHip Integrity: <3 months=Ortolani &Barlow54, >3 months=Galeazzi sign55

Palpation SCM nodule? Trigger points in upper trapezius or SCM? Bony abnormalities (clavicle, humerus)?

EVALUATION: OBJECTIVE ASSESSMENTArea of Concern Assessment/Outcome Measure

Pain Faces, Legs, Activity, Cry, Consolability Scale (FLACC)12

Craniofacial assessment~facial asymmetry~fontanelles assessment~cranium shape

Asymmetry(face/cranium) via 6 views: anterior, vertex (top down),posterior,two laterals, inferior12

Argenta Classification Scale

Spinal assessment Palpation of spinous process, pelvis assessment (level landmarks?), muscle palpation (asymmetry or hypertrophy?)

Jacob’s clinical findings and

history

● Referred to P.T. at 6 months old after mom performed home stretches from guidance by her PCP

● No SCM nodule found● Rotation findings: Active:R=100 degrees, L=75 degrees, Passive:

R=100 degrees, L=80 degreesClassification: Grade 2~ Early Moderate

● Muscle Function Scale: L=3, R=2● Lateral Flexion PROM: L=65 degrees, R=50 degrees● History: No therapy prior, does not tolerate prone, prefers time in

the exersaucer, no hx of reflux, WNL gestation age, no complications with vaginal delivery

● UE and LE A/PROM=WNL, to include hip integrity● Developmental assessment: weakness with trunk control as noted in

ring sitting, prefers rolling to the right but min A to the left prone<->supine. Min A supine<->prone bilaterally

● Pain scale via FLACC is WNL● Facial Asymmetry=WNL, left eye is lower than right but due to

gravity● Cranial Assessment: Plagiocephaly, right occiput. R/O

craniosynostosis, no forehead bossing, mild right ear shift=Argenta Classification Type 2

● Postures in positions of ○ prone=left lateral tilt, poor extension○ Sitting=Left lateral tilt

PROGNOSIS FOR JACOB?

Referral age Avg Tx time % recovery Outcomes Surgical

< 1 mo old 1.5 mos 99 % No lateral tilt, full c-spine rotation N/A

1-3 mo old 5.9 mos 89% No lateral tilt, full c-spine rotation N/A

Before 3-4 mos 92-100% Full passive c-spine rotation and lateral tilt 0-1 % cases

Between 3-6 mos 7.2 mos 62 % As above, plus active ROM N/A

Btwn 6-12 mos 8.9 mos 19% “Excellent outcomes” N/A

DIFFERENTIAL DIAGNOSISDiagnosis/Clinical Symptoms

Diagnosis Mimics Differential Diagnosis

Persistent C-spine tilt with no loss of A/PROM of the cervical spine

CMT Ocular Torticollis~The abnormal head posture is adopted to improve visual acuity to maintain binocular single vision, center residual visual field with the body or for cosmetic reasons56

Persistent C-spine tilt with no loss of A/PROM of the cervical spine and no improvement of treatment after one year

CMT Klippel-Feil syndrome~fusion of cervical vertebrae 57

C1-C2 rotatory subluxation57

Congenital scoliosis57

Pain and intolerance to movement

CMT brachial plexus injury,brain stem gliomas, agenesis of CNS structures.57,58Hearing deficits59

EVALUATION~RED FLAGSArea of Measurement Red Flag Findings Action to Take/Referral

Hip Clunking/clicking (<3 mos)Gluteal Fold AsymmetryLeg length differenceAntalgic gait

Pediatric OrthopedicsHip Dysplasia~correlated with CMT in 8 % of cases60

Cervical Spine Treatment for a year (prior) with no resolutionFull ROM, passive/active (strength) with tilt11

Pediatric OrthopedicsPCPGeneticsKlippel Feil Syndrome12

Congenital scoliosisHemivertebrae

Vision Nystagmus,StrabismusTilt with full A/PROM of cervical spine and cervical strength WNL

Pediatric Opthamologist Ocular torticollis~Rate is 3.19%56

Cranial Assessment Bony ridges on craniumFacial asymmetry not due to gravity (nasal bridge to eye)

CraniofacialPCPNeurology/Neurosurgery~R/O craniosynostosis

TREATMENT~CMT

First Choice Interventions: Most common practice12

1. Parent Education2. Environmental Adaptations3. Passive C spine ROM: Most Effective First Choice of

Tx11,14,61,62

4. Active ROM of C spine and trunk (rolling)5. Facilitation of symmetrical movement activities

(acquisition of developmental milestones)

TREATMENT~CMT~2018 APTA CPG on CMT11 for specific CMT severity

classifications~

● Stretching should be frequent through the day, every day...However…..● Still no data supporting the amount of dosage standard for the technique or duration of

stretches ● Still no data supporting repetitions for each treatment session (e.g. 10 vs 20 reps)● No standard linking frequency of treatment sessions per day or overall duration of care or

frequency of clinic visits● No standard linking tapering schedule standard norms

All of the above indicates more information needs to be gathered in terms of: dosage, technique, tapering, frequency, repetitions for the best outcomes for CMT.

TREATMENT~CMTIntervention Duration Techniques

Stretches: Active and Passive

APTA CPG reports a study that shows 10 stretches

per 10 sessions/day is more effective than 5

sessions per day of 10 stretches or 100 stretches

vs 50 stretches per day. They found 100 stretches

is more effective.2

1. Football carry2. Stabilizing the trunk

between caregiver/PT lap for rotation and lateral flexion

3. Placing suction balls on mirror for rotation

4. Carry hold

Parent Education Each session inquire about the daily routine of the family and child to include preferred sleeping postures and preferred position and seating options

Placing a child with poor head control and neck weakness in certain seats can lead to prolonged tightness such as: carriers, swings, bouncy seats, exersaucer(put brakes on).

1. Repositioning: place toys on opposite side of preferred rotation, towels/positioning devices in carriers, decrease time in carriers/bouncy seats

2. Present toys to all visual fields

3. Promote midline play4. Prone play! Build up

tolerance

Treatment~ CMT

Hold-Carry for lateral flexion stretch Football carry-lateral flexion

Treatment ~CMT

Active cervical rotationE.g. for left CMT to work on L rotation

Prone work; placing toys at level with facilitation of thoracic extension & cervical extension

Treatment ~ CMT

Promotion of different positions throughout the day is important with an emphasis on decreasing supine.

Back to Sleep~ Belly to Play

TREATMENT~CMTIntervention Duration Techniques/Exercises

Strengthening:~Developmental~Cervical muscles

Studies show possible association linking CMT and delayed motor skill development and any bias to one side may impact associated rolling along the spine resulting in asymmetric postures12,47,48,63

Sitting is also impacted due to imbalances with lateral righting and head righting reactions

Discretion of the therapist based on findings of evaluation and underlying needs (e.g. hypotonia)

Rolling<->Supine to prone

Prone: Keep toys at eye level to promote extension.Prone “belly time” is crucial for decreasing time on the infant’s back (cranium flattening) as well as strengthening cervical mms.

Note: Due to gravity this is very challenging for infants. Prescribe as you would bicep curls or squats; small does, multiple sets

side sitting (observe what happens to c spine)-stabilize the trunk

Long sitting and ring sitting-Stabilize the trunk

Crawling: Stabilize the shoulder to decrease elevation and overuse of the upper trapezius.

TREATMENT~ CMT

Intervention Duration Techniques/Exercises

Strengthening Up to the duration of the treating therapists based on underlying findings in the evaluation.

Visual Tracking: stabilize the trunk (aids with rotation) for c-spine strengthening.

Lateral Righting Reactions: Therapy ball or lap, slow and controlled movement to allow for active return to midline

Soft tissue work No data suggesting best practice. In this population the tolerance is typically less than 30 seconds each time

To SCM, upper trapezius, pectoral mm.Avoid stretching a mass if present.

TREATMENT~ CMTIntervention Duration Technique/Exercise

Myofascial Release Advanced coursework is helpful. Specifically, for pectoral muscles, upper trapezius, and SCM.~The shoulder is often rotated internally with forward protraction of the shoulder, especially in advanced cases. Address the pectoral muscle!

Taping (Kt Tape, leukotape)~A retrospective study for Kt Tape showed when it is applied for relaxation of the affected side, immediate Muscle Function Scale gains were reported.12,64

~weak evidence/data but promising

Typically four days to one week, depending on the tolerance of the child and the type of tape.

~Same side =relaxation, cueing~Contralateral side=cueingLeukotape: for shoulder stability due to compensation of upper trapezius.

TREATMENT FOR JACOB● Trunk control work in ring sitting, side-sitting to the right to facilitate right c-spine lateral

flexion, In sitting with toys to the left and stabilizing trunk for left c-spine active rotation: Strengthening, A/PROM

● Rolling to the left supine->prone and prone<->supine● Play in prone with toys placed at eye level (used a bench) and moved toy to the left to facilitate

left c-spine rotation● Therapy ball: prone to facilitate c-spine extension (toys above or on mirror), in sitting for head

righting reaction and lateral trunk righting reaction (move slow, allow active movement into midline)

● Football and hold carry for elongation of the left SCM and upper trapezius● Soft tissue work to the left SCM and upper trapezius● Leukotape to left shoulder when Jacob started crawling● Parent education: ↓ time in gravity dependent devices (exersaucer), towels for support when in

carrier, educate mom on how to do the things we do in therapy

TREATMENT~ CMT: Supplemental Intervention with Evidence, When First Choice Treatment is not effective

Intervention Duration Technique/Exercise

ManipulationPer the APTA CPG for CMT there is no good data supporting this over

stretching.11

N/A N/A

Microcurrent for CMT

Two small randomized controlled trials have shown similar outcomes of increased ROM in considerably less time with microcurrent vs stretching alone. Overall episodes of care on average of 2.6 months with microcurrent vs 6.3 months for stretching alone.65

“ Low intensity alternating current (200uA) is applied superficially over the involved SCM so that the infant does not perceive the current; stretching follows the Tx” 12

“ Low intensity alternating current (200uA) is applied superficially over the involved SCM so that the infant does not perceive the current; stretching follows the Tx” 12

TREATMENT~ CMT: Supplemental Intervention with Evidence, When First Choice Treatment is not effective

Intervention Duration Technique/Exercise

Myokinetic stretching for CMT

~Not conclusive data on this treatment in comparison to first choice treatment.66

PT provides 60 reps over 30 minute tx session, 5 times a week on infants a week on infants less than 50 days old. 66

Technique consists of applying mild overpressure with 1 or 2 fingers on the SCM while it is in its lengthened position.12,66

Tscharnuter Akademie for Motor Organization (TAMO)

Poor outcomes in study with comparison to first choice treatment so hard to determine if beneficial. Not common practice.67

Use of light touch and the infant’s response to gravity and support surfaces to facilitate movement exploration

Treatment Ideas for “SAle”The Tortle: www.tortle.com Goal: move the strap around to redistribute weight to different parts of the cranium. If already a flat spot then the strap will go over flat part so child stays off of it. Move every 2-3 hours. Works well for newborns. Commonly given in NICU.68

Soft foam collar: Used post-surgery but have not been shown to be effective in isolation of other intervention.11

Custom Fabricated Orthosis: Post-surgery. Show better results than the soft collar but not good data in the literature. 11

Not a great deal of evidence based information on these items to date.

TREATMENT~ CMT~Non-conservative options

If torticollis is persistent past one year of TREATMENT (not age) then options. Also consider for infants referred after 12 months and who have a Grade 7 and 8 severity (CMT classification).11

● Tendon lengthening:Unipolar or bipolar release of SCM if persistent residual tightness of > 15 degrees.69

○ Children who have the tendon lengthening prior to one of age have a better chance of reversing facial and skull deformities.69

● Botox (Type A): growing body of support and evidence for use of this in cases of CMT not responding to First Choice Intervention.70-72

TREATMENT~CD

1. R/O CRANIOSYNOSTOSIS:A birth defect impacting an infant’s skull in which one or more fontanelles fuse prematurely.73

Red Flags73: Bony ridges, lack of cranium growth,lack of a “soft spot” on the cranium

2. REPOSITIONING ~First Choice Treatment3. Decrease supine time/Increase Prone time:Back to Sleep, Belly to Play

Campaign. ~ First Choice Treatment4. HELMET ~Continues to be controversial. Thus, the need to discuss

evidence-based information for helmets in children with CD

TREATMENT~CD~HELMETS

Cranial Orthoses: Goal is NOT to restrict cranial growth but instead to redirect subsequent cranial growth into voided areas facilitating a symmetrical shape. Should be initiated from 4-6 months, worn 20 to 23.5 hours/day, for 2-7 months.12

Studies have shown at 5 months the rate of cranial asymmetry improvement is .93 mm/wek vs at 8-11 months the rate of improvement stabilizes at .41-.42 mm per week.74

Best outcome if correction initiated before 6 months, but correction can occur up to 15-18 months of age although correction will be likely incomplete and require longer wear.74-76 After 12 months there is less improvement due to rate of skull growth.74

Challenge getting pediatricians on board due to studies to date comparing cranial remolding therapy with parent ed in repositioning in 5-6 month old infants with mod to severe CD.

Outcome=did not find statistically significant difference in cranial asymmetry between the two interventions when children were 2 years of age.77

TREATMENT~CD~HELMETSCranial orthotic assessment recommended for infants > 4 months with severe CD that includes facial asymmetry (Argenta DP, Type IV and temporal bulging and abnormal vertical growth of the skull. Argenta DP type V, Argenta DP type III) as outlined in the APTA CPG for CMT.11

Note: Jacob does not qualify=Type II

Cranial orthotic assessment recommended for infants over 6 months with mod CD that include ear displacement (Arenta DP Type III), frontal bone protrusion (Argenta DP Type III) as outlined in the APTA CPG for CMT.11

Argenta Classification Scale

TREATMENTS~CD~CONTRAINDICATIONS

Helmets Contraindicated for: Infants less than 4 months of age or an infant at any age with mild CD limited to posterior skull (Argenta DP Type I or Argenta DB Type I)

Type I=posterior skull

DP=Deformational plagiocephaly

DB=Deformational brachycephaly

Need to educate yourself on the Argenta scale, when appropriate to refer, and what orthotist in your area are consulting on the helmets.

DISCHARGE CRITERIA ~as outlined by the APTA CPG11~

1. Full ROM of c spine, trunk, and extremities to within 5 degrees of non-affected side

2. Symmetrical movement patterns throughout the passive range3. Age-appropriate gross motor development including symmetrical movement

patterns between the left and right sides during static, dynamic, and reflexive movements

4. Improved skull symmetry to Argenta Type I or referred for further mgt of CD

5. No visible head tilt6. Parents/caregivers understand what to monitor as the child grows

GUIDELINES FOR FOLLOW-UP CARE

Per the CPG:Action Statement 17: Revised and updated

REASSESS INFANTS 3 TO 12 MONTHS AFTER DISCONTINUATION OF DIRECT SERVICES OR WHEN THE CHILD INITIATES WALKING AND THEN DISCHARGE IF APPROPRIATE 11

● Postural preference

● The structural and movement symmetry of the neck, face and head, trunk, hips, upper and lower extremities

● Developmental milestones to assess for recurrence of CMT and evidence of atypical development

Evidence quality: II; Recommendation strength: Moderate11

JACOB TODAY ~ 2.5 years old

● Long-term outcomes? Even with Classification 2 there is persistent tilt and weakness with fatigue and sickness

● Ongoing Intervention? Refer back to D/C criteria● Education: Explain to caregivers that there can be

ongoing weakness, especially with fatigue or sickness

Summary● Education of referral providers is imperative for early

referral: prognosis, classification system, evidence-based data for CMT and CD

● Continuation of research for best evidence-based practice: duration, interventions, dosage.

● Create a network with other pediatric providers● Create an evaluation in your practice with classification

systems as outlined by the APTA CPG

Resources For Caregivers And Clinicians● The Academy of the Pediatric Physical Therapy: Tips for Positioning and

Play to Help Your Newborn Baby's: https://mail.google.com/mail/u/0/?tab=rm&ogbl#search/mica/FMfcgxwDqfHlXgfphCdfJMbGNBtTQCxL?projector=1&messagePartId=0.1

● The Academy of Pediatric Physical Therapy: Guidelines and Roles for Clinicians (e.g. therapists, MDs): https://mail.google.com/mail/u/0/?tab=rm&ogbl#search/mica/FMfcgxwDqfHlXgfphCdfJMbGNBtTQCxL?projector=1&messagePartId=0.1

● Tummy Time Tools: https://www.choa.org/medical-services/orthopaedics/orthotics-and-prosthetics/tummy-time-tools

● Safe to Sleep: https://safetosleep.nichd.nih.gov/

● Plagiocephaly: http://pediatricapta.org/includes/fact-sheets/pdfs/Plagiocephaly.pdf

● The 2018 APTA CGP for CMT: https://journals.lww.com/pedpt/Fulltext/2018/10000/Physical_Therapy_Management_of_Congenital_Muscular.2.aspx

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