“What is the optimal evidence based physical therapy intervention for an

infant who is experiencing Congenital Muscular Torticollis (CMT)?”

Research Project: Daniel Obradovich, SPT

University of North Florida 04 October 2010

What is the optimal evidence based physical therapy intervention for an infant experiencing

congenital muscular torticollis (CMT). To answer this clinical question several online databases

were used: PubMed, Physical Therapy Journal, Medline, CINAHL, and ProQuest. The

following are the search terms that were used to find high quality peer reviewed articles for the

clinical question: Congenital Muscular Torticollis, Torticollis, clinical practice guidelines, and

physical therapy.

Petronic et al. (2010) conducted a retrospective study to evaluate the proportion of right

versus left sided pediatric clients with Congenital Muscular Torticollis (CMT) in both genders

and different age groups. They also wanted to investigate the duration of physical therapy and

treatment outcomes in defined age groups and genders. The article was a grade B (level 3b) type

of evidence. There were a total of 980 children with clinically diagnosed CMT that were

included in the retrospective study. The children were from Serbia, Bosnia, Herzegonia, and

Montenegro. I was not able to find what statistical analysis was used to analyze the data because

there was a page missing from the article. The page was missing probably due to copyright laws

or an error with the upload of the article, which was a major limitation of the study. The results

from the unknown analysis revealed that right CMT is frequent but not significant in both

genders and different age groups. There was no significant difference with CMT between

genders. Younger pediatric clients especially younger than one month have lower treatment

durations and have better outcomes. Infants with CMT who are not diagnosed until 6 months

require more time with treatment and have poor outcomes. The authors highly recommend early

diagnosis within the first three months of life and start physical therapy treatment (protocol of

stretching & active positioning stimulation) as early as possible.

Cheng et al. (2001) designed a longitudinal prospective study to investigate the effect of a

standardized manual stretching program on pediatric clients with Congenital Muscular

Torticollis (CMT). They also evaluated the factors that predict the outcome of treatment. The

authors advised the importance of classifying the pediatric clients with CMT into three groups.

First, the sternomastoid tumor group has a palpable mass on the sternocleidomastoid muscle.

Second, the muscular torticollis group has only sternocleidomastoid muscle (SCM) tightness

without a palpable tumor. Third, the postural torticollis group has no palpable tumor or (SCM)

muscle tightness. This article was a grade B (level 3b) type of evidence. There were a total of

821 children within the clinically diagnosed torticollis groups that were included in the

longitudinal prospective study from 1985 to 1997. Statistical analysis was conducted on SPSS

using univariate and multivariate data. The results from the analysis shows good evidence that

controlled manual stretching is safe and effective in about 95% of pediatric clients with CMT

that are seen before the first year of life. The results reveal that the most important factors of

predicting the outcome of the manual stretch treatment are the torticollis clinical diagnosis

category group (sternomastoid tumor= fair/poor outcome), initial cervical rotation deficit (>

15deg from neutral= fair/poor outcome), and age at initial treatment (>1 year = fair/poor

outcome). Surgical intervention is indicated when manual stretch treatment has gone past six

months with no improvement, and the infant continues with deficits.

Carolyn Emery (1997) conducted a literature review on conservative management of

Congenital Muscular Torticollis (CMT). The literature review was a grade B (level 3a) type of

evidence that included only studies that systematically documented their outcomes from the

conservative CMT treatments used. No statistical analysis was mentioned in the article, which

was a major limitation of the literature review. The conclusion of the review stated that fewer

than 16% of infants with CMT treated conservatively before one year of age will require surgery.

The conclusion also stated that typical treatment duration to produce full neck mobility ranged

from 3 to 12 months.

Ohman et al. (2009) designed a study to investigate whether infants with CMT are at risk of a

delay in early motor milestones in comparison with healthy infants. The authors also wanted to

investigate whether the time spent in the prone position or the presence of plagiocephaly had any

influence on motor development. This article was a grade B level (2b) type of evidence. Motor

development was assessed with the Alberta Infant Motor Scale (AIMS). There were a total of

122 infants aged 2 to 18 months included in the study; 82 infants with CMT & 40 healthy

infants. Statistical Analysis was conducted on SPSS using analysis of the covariance. Results

indicate that the CMT group in the study had significant risk of early motor developmental

milestone delay compared with the healthy control group until the age of 10 months. The results

also indicate that the time spent in prone position when awake seems to be of greatest importance

in reducing delay in early motor developmental milestones. The authors strongly encourage

providing caregivers with information on the benefits of prone position awake time to help

prevent early motor developmental milestone delay.

Luther (2002) wrote a detailed educational article on the management of Congenital

Muscular Torticollis (CMT) in the Journal of Orthopaedic Nursing. Her objective was to

increase knowledge and understanding to other clinicians on the clinical management options for

infants with CMT. Physical exam usually indicates limited cervical range of motion and a

palpable mass on the sternocleidomastoid muscle belly. A facial asymmetrical deformity called

plagiocephaly is common in infants with CMT. The currently accepted theory of the

pathophysiology of CMT is that a vascular insult of the sternocleidomastoid muscle causes

fibrosis of the muscle resulting in muscle shortening. The author reported a CMT incidence rate

of 1 per 250 live births from a study conducted by Hollier et al. in 2002. Differential diagnosis

should be performed to rule out congenital cervical vertebral anomalies, infections,

inflammations, Klippel-Feil Syndrome, Sandifer Syndrome, neoplasms, and other possible

neurologic causes. There are three types of torticollis: osseous, non-osseous (CMT), and

neurogenic. There are three types of CMT from (Cheng, 2001): sternocleidomastoid muscle

tumor, muscular torticollis, and postural torticollis. The most common form of treatment for

CMT is manual stretching. The author stated that 90% of infants with CMT resolve with manual

stretching alone, and that 10% require surgery. One stretching technique mentioned by the

author is to bring the infant’s face to neutral and gently rotate away from the affected side until

the gaze faces laterally. Another technique is to keep the face in neutral facing forward and

laterally flexing the neck to the unaffected side bringing the ear to his/her shoulder. The

stretches should be performed for 30 seconds duration, repeated 10-15 times per session at two

times per day. If manual stretching is not effective, then there are the options of surgery or

Botox injections. The physical therapist needs to train the parents on specific positions that

facilitate the infant to stretch the affected side with the use of toys, a mirror, or any other visual

cue to grab the infant’s attention. The physical therapist also needs to train the parents specific

handling techniques that facilitate the infant to stretch the affected side to be able to see them.

Parents need to be educated that the tumor in the sternocleidomastoid muscle is not malignant,

and that there are excellent outcomes with manual stretching, positioning, and handling therapy.

What is the optimal evidence based physical therapy intervention for an infant experiencing

congenital muscular torticollis (CMT)? In conclusion there are some good/fair evidence based

results from the literature on infants who are experiencing CMT. Early diagnosis within the first

three months of life and start of physical therapy treatment as early as possible is highly

important for a positive outcome (Petronic et al., 2010). There are three types of CMT and that

the sternocleidomastoid tumor group has the worse prognosis. Initial cervical rotation deficit

greater than 15deg from neutral has fair/poor outcome, and age at initial treatment greater than 1

year has fair/poor outcome (Cheng et al., 2001). Typical treatment duration to produce full neck

mobility ranges from 3 to 12 months (Emery, 1997). Time spent in prone position when awake

seems to be of greatest importance in reducing delay in early motor developmental milestones

with infants who are experiencing CMT (Ohman et al., 2009). Parents & clinicians need to be

educated on the diagnosis, and trained with evidence based management of CMT (Luther, 2002).

More high quality research needs to be performed to further answer the clinical question.

References

1.) Petronic I, Brdar R, Cirovic D, et al. Congenital Muscular Torticollis in Children: distribution, treatment duration, and outcome. Eur J Phys Rehabil Med. 2010; 45(2):153-158.

2.) Cheng J.C.Y., Wong M.W.N., Tang S.P., et al. Clinical Determinants of the Outcome of Manual Stretching in the Treatment of Congenital Muscular Torticollis in Infants. Journal of Bone and Joint Surgery. 2001; 83(5):679-687.

3.) Emery C. Conservative Management of Congenital Muscular Torticollis- Literature Review. Physical & Occupational Therapy in Pediatrics. 1997; 17(2):13-20.

4.) Ohman A, Staffan N, Lagerkvist AL, Beckung E. Are Infants with Torticollis at Risk of a Delay in Early Motor Milestones Compared with a Control Group of Healthy Infants? Developmental Medicine & Child Neurology. 2009; 51:545-550.

5.) Luther BL. Congenital Muscular Torticollis. Orthopaedic Nursing. 2002; 21(3):21-28.