congenital torticollis

[emcullingworth]

Just wondering if anyone has any protocols in place regarding the need for a cervical spine xray prior to physio for babies with congnital muscular torticollis? Or does anyone know of any evidence supporting/refuting the need for an xray before any physio/stretches/manips Thank you!

Similar Threads:

• Congenital muscular torticollis (CMT) in newsletter IOPTP issue 11 july 2013
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• Congenital Talipes Equinovarus
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[geetitrivedi]

hi all physiofriends
i m doing internship in india.i want a favour from u guys in preparing my dissertation on effects of stretching in torticollis patient.
i also want to know the indication of using ultrasound therapy in torticollis children.
i want to know any website or book from which i get more details on this topic.
waiting for ur favourable response.
bye

[1234nale]

How on earth you get such an idea to do ultrasound therapy on neonates? For ultrasound is contraindicate to be application in zone of the head (zone of highly differential cell) to adult people and yet you want to do it on new born baby (with little or no barrier to ultrasound)?
You have so much appropriate methods to threat torticolis, such as kinesytherapy and stretching as you sad, and if you want to treat hemathoma, there is electrotherapy (EF) and heat packs (before stretching, of course).
I believe this is not new for you because this is the protocol that exists for quite period of time but if you have some question about this if I can I’ll be answering to you, just PLEASE DON’T DO ULTRASOUND THERAPY ON BABY!

[alophysio]

Hi 1234nale,

I don't think the OP was talking about a newborn with torticollis (i hope!).

People often use the term to describe postural abnormalities (where an uncorrected torticollis may have been present) or acute wry neck.

Wouldn't it be nicer to check to see what he/she meant before flaming him???

So OP... what did you mean???

[Physiobase]

To make that a bit clearer for all, the term "torticollis" is used when refering to this condition in a baby/infant. For an adult the term used is a "Wry neck". So perhaps the originator can update us accordingly. 8o

[geetitrivedi]

thanks for reply.
there was some misunderstanding and i m sorry for that.
i am not talking about newborn babies.
i have a boy of 3 and half year suffering from torticollis since birth.
as i m student i have not much clinical experience so i just want to know that should ultrasound be used as a second option to stretching and proper positioning?
i m stilllerning and want to learn a lot things. so please give me proper guiadance.
waiting for your favourable reply.
bye.
have a nice day.

[Physiobase]

I would suggest ultrasound is contraindicated in this case. You must consider the patients ability to understand a warning and be able to give feedback for any type of EPA at this age. Furthermore the skeleton is still forming at this time.

The is a basic list of contraindications at www.electrotherapy.org/contraindications.htm

Some of these include but are not limited to the following:

CONTRAIDICATION
• Undiagnosed pain
• Cancer
• Active tuberculosis
• Psoriasis
• Decreased circulation
• Infection
• Pregnancy
• Central nervous system tissue
• Joint cement (cannot use continuous mode, but may use pulsed mode 50% or less)
• Plastic components
• Pacemakers
• Thrombophlebitis
• Uncontrolled bleeding or blood-thinning medication (coumadin)
• Eyes
• Reproductive organs
• Heart

PRECAUTIONS
• Acute inflammation (use non-thermal settings only)
• Epiphyseal plates (use pulsed, low intensity <0.5w/cm2)
• Decreased sensation (esp. with thermal US)
• Over implanted materials: metal reflects 90% of incident US; plastic respond like periosteum and it absorbs a large % of US; generally safe if the sound head is kept moving.

[1234nale]

After age of two years, torticollis is managed with a surgical intervention, elongation of the SCM, and that means that the end of pre-operative kinesitherapy treatment; you could consult child surgeon for that. And I’m sorry for the sharpness of my last reply, I didn’t mean to insult anyone yet in physio discussion on this site I was already found several times that opinion of application ultrasound therapy on the area of the head and that make me angry…
This discussion was designed to ask question about the things we don’t know, so go on, as long there are question there where be a different opinion…

[Physiobase]

Thanks, I would suggest a surgical intervention would be the very, very, very last possible direction in what is a fairly common problem. There is nothing to stop you doing gentle mobilitation to the neck in a NAG/Snag type of fashion. Also perhaps gain some input from someone who does craniosacral work on infants. There may be various reasons for the presentation? 8o

[alophysio]

Hi.

1234nale, I agree with you that U/S to the head is not very appropriate. In fact, I only use my U/S to muscles for psychological reasons more that physical therapeutic reasons (my opinion only of course...).

In addition to NAGs, SNAGs and MWMs, I would also use muscle energy for the C/S, massage, games (since the child is 3 years old) amongst other things.

Most importantly, i would teach the parent what they can do to help since 30mins with you doesn't go far when the average 3 year old is awake for 12 or more hours!

[1234nale]

I agree with you physiobase that this is the very common problem, and exactly because of that it is usually resolved until child’s age of two with no aggressive methods. You must have in mind that we are talking about child in very difficult age to cooperate, it to small to be told what need to do(if you want to stronger opposite SCM), and to big to be managed with stretching or other methods ( because it usually is afraid and push in wrong direction). Of course that we should try as much as possible to get trough game with child and surgery is always last possible option, but remember that child skeleton is still in growth so there is possible to develop some disorder like hemi vertebra etc or only the poor pattern of head movement (habitually). So that’s why is recommended surgery after the age of two if the state isn’t resolved with all possible kinesitherapy methods, so the child could grow properly.
Also alophysio is right, education of parents is essential in all cases.

[sdkashif]

See the following topic Torticollis

Also see Torticollis Kids

For more exercise resources see Exercise HQ

I would not recommend the use of ultrasound for torticollis. Infact, I would strongly discourage the ultrasound use in case of torticollis. See any good textbook of Electrotherapy for detail of contra indications.

For more exercise resources see Therapeutic Exercise Foundation and Techniques Third edition By Carolyn Kisner & Lynn Allen Colby and many more good textbook in this regard.

For detail of Surgcal information see good textbooks on orthopaedic and/or paediatric Surgery.

These are

Campbell's Operative Orthopaedics. 9th ed. St Louis, Mo: Mosby-Year Book.

Turek's Orthopaedics: Principles and Their Application. 5th ed. Philadelphia, Pa: Lippincott-Raven.

Apley's A System of Orthopaedics and fractures 8th edition by Louise Solomon, David J. Warwick and Selvadurai Nayagam.

Data Trace Publishing Orthopaedics

Adult-onset idiopathic torticollis

Posttraumatic painful torticollis

Idiopathic muscular torticollis in infants

[angelpriya]

I want to know the exercises for congenital torticollis in infants. Also I would like to know the rehabilitation program following surgery in a child aged 8 years for congenital torticollis. Let me know the precautions to be taken while stretching. Is traction beneficial after surgery?

Many thanks

[meganli]

It's hard to teach exercises for infants cos it's hard for them to do exactly what u need them to do. You can educate the patrents to hold the baby on the problematic side and let the righting reaction of the head stretching the SCM by side flexion.

I've done a post-op rehab to a 14-year-old. In the first few days his neck is immobilized in a soft collar. The following physiotherapy sessions are mainly passve stretching the SCM(exactly what to do to the infants, which is quite tiring to the therapists) Ultrasound and postural correction of the neck. The progression was good without any traction so I don't know if traction can be helpful.

The most important part is the postural correction. Because the child have already used to be in the habitual posture and it needs time to adapt and rehabilitate what is the true correct posture of the neck after the SCM is surgically released.

Hope these informations are useful

[neurospast]

Do not think as this child as an infant but more as an adult. What would you do with an adult in case you would chose for a "passive" treatment?
In general you should stretch actively by strengthening the "non torrticollis side" how about heading a ball side ways? pushing like a bull side ways? Make a play of it.

[physiobob]

Do not think as this child as an infant but more as an adult. What would you do with an adult in case you would chose for a "passive" treatment?
In general you should stretch actively by strengthening the "non torrticollis side" how about heading a ball side ways? pushing like a bull side ways? Make a play of it.

If you have ever had a torticollis or seen one you would not recommend this approach. There is cleary an underlying cause and there is nothing wrong with gentle mobilisation. Heading a ball ... r you crazy?

[meganli]

If you push the head sidewaysw with ball, you won't strengthen in isolation of SCM, but also upper trapezius, scalene, levator scapulae....... muscles of the neck.

If will cause muscle imbalance which will hinder postural re-education

[physiobob]

If you push the head sidewaysw with ball, you won't strengthen in isolation of SCM, but also upper trapezius, scalene, levator scapulae....... muscles of the neck. If will cause muscle imbalance which will hinder postural re-education

I totally agree with you on that one. Who would even suggest that sternocleidomastoid (SCM) is weak on one side? I have never seen an actually weak SCM, only ever overactive one's. The deep neck flexors might well be weak and also easily fatigued. Simple retractions exercises are often enough to tire them out so tread carefully. Don't focus on SCM at all as it's overactivity has been part of the problem (OK, passive stretching would be fine). Look at the thoracocervical junction and the mobility of the thoracic spine and even further down to the upper lumbar spine for a comprehensive approach to rehab in the older client where this is also known as a wry neck.

[meganli]

So, has I said that strengthening should be included in the treatment? I'd never.

[physiobob]

I agree with you and have edited my message to make it clearer on that issue. You do raise a good point about other elevators and accessories what we wish to keep quiet. We could also assess breathing patterns in the younger person to see if increased accessory mm use might be impacting on the problem. Respiratory problems can arise with positioning in the very young. That said positioning them to assist "stretch the SCM" can assist to add some passive treatment when they are resting.

p.s. There is also another discussion on torticollis in the forum. Click on the tags link and then on torticollis to find it

[neurospast]

If you have ever had a torticollis or seen one you would not recommend this approach. There is cleary an underlying cause and there is nothing wrong with gentle mobilisation. Heading a ball ... r you crazy?

You are right about the approach of heading a ball is inappropriate. You do have to realise though that active mobilisation is a far better approach than gentle passive mobilisation. Voita technique is in principle based on this and has after my observations very good results on infants. The idea is that you can inhibit one muscle by strengthening the other (in this case likely sterno cleido mastoideus).

[physiobob]

You are right about the approach of heading a ball is inappropriate. You do have to realise though that active mobilisation is a far better approach than gentle passive mobilisation. Voita technique is in principle based on this and has after my observations very good results on infants. The idea is that you can inhibit one muscle by strengthening the other (in this case likely sterno cleido mastoideus).

If in deed that muscle is not scm on the opposite side? Voita therapy is another interesting topic that we have discussed in the past on this forum with both positive and negative views. If anyone is interested the link is /forum/showthread.php?t=457&highlight=Voita

[MrPhysio+]

Hi
I have had some success with babies presenting with torticollis. One lass was seen at about 5 months of age, and is now 11, and only just reporting some mild neck stiffness on the original torticollis side. The condition occcurs due to the babies position in utero. I treated her as a baby, by firm massage, and sustained stretching, plus taught the parents to do the same. No traction. I have not had to treat her as an 11 year old, but may catch up with her soon.
The treatment is simple but effective. Obviously other risk factors must be excluded prior to treatment initiation, but that is what assessment is all about!
MrPhysio+

[sweet23]

i wanna make project on cmt .... cud u guys plz help me in any way..

i need articles..or any pics of patients..case history..assessment criteria/scales..treatement comparison.PLZ reply ASAP at surbhi_aqua84@yahoo.com.
THANKING U ALL IN ANTICIPATION..

[marticlar]

Hi,

I was wondering whether there is any difference in the duration and repetitions of stretches in paediatric patients as opposed to adult patients.

If yes, can anyone tell me the difference please?

Thanks