CONGENITAL MUSCULAR

TORTICOLLIS
DEFINITION
 CMT describes the posture of head and neck from unilateral
shortening of sternocleidomastoid muscle causing head to tilt
toward and rotate away from the affected SCM muscle.
 In addition to rotation and tilting, the infant may exhibit
asymmetric neck extension and forward head posture due to
upper cervical extension.
 It is also called wry neck or twisted neck.
Cont
 If the muscular torticollis is developed secondary to gestational
fetal constraint (versus trauma to the SCM during labour and
delivery),characteristics noted at birth may also include
deformation of craniofacial skeleton on the same side as the
affected SCM.

 These skeletal changes are caused by compression of the

anterior chest and shoulder against the face and the resultant
impact of mechanical forces on otherwise normal tissue ,
causing associated positional deformation.
SYMPTOMS
 The head tilts to one side and the chin points to the opposite
shoulder. In 75% of babies with torticollis, the muscle on the
right side of the neck is affected.
 Limited range of motion in the neck makes it difficult for the
baby to turn the head side to the side, and up and down.
 During the baby's first few weeks, a soft lump may be felt in
the affected neck muscle. This lump is not painful and
gradually goes away before the baby reaches 6 months of
age.
 One side of the face and head may flatten because the child
always sleeps on one side.
PATHOPHYSIOLOGY
 Theories includes
 Direct injury to the muscle
 Ischemic injury based on abnormal vascular pattern.
 Rupture of muscle
 Infective myositis
 Neurogenic injury
 Intrauterine compartment syndrome
 Intrauterine malposition.
 Birth trauma.
ETILOGY
 Muscular torticollis is the third most common congenital
anomaly after dislocated hip and club foot.
 Associated with muscular torticollis at birth are ipsilateral
mandibular asymmetry, ear displacement, plagiocephaly,
scoliosis etc.
RISK FACTORS
 Large birth weight
 Breech position
 Multiple birth
 Difficult labour and delievery
 Maternal uterine abnormalities.
ANATOMY OF STM
 SCM compromises of four bands, a deep band called
cleidomastoid runs from medial third of the clavicle to mastoid
process and three superficial bands form an N shaped over
the deep band. The superficial bands are cleidoccipital, insert
into the superior nuchal line of the occiput.
SUBTYPES
 Three subtypes of CMT have been identified
 STERNOCLEIDOMASTOID TUMOR
 MUSCULAR TORTICOLLIS
 POSTURAL TORTICOLLIS
STERNOCLEIDOMASTOID TUMOR
 In which a discrete mass is palpable within the SCM
muscle( 1 to 3cm in diameter) between 14 and
21days after birth.
MUSCULAR TORTICOLLIS
 In which there is a tightness but no palpable mass
within the SCM and x-rays are normal.
POSTURAL TORTICOLLIS
 In which there is SCM tightness no palpable mass
and x-rays are normal.
DIFFERNTIAL DIAGNOSIS
 One in five children presenting with a torticollis
posture has a non muscular etiology.
 Normal causes may include skeletal abnormalities
such as klippel-fliel syndrome or neurologic causes
such as brachial plexus injury.
CHANGES IN BODY STRUCTURE AND
FUNCTION
 In infants with CMT, neck range of motion is decreased for
ipsilateral rotation, contralateral lateral flexion and
contralateral asymmterical flexion and extension.
 The infant is not able to maintain mid line alignment of head
with torso in static postures or during movement because of
neck imbalances and muscle contractures
cont
 Prolonged uncontrolled head tilt caused by the underlying
mechanism of imbalanced muscle pull acting on the growing
spinal and craniofacial skeleton may worsen any scoliosis , skull
and facial asymmetry.
PLAGIOCEPHALY AND FACIAL
ASYMMETRY
 In plagiocephaly the occiput and the frontal bone
and the full face become deformed by molding
forces induced by utero constraint caused by
compression of fetal cranium between the maternal
pelvic bone and lumber sacral spine in the last
trimester.
TYPICAL ACTIVITY LIMITATION
 The young infant with CMT is unable to have purposeful
asymmetric movement of the head because of the neck muscle
contracture and neck muscle strength imbalances.
 Neglect of ipsilateral hand, decreased visual awareness of the
ipsilateral hand ,decreased visual awareness of the ipsilateral
lateral visual field , delayed rolling over the involved side and
limited vestibular , proprioceptive , and sensorimotor
development
PHYSICAL THERAPY EXAMINATION
 The physical therapy examination should include both the
prenatal and birth history
 Sex of the infant
 Side of the SCM involvement
 Other congenital anomalies,
 X-rays or other diagnostic testing
cont
 The interview with the caregiver or parent should include
questions about who provide care to the infant and the amount
of time the child spends in infant seats, car seats or other infant
positioning devices as well as amount of time spent prone and
supine.
Physical therapy intervention
 Intervention is directed toward resolving each impairment or
activity limitation identified in the physical therapy
examination.
 Intervention typically consists of passive neck ROM exercises
,active assistive ROM, strengthening and postural control
exercises.
 Correct postural alignment and education about maintaining
correct postural alignment are an integral part of
rehabilitation , with the overall goals being to restore joint and
muscle ROM.
PHYSICAL THERAPY INTERVENTION
PROTOCOL
 Neck stretching done twice daily, repeating each stretch five
times with a ten sec hold.
 Manual stretches by physiotherapist three times a week
consisting of three repetition of 15 manual stretches of the
tight SCM, held for 1sec with a ten sec rest period combined
with a prone sleeping home program.
CONTRAINDICATION FOR PROM
 Bony abnormalities
 Fractures
 Down syndrome
 Circulatory or respiratory system malignancies
 osteomyelitis
STRETCHING PROTOCOL
 To properly stretch the SCM muscle , one should stabilize at the
origin and insertion ,moving the muscle into elongated position.
 The elongated position can be attained with ipsilateral rotation
,contralateral lateral flexion and contralateral asymmetric
extension.
cont
 The infant shoulder be positioned supine with the
head and neck free of the supporting surface and
with both shoulders stabilize and held parallel to a
stable pelvis.
ORTHOTIC DEVICE
 Assistive devices that may be used to help obtain,
maintain or restrain motion include a neck collar or
a tubular orthosis for torticollis.
 Use of these devices is indicated for those infant of
children who are 4 month of age or older having a
constant head tilt of 5 degree or greater.
Instructions to caregiver
 The caregiver should be taught how to carry and hold the
infant, how to position the infant during sleep or nap time to
create a prolonged stretch of the tight muscle and promote
midline development, and how to create toys to the involved
side to facilitate reaching in a horizontal and upward
diagonal plane.