Congenital Muscular Torticolli 4

CONGENITAL MUSCULAR
TORTICOLLIS kashmala
Afzal
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.

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CONGENITAL MUSCULAR

 These skeletal changes are caused by

 In which a discrete mass is palpable

 In plagiocephaly the occiput and the

 The young infant with CMT is unable to have

 The physical therapy examination should include

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