Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved. Page 1 of 9 CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES The following congenital muscular torticollis (CMT) guidelines were developed by HSS Rehabilitation to assist clinical decision making to optimize patient outcomes with ultimate goal of patient’s full recovery. The guidelines are based on the most current evidence including 2018 Academy of Pediatric Physical Therapy Congenital Muscular Torticollis Clinical Practice Guideline, and clinical pearls from experienced clinicians. However, these guidelines are not meant to substitute for clinical reasoning and decision making. The guidelines are categorized into 3 phases. The first phase is focused on increasing cervical passive and active range of motion, increasing amount of time a child holds her/his head in midline, and promoting symmetrical gross and fine motor development. Phase 2 is focused on achieving full cervical passive and active range of motion (PROM, AROM), midline head control in supine 95% of time and 50-75% of time in other positions, and improved anti-gravity cervical muscle strength in various age-appropriate positions. At the completion of phase 3, a child is expected to present with full cervical active and passive ROM of both lateral flexion and rotation, age-appropriate anti-gravity neck strength, ability to maintain the head in midline 95% of the time in all age-appropriate developmental positions, and demonstrate no preference when performing age-appropriate functional activities such as rolling, reaching, transitions to standing. Re-assessment is recommended 3 to 12 months after discontinuation of direct services to assess if resolution is maintained as the child continues to develop and grow. If any of these findings are present in conjunction with a head tilt, refer to the appropriate specialist: • Atypical presentation • Abnormal muscle tone • Cranial deformation inconsistent with plagiocephaly • Changes in infant’s skin coloring during cervical PROM • History of acute onset • Leg length discrepancy and foot asymmetries • Late-onset CMT at 6 months or older • Suspected developmental dysplasia • Visual abnormalities FOLLOW REFERRING PROVIDER MODIFICATIONS AS PRESCRIBED
CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES
Dec 27, 2022
The guidelines are categorized into 3 phases. The first phase is focused on increasing cervical passive and active range of motion, increasing amount of time a child holds her/his head in midline, and promoting symmetrical gross and fine motor development. Phase 2 is focused on achieving full cervical passive and active range of motion (PROM, AROM), midline head control in supine 95% of time and 50-75% of time in other positions, and improved anti-gravity cervical muscle strength in various age-appropriate positions.
Welcome message from author
At the completion of phase 3, a child is expected to present with full cervical active and passive ROM
of both lateral flexion and rotation, age-appropriate anti-gravity neck strength, ability to maintain the
head in midline 95% of the time in all age-appropriate developmental positions, and demonstrate no
preference when performing age-appropriate functional activities such as rolling, reaching, transitions
to standing. Re-assessment is recommended 3 to 12 months after discontinuation of direct services
to assess if resolution is maintained as the child continues to develop and grow.
Transcript
HSSRehabilitationClinicalGuidelines-Torticollis-CongenitalMuscular-Non-operativeCopyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 1 of 9
CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES The following congenital muscular torticollis (CMT) guidelines were developed by HSS Rehabilitation to assist clinical decision making to optimize patient outcomes with ultimate goal of patient’s full recovery. The guidelines are based on the most current evidence including 2018 Academy of Pediatric Physical Therapy Congenital Muscular Torticollis Clinical Practice Guideline, and clinical pearls from experienced clinicians. However, these guidelines are not meant to substitute for clinical reasoning and decision making.
The guidelines are categorized into 3 phases. The first phase is focused on increasing cervical passive and active range of motion, increasing amount of time a child holds her/his head in midline, and promoting symmetrical gross and fine motor development. Phase 2 is focused on achieving full cervical passive and active range of motion (PROM, AROM), midline head control in supine 95% of time and 50-75% of time in other positions, and improved anti-gravity cervical muscle strength in various age-appropriate positions.
At the completion of phase 3, a child is expected to present with full cervical active and passive ROM of both lateral flexion and rotation, age-appropriate anti-gravity neck strength, ability to maintain the head in midline 95% of the time in all age-appropriate developmental positions, and demonstrate no preference when performing age-appropriate functional activities such as rolling, reaching, transitions to standing. Re-assessment is recommended 3 to 12 months after discontinuation of direct services to assess if resolution is maintained as the child continues to develop and grow.
If any of these findings are present in conjunction with a head tilt, refer to the appropriate specialist:
• Atypical presentation • Abnormal muscle tone • Cranial deformation inconsistent with plagiocephaly • Changes in infant’s skin coloring during cervical PROM • History of acute onset • Leg length discrepancy and foot asymmetries • Late-onset CMT at 6 months or older • Suspected developmental dysplasia • Visual abnormalities
FOLLOW REFERRING PROVIDER MODIFICATIONS AS PRESCRIBED
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 2 of 9
CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES Phase 1: Weeks 1-8 PRECAUTIONS
• Keep the infant’s neck in a neutral position during stretches • Do not stretch infant’s neck in a flexed or hyperextended position • Keep the stretches slow and gentle • Stop if you observe any signs of discomfort or pain during the treatment • Watch for compensations (faulty movement patterns)
ASSESSMENT • Examine body structures
o Infant posture and tolerance to the supine, prone, sitting, and standing positions for body symmetry with or without support as appropriate for infant’s age
o Bilateral PROM into cervical rotation and lateral flexion o Bilateral AROM into cervical rotation and lateral flexion o PROM and AROM of trunk and upper and lower extremities o Cervical muscle strength using Muscle Function Scale (MFS) o Pain and discomfort at rest and during PROM/AROM o Skin integrity, symmetry of neck and hip skin folds, presence and location of a
sternocleidomastoid (SCM), and size, shape and elasticity of the SCM and secondary muscles
o Craniofacial asymmetries and head/skull shape (Argenta scale or Cranial Vault Asymmetry Index (CVAI), and Cephalic Ratio (CR)
• Classify level of severity using CMT Severity Classification Scale (CMT-SCS) • Examine activity and developmental status
o Types of and tolerance to position changes o Motor development for movement symmetry and milestones o May use standardized test such as Peabody 2, AIMS, TIMP
• Examine participation status o Positioning when awake and asleep o Infant time spent in prone position o Whether parent is alternating sides when breast- or bottle-feeding the infant o Infant time spend in positioning devices
• Determine prognosis
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 3 of 9
TREATMENT RECOMMENDATIONS • Provide these 5 components as the first-choice interventions:
o Neck PROM and neck and trunk AROM o Development of symmetrical movement o Environmental adaptations o Parent/caregiver education o Positioning, gentle manual stretching and home programs
• Additional/supplemental interventions: o Kinesiological tape o Manual techniques:
Myofascial/soft tissue mobilization to the SCM and surrounding tissues, upper trapezius, upper chest, shoulder girdle, scapulohumeral muscles
o Tubular orthosis for torticollis (TOTTM) collar o Microcurrent
• Parent’s return demonstration to support parent learning • Strengthening exercises for the neck and trunk (gravity assisted) • Righting reactions in supine, prone and side-lying • Mild vestibular techniques to encourage eyes horizontal
CRITERIA FOR ADVANCEMENT
• Increased cervical rotation PROM to the uninvolved side by 10°-15° • Increased cervical lateral flexion PROM to the involved side by 10°-15° • Able to maintain head in midline in supine for 50% of the time • Able to rotate head from side to side in supine to track a toy in available ROM • Able to right head to midline in side-lying and supported sitting away from the involved side • Able to hold head in cervical extension for 10 seconds in prone position • Able to maintain forearm prone prop with weight-bearing on the upper extremity on the
involved side • Demonstrates age-appropriate head righting reactions 50% of the ROM during facilitated
rolling • Caregiver’s independence and compliance with home exercise program (HEP)
EMPHASIZE • Increasing cervical PROM • Increasing cervical and trunk AROM • Midline head control in age-appropriate developmental positions • Symmetrical gross motor skills development • Parent/caregiver education and coaching during each session • Parent/caregiver compliance with HEP
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 4 of 9
CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES Phase 2: Weeks 9-16 PRECAUTIONS
• Keep the infant’s neck in a neutral position during stretches • Keep the stretches slow and gentle • Stop if you observe any signs of discomfort or pain during the treatment • Watch for compensations (faulty movement patterns)
ASSESSMENT
• Examine body structures o Infant posture and tolerance to the all developmentally appropriate positions for body
symmetry with or without support o Bilateral PROM into cervical rotation and lateral flexion o Bilateral AROM into cervical rotation and lateral flexion o PROM and AROM of trunk and upper and lower extremities o Cervical muscle strength (MFS) o Craniofacial asymmetries and head/skull shape (Argenta scale or CVAI, CR)
• Examine activity and developmental status o Types of and tolerance to position changes o Motor development for movement symmetry and milestones
• Examine participation status • Determine prognosis
TREATMENT RECOMMENDATIONS Continue 5 components as the first-choice interventions:
• Neck PROM • Neck and trunk AROM • Development of symmetrical movement • Environmental adaptations • Parent/caregiver education
Additional/supplemental interventions:
• Active head rotation in all postures • Concentric strengthening exercises for the neck and trunk (against gravity) in supine, prone
and side-lying • Eccentric neck and trunk strengthening • Righting and equilibrium reactions in supine, prone, side-lying, sitting and vertical suspension
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 5 of 9
• Myofascial/soft tissue mobilization to maintain mobility of the neck, upper chest, and shoulder girdle
• Transitional movements and symmetrical weight-shifting skills • Ball activities • Vestibular techniques • Kinesiological taping • Microcurrent
CRITERIA FOR ADVANCEMENT
• Full cervical PROM • Increase in cervical AROM with emerging head control in midline • Able to maintain head in midline in supine for 100% of the time • Able to rotate head from side to side in all age-appropriate developmental positions to track a
toy in available ROM • Able to maintain head in midline in supported or independent sitting 50% of time • Able to hold head in cervical extension for at least 60 seconds in prone position • Able to maintain forearm prone prop with symmetrical weight-bearing • Demonstrates age-appropriate head righting reactions at least 75% of the ROM during
facilitated rolling • Caregiver’s independence and compliance with HEP
EMPHASIZE
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 6 of 9
CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES Phase 3: Weeks 17-24 PRECAUTIONS
• Keep the infant’s neck in a neutral position during stretches • Do not stretch infant’s neck in a flexed or hyperextended position • Keep the stretches slow and gentle • Stop if you observe any signs of discomfort or pain during the treatment • Watch for compensations (faulty movement patterns)
ASSESSMENT
• Examine body structures o Infant posture and tolerance to all developmentally appropriate positions for body
symmetry o Bilateral AROM into cervical rotation and lateral flexion o PROM and AROM of trunk and upper and lower extremities o Cervical muscle strength (MFS) o Craniofacial asymmetries and head/skull shape (Argenta scale or CVAI, CR)
• Examine activity and developmental status o Types of and tolerance to position changes o Motor development for movement symmetry and milestones o Recommended use of standardized age-appropriate test
• Examine participation status • Determine prognosis
TREATMENT RECOMMENDATIONS
In addition to strategies listed in Phase 2: • Normalizing balance and equilibrium reactions sequences and timing • Protective extension exercises • Advanced therapeutic ball activities • Advanced scapula stabilization exercises • Bimanual activities • Proprioception exercises • Use tactile, visual, and vestibular feedback • Tubular Orthosis for Torticollis (TOTTM) collar
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 7 of 9
CRITERIA FOR DISCHARGE • Full cervical PROM • Head in midline 95% of time in all developmentally appropriate positions • Symmetrical active movement patterns • Age-appropriate motor development • Age-appropriate and symmetrical neck strength • Full active cervical rotation to the involved side without compensations • Demonstrates no preference when performing functional activities • Parents understand what to monitor as the child grows
EMPHASIZE
• Maintaining full cervical PROM • Maintaining full cervical AROM • Midline head control in age-appropriate developmental positions without compensations • Symmetrical and age-appropriate gross motor skills development • Parent/caregiver education and coaching during each session • Parent/caregiver compliance with HEP • Parents understanding what to monitor as the child grows • Need for reassessment 3-12 months after discharge
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 8 of 9
CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES References
Bess LK, Costa J, Nguygen ATH, Amankwah E, Wilsey MJ. Prevalence of gastroesophageal reflux disease in infants with congenital muscular torticollis: a prospective cohort study. Pediatr Phys Ther. 2022 Apr 1;34(2):180-183.
Cheng JCY, Tang SP, Chen TMK, Wong MWN, Wong EMC. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants—a study of 1,086 cases. J Pediatr Surg. 2000;35(7):1091-1096.
Cheng JCY, Wong MWN, Tang SP, Chen TMK, Shum SLF, Wong EMC. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. J Bone Joint Surg Am. 2001;83-A(5):679-687.
Emery C. The determinants of treatment duration for congenital muscular torticollis. Phys Ther. 1994;74:921-9.
Fradette J, Gagnon I, Kennedy E, et al. Clinical decision making regarding intervention needs of infants with torticollis. Pediatr Phys Ther. Fall 2011;23(3):249-256.
Greve KR, Goldsbury CM, Simmons EA. infants with congenital muscular torticollis requiring supplemental physical therapy interventions. Pediatr Phys Ther. 2022 Jul 1;34(3):335-341.
Greve KR, Perry RA, Mischnick AK. Infants with torticollis who changed head presentation during a physical therapy episode. Pediatr Phys Ther. 2022 Apr 1;34(2):185-191.
Greve KR, Sweeney JK, Bailes AF, Van Sant AF. Infants with congenital muscular torticollis: demographic factors, clinical characteristics, and physical therapy episode of care. Pediatr Phys Ther. 2022 Jul 1;34(3):343-351.
Heidenreich E, Johnson R, Sargent B. Informing the update to the physical therapy management of congenital muscular torticollis evidence-based clinical practice guideline. Pediatr Phys Ther. 2018 Jul;30(3):164-175.
Kahraman A, Büüan Oruç S, Erdoan D, Mutlu A. Analysis of spontaneous movements in infants with torticollis. Pediatr Phys Ther. 2022 Jan 1;34(1):17-21.
Kaplan SL, Coulter C, Fetters L. Physical therapy management of congenital muscular torticollis: an evidence-based clinical practice guideline. Pediatr Phys Ther. 2013;25:348-394.
Kaplan SL, Coulter C, Sargent B. Physical therapy management of congenital muscular torticollis: A 2018 evidence-based clinical practice guideline: From the section on Pediatrics of the American Physical Therapy Association. Pediatr Phys Ther. 2018;30(4):240-290.
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 9 of 9
Kaplan S, Sargent B, Coulter C. Congenital muscular torticollis. In: Palisano RJ, ed. Campbell’s Physical therapy for children. 5th ed. St. Louis, Missouri: Elsevier; 2017:184-206.
Karmel-Ross K, Lepp M. Assessment and Treatment of Children with Congenital Muscular Torticollis. Physical & Occupational Therapy in Pediatrics. 1997;17:21-68.
Karmel-Ross K. Congenital muscular torticollis. In: Campbell SK, ed. Physical Therapy for Children. 4th ed. St Louis, MO: Saunders Elsevier; 2012:359-380.
Kim MY, Kwon DR, Lee HI. Therapeutic effect of microcurrent therapy in infants with congenital muscular torticollis. PMR. 2009 Aug;1(8):736-9.
Kwon DR, Park GY. Efficacy of microcurrent therapy in infants with congenital muscular torticollis involving the entire sternocleidomastoid muscle: a randomized placebo-controlled trial. Clin Rehabil. 2017;31(8):983-91.
Rabino SR, Peretz SR, Kastel-Deutch T, Tirosh E. Factors affecting parental adherence to an intervention program for congenital torticollis. Pediatr Phys Ther. 2013;25:298-303.
Rahlin M, Barnett J, Sarmiento B. Functional Symmetry Observation Scale, Version 2: Development and Content Validation Using a Modified Delphi Method. Pediatr Phys Ther. 2022 Jan 1;34(1):37-44.
Ohman A, Nilsson S, Beckung E. Stretching treatment for infants with congenital muscular torticollis: physiotherapist or parents? A randomized pilot study. PMR. Dec 2010;2(12):1073-1079.
Ohman A, Mardbrink EL, Stensby J, Beckung E. Evaluation of treatment strategies for muscle function in infants with congenital muscular torticollis. Physiother Theory Pract. 2011;27:463-70.
Oledzka M, Kaplan SL, Sweeney JK, Coulter C, Evans-Rogers DL. Interrater and intrarater reliability of the congenital muscular torticollis severity classification system. Pediatr Phys Ther.2018: 30:176- 82.
Rabino SR, Peretz SR, Kastel-Deutch T, Tirosh E. Factors affecting parental adherence to an intervention program for congenital torticollis. Pediatr Phys Ther. 2013;25:298-303.
Ryu JH, Kim DW, Kim SH, et al. Factors correlating outcome in young infants with congenital muscular torticollis. Can Assoc Radiol J. 2016;67:82-87.
Schertz M, Zuk L, Zin S, Nadam L, Schwartz D, Bienkowski RS. Motor and cognitive development at one-year follow-up in infants with torticollis. Early Hum Dev. 2008;84(1):9-14.
Thompson R, Kaplan SL. Frequency-specific microcurrent for treatment of longstanding congenital muscular torticollis. Pediatr Phys Ther. 2019 Apr;31(2):E8-E15.
Created 6/2020 Revised 9/2022
Page 1 of 9
CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES The following congenital muscular torticollis (CMT) guidelines were developed by HSS Rehabilitation to assist clinical decision making to optimize patient outcomes with ultimate goal of patient’s full recovery. The guidelines are based on the most current evidence including 2018 Academy of Pediatric Physical Therapy Congenital Muscular Torticollis Clinical Practice Guideline, and clinical pearls from experienced clinicians. However, these guidelines are not meant to substitute for clinical reasoning and decision making.
The guidelines are categorized into 3 phases. The first phase is focused on increasing cervical passive and active range of motion, increasing amount of time a child holds her/his head in midline, and promoting symmetrical gross and fine motor development. Phase 2 is focused on achieving full cervical passive and active range of motion (PROM, AROM), midline head control in supine 95% of time and 50-75% of time in other positions, and improved anti-gravity cervical muscle strength in various age-appropriate positions.
At the completion of phase 3, a child is expected to present with full cervical active and passive ROM of both lateral flexion and rotation, age-appropriate anti-gravity neck strength, ability to maintain the head in midline 95% of the time in all age-appropriate developmental positions, and demonstrate no preference when performing age-appropriate functional activities such as rolling, reaching, transitions to standing. Re-assessment is recommended 3 to 12 months after discontinuation of direct services to assess if resolution is maintained as the child continues to develop and grow.
If any of these findings are present in conjunction with a head tilt, refer to the appropriate specialist:
• Atypical presentation • Abnormal muscle tone • Cranial deformation inconsistent with plagiocephaly • Changes in infant’s skin coloring during cervical PROM • History of acute onset • Leg length discrepancy and foot asymmetries • Late-onset CMT at 6 months or older • Suspected developmental dysplasia • Visual abnormalities
FOLLOW REFERRING PROVIDER MODIFICATIONS AS PRESCRIBED
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 2 of 9
CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES Phase 1: Weeks 1-8 PRECAUTIONS
• Keep the infant’s neck in a neutral position during stretches • Do not stretch infant’s neck in a flexed or hyperextended position • Keep the stretches slow and gentle • Stop if you observe any signs of discomfort or pain during the treatment • Watch for compensations (faulty movement patterns)
ASSESSMENT • Examine body structures
o Infant posture and tolerance to the supine, prone, sitting, and standing positions for body symmetry with or without support as appropriate for infant’s age
o Bilateral PROM into cervical rotation and lateral flexion o Bilateral AROM into cervical rotation and lateral flexion o PROM and AROM of trunk and upper and lower extremities o Cervical muscle strength using Muscle Function Scale (MFS) o Pain and discomfort at rest and during PROM/AROM o Skin integrity, symmetry of neck and hip skin folds, presence and location of a
sternocleidomastoid (SCM), and size, shape and elasticity of the SCM and secondary muscles
o Craniofacial asymmetries and head/skull shape (Argenta scale or Cranial Vault Asymmetry Index (CVAI), and Cephalic Ratio (CR)
• Classify level of severity using CMT Severity Classification Scale (CMT-SCS) • Examine activity and developmental status
o Types of and tolerance to position changes o Motor development for movement symmetry and milestones o May use standardized test such as Peabody 2, AIMS, TIMP
• Examine participation status o Positioning when awake and asleep o Infant time spent in prone position o Whether parent is alternating sides when breast- or bottle-feeding the infant o Infant time spend in positioning devices
• Determine prognosis
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 3 of 9
TREATMENT RECOMMENDATIONS • Provide these 5 components as the first-choice interventions:
o Neck PROM and neck and trunk AROM o Development of symmetrical movement o Environmental adaptations o Parent/caregiver education o Positioning, gentle manual stretching and home programs
• Additional/supplemental interventions: o Kinesiological tape o Manual techniques:
Myofascial/soft tissue mobilization to the SCM and surrounding tissues, upper trapezius, upper chest, shoulder girdle, scapulohumeral muscles
o Tubular orthosis for torticollis (TOTTM) collar o Microcurrent
• Parent’s return demonstration to support parent learning • Strengthening exercises for the neck and trunk (gravity assisted) • Righting reactions in supine, prone and side-lying • Mild vestibular techniques to encourage eyes horizontal
CRITERIA FOR ADVANCEMENT
• Increased cervical rotation PROM to the uninvolved side by 10°-15° • Increased cervical lateral flexion PROM to the involved side by 10°-15° • Able to maintain head in midline in supine for 50% of the time • Able to rotate head from side to side in supine to track a toy in available ROM • Able to right head to midline in side-lying and supported sitting away from the involved side • Able to hold head in cervical extension for 10 seconds in prone position • Able to maintain forearm prone prop with weight-bearing on the upper extremity on the
involved side • Demonstrates age-appropriate head righting reactions 50% of the ROM during facilitated
rolling • Caregiver’s independence and compliance with home exercise program (HEP)
EMPHASIZE • Increasing cervical PROM • Increasing cervical and trunk AROM • Midline head control in age-appropriate developmental positions • Symmetrical gross motor skills development • Parent/caregiver education and coaching during each session • Parent/caregiver compliance with HEP
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 4 of 9
CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES Phase 2: Weeks 9-16 PRECAUTIONS
• Keep the infant’s neck in a neutral position during stretches • Keep the stretches slow and gentle • Stop if you observe any signs of discomfort or pain during the treatment • Watch for compensations (faulty movement patterns)
ASSESSMENT
• Examine body structures o Infant posture and tolerance to the all developmentally appropriate positions for body
symmetry with or without support o Bilateral PROM into cervical rotation and lateral flexion o Bilateral AROM into cervical rotation and lateral flexion o PROM and AROM of trunk and upper and lower extremities o Cervical muscle strength (MFS) o Craniofacial asymmetries and head/skull shape (Argenta scale or CVAI, CR)
• Examine activity and developmental status o Types of and tolerance to position changes o Motor development for movement symmetry and milestones
• Examine participation status • Determine prognosis
TREATMENT RECOMMENDATIONS Continue 5 components as the first-choice interventions:
• Neck PROM • Neck and trunk AROM • Development of symmetrical movement • Environmental adaptations • Parent/caregiver education
Additional/supplemental interventions:
• Active head rotation in all postures • Concentric strengthening exercises for the neck and trunk (against gravity) in supine, prone
and side-lying • Eccentric neck and trunk strengthening • Righting and equilibrium reactions in supine, prone, side-lying, sitting and vertical suspension
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 5 of 9
• Myofascial/soft tissue mobilization to maintain mobility of the neck, upper chest, and shoulder girdle
• Transitional movements and symmetrical weight-shifting skills • Ball activities • Vestibular techniques • Kinesiological taping • Microcurrent
CRITERIA FOR ADVANCEMENT
• Full cervical PROM • Increase in cervical AROM with emerging head control in midline • Able to maintain head in midline in supine for 100% of the time • Able to rotate head from side to side in all age-appropriate developmental positions to track a
toy in available ROM • Able to maintain head in midline in supported or independent sitting 50% of time • Able to hold head in cervical extension for at least 60 seconds in prone position • Able to maintain forearm prone prop with symmetrical weight-bearing • Demonstrates age-appropriate head righting reactions at least 75% of the ROM during
facilitated rolling • Caregiver’s independence and compliance with HEP
EMPHASIZE
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 6 of 9
CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES Phase 3: Weeks 17-24 PRECAUTIONS
• Keep the infant’s neck in a neutral position during stretches • Do not stretch infant’s neck in a flexed or hyperextended position • Keep the stretches slow and gentle • Stop if you observe any signs of discomfort or pain during the treatment • Watch for compensations (faulty movement patterns)
ASSESSMENT
• Examine body structures o Infant posture and tolerance to all developmentally appropriate positions for body
symmetry o Bilateral AROM into cervical rotation and lateral flexion o PROM and AROM of trunk and upper and lower extremities o Cervical muscle strength (MFS) o Craniofacial asymmetries and head/skull shape (Argenta scale or CVAI, CR)
• Examine activity and developmental status o Types of and tolerance to position changes o Motor development for movement symmetry and milestones o Recommended use of standardized age-appropriate test
• Examine participation status • Determine prognosis
TREATMENT RECOMMENDATIONS
In addition to strategies listed in Phase 2: • Normalizing balance and equilibrium reactions sequences and timing • Protective extension exercises • Advanced therapeutic ball activities • Advanced scapula stabilization exercises • Bimanual activities • Proprioception exercises • Use tactile, visual, and vestibular feedback • Tubular Orthosis for Torticollis (TOTTM) collar
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 7 of 9
CRITERIA FOR DISCHARGE • Full cervical PROM • Head in midline 95% of time in all developmentally appropriate positions • Symmetrical active movement patterns • Age-appropriate motor development • Age-appropriate and symmetrical neck strength • Full active cervical rotation to the involved side without compensations • Demonstrates no preference when performing functional activities • Parents understand what to monitor as the child grows
EMPHASIZE
• Maintaining full cervical PROM • Maintaining full cervical AROM • Midline head control in age-appropriate developmental positions without compensations • Symmetrical and age-appropriate gross motor skills development • Parent/caregiver education and coaching during each session • Parent/caregiver compliance with HEP • Parents understanding what to monitor as the child grows • Need for reassessment 3-12 months after discharge
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 8 of 9
CONGENITAL MUSCULAR TORTICOLLIS NON-OPERATIVE GUIDELINES References
Bess LK, Costa J, Nguygen ATH, Amankwah E, Wilsey MJ. Prevalence of gastroesophageal reflux disease in infants with congenital muscular torticollis: a prospective cohort study. Pediatr Phys Ther. 2022 Apr 1;34(2):180-183.
Cheng JCY, Tang SP, Chen TMK, Wong MWN, Wong EMC. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants—a study of 1,086 cases. J Pediatr Surg. 2000;35(7):1091-1096.
Cheng JCY, Wong MWN, Tang SP, Chen TMK, Shum SLF, Wong EMC. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. J Bone Joint Surg Am. 2001;83-A(5):679-687.
Emery C. The determinants of treatment duration for congenital muscular torticollis. Phys Ther. 1994;74:921-9.
Fradette J, Gagnon I, Kennedy E, et al. Clinical decision making regarding intervention needs of infants with torticollis. Pediatr Phys Ther. Fall 2011;23(3):249-256.
Greve KR, Goldsbury CM, Simmons EA. infants with congenital muscular torticollis requiring supplemental physical therapy interventions. Pediatr Phys Ther. 2022 Jul 1;34(3):335-341.
Greve KR, Perry RA, Mischnick AK. Infants with torticollis who changed head presentation during a physical therapy episode. Pediatr Phys Ther. 2022 Apr 1;34(2):185-191.
Greve KR, Sweeney JK, Bailes AF, Van Sant AF. Infants with congenital muscular torticollis: demographic factors, clinical characteristics, and physical therapy episode of care. Pediatr Phys Ther. 2022 Jul 1;34(3):343-351.
Heidenreich E, Johnson R, Sargent B. Informing the update to the physical therapy management of congenital muscular torticollis evidence-based clinical practice guideline. Pediatr Phys Ther. 2018 Jul;30(3):164-175.
Kahraman A, Büüan Oruç S, Erdoan D, Mutlu A. Analysis of spontaneous movements in infants with torticollis. Pediatr Phys Ther. 2022 Jan 1;34(1):17-21.
Kaplan SL, Coulter C, Fetters L. Physical therapy management of congenital muscular torticollis: an evidence-based clinical practice guideline. Pediatr Phys Ther. 2013;25:348-394.
Kaplan SL, Coulter C, Sargent B. Physical therapy management of congenital muscular torticollis: A 2018 evidence-based clinical practice guideline: From the section on Pediatrics of the American Physical Therapy Association. Pediatr Phys Ther. 2018;30(4):240-290.
Copyright © 2020-2022 by Hospital for Special Surgery. All rights reserved.
Page 9 of 9
Kaplan S, Sargent B, Coulter C. Congenital muscular torticollis. In: Palisano RJ, ed. Campbell’s Physical therapy for children. 5th ed. St. Louis, Missouri: Elsevier; 2017:184-206.
Karmel-Ross K, Lepp M. Assessment and Treatment of Children with Congenital Muscular Torticollis. Physical & Occupational Therapy in Pediatrics. 1997;17:21-68.
Karmel-Ross K. Congenital muscular torticollis. In: Campbell SK, ed. Physical Therapy for Children. 4th ed. St Louis, MO: Saunders Elsevier; 2012:359-380.
Kim MY, Kwon DR, Lee HI. Therapeutic effect of microcurrent therapy in infants with congenital muscular torticollis. PMR. 2009 Aug;1(8):736-9.
Kwon DR, Park GY. Efficacy of microcurrent therapy in infants with congenital muscular torticollis involving the entire sternocleidomastoid muscle: a randomized placebo-controlled trial. Clin Rehabil. 2017;31(8):983-91.
Rabino SR, Peretz SR, Kastel-Deutch T, Tirosh E. Factors affecting parental adherence to an intervention program for congenital torticollis. Pediatr Phys Ther. 2013;25:298-303.
Rahlin M, Barnett J, Sarmiento B. Functional Symmetry Observation Scale, Version 2: Development and Content Validation Using a Modified Delphi Method. Pediatr Phys Ther. 2022 Jan 1;34(1):37-44.
Ohman A, Nilsson S, Beckung E. Stretching treatment for infants with congenital muscular torticollis: physiotherapist or parents? A randomized pilot study. PMR. Dec 2010;2(12):1073-1079.
Ohman A, Mardbrink EL, Stensby J, Beckung E. Evaluation of treatment strategies for muscle function in infants with congenital muscular torticollis. Physiother Theory Pract. 2011;27:463-70.
Oledzka M, Kaplan SL, Sweeney JK, Coulter C, Evans-Rogers DL. Interrater and intrarater reliability of the congenital muscular torticollis severity classification system. Pediatr Phys Ther.2018: 30:176- 82.
Rabino SR, Peretz SR, Kastel-Deutch T, Tirosh E. Factors affecting parental adherence to an intervention program for congenital torticollis. Pediatr Phys Ther. 2013;25:298-303.
Ryu JH, Kim DW, Kim SH, et al. Factors correlating outcome in young infants with congenital muscular torticollis. Can Assoc Radiol J. 2016;67:82-87.
Schertz M, Zuk L, Zin S, Nadam L, Schwartz D, Bienkowski RS. Motor and cognitive development at one-year follow-up in infants with torticollis. Early Hum Dev. 2008;84(1):9-14.
Thompson R, Kaplan SL. Frequency-specific microcurrent for treatment of longstanding congenital muscular torticollis. Pediatr Phys Ther. 2019 Apr;31(2):E8-E15.
Created 6/2020 Revised 9/2022
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