-
Official Document
Physical Therapy Management ofCongenital Muscular Torticollis:An
Evidence-Based ClinicalPractice GuidelineFROM THE SECTION ON
PEDIATRICS OF THE AMERICANPHYSICAL THERAPY ASSOCIATION
Sandra L. Kaplan, PT, DPT, PhD; Colleen Coulter, PT, DPT, PhD,
PCS; Linda Fetters, PT, PhD, FAPTA
Department of Rehabilitation and Movement Sciences (Dr Kaplan),
Doctoral Programs in Physical Therapy, Rutgers, TheState University
of New Jersey, Newark, New Jersey; Children’s Healthcare of Atlanta
(Dr Coulter), Orthotics andProsthetics Department, Atlanta,
Georgia; Division of Biokinesiology and Physical Therapy at the
Herman Ostrow Schoolof Dentistry, Department of Pediatrics (Dr
Fetters), Keck School of Medicine, University of Southern
California, LosAngeles, California.
Correspondence: Sandra L. Kaplan, PT, DPT, PhD,Doctoral Programs
in Physical Therapy, Rehabilitationand Movement Sciences, Rutgers,
The State University ofNew Jersey, 65 Bergen Street, Room 718C,
Newark,NJ 07107 ([email protected]).Grant Support:
The Section on Pediatrics, AmericanPhysical Therapy Association,
provided funds to supportthe development and preparation of this
document.The authors declare no conflicts of interest.
The American Physical Therapy Association Sectionon Pediatrics
welcomes comments on this guideline.Comments may be sent to the
corresponding author orto [email protected]. This guideline
may bereproduced for educational and implementationpurposes.
Reviewers: Andrea Perry Block (Parent and publicrepresentative);
Carol Burch, PT, DPT, MEd; FernandoBurstein, MD; Elaine K.
Diegmann, CNM, ND, FACNM;Joe Godges, PT, DPT; Didem Inanoglu, MD;
Lynn Jeffries,PT, DPT, PhD, PCS; Anna Ohman, PT, PhD; ScottParrott,
PhD; Melanie Percy, RN, PhD, CPNP, FAAN;Alex Van Speybroeck,
MD.
Supplemental digital content is available for this
article.Direct URL citations appear in the printed text and
areprovided in the HTML and PDF versions of this article onthe
journal’s Web site (www.pedpt.com).
DOI: 10.1097/PEP.0b013e3182a778d2
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
348 Kaplan et al Pediatric Physical Therapy
mailto:[email protected]
-
A B S T R A C T
Background: Congenital muscular torticollis(CMT) is an
idiopathic postural deformity evidentshortly after birth, typically
characterized by lateralflexion of the head to one side and
cervical rota-tion to the opposite side due to unilateral
shorten-ing of the sternocleidomastoid muscle. CMT maybe
accompanied by other neurological or muscu-loskeletal conditions.
Key Points: Infants withCMT are frequently referred to physical
therapists(PTs) to treat their asymmetries. This
evidence-basedclinical practice guideline (CPG) provides guidanceon
which infants should be monitored, treated,and/or referred, and
when and what PTs shouldtreat. Based upon critical appraisal of
literature andexpert opinion, 16 action statements for screen-ing,
examination, intervention, and follow-up arelinked with explicit
levels of evidence. The CPG ad-dresses referral, screening,
examination and eval-uation, prognosis, first-choice and
supplementalinterventions, consultation, discharge,
follow-up,suggestions for implementation and complianceaudits, flow
sheets for referral paths and classifi-cation of CMT severity, and
research recommenda-tions. (Pediatr Phys Ther 2013;25:348–394)
Keywords: congenital muscular torticollis, evidence-based practice,
infant, physical therapy, practiceguideline
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
Pediatric Physical Therapy Congenital Muscular Torticollis
Practice Guidelines 349
-
T A B L E O F C O N T E N T S
INTRODUCTION AND METHODS
Levels of Evidence and Grades of Recommendations . . . . . . . .
. . . . . . . . . . . . . . . . . . . . 351
Summary of Action Statements. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
352
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 356
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 357
CONGENITAL MUSCULAR TORTICOLLIS RECOMMENDATIONS
Congenital Muscular Torticollis . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
360
Action Statements 1-6: Identification and Referral . . . . . . .
. . . . . . . . . . . . . . . . . . . . . 361
Action Statements 7-11: Physical Therapy Examination... . . . .
. . . . . . . . . . . . . . . . . 365
Action Statements 12-14: Physical Therapy Intervention. . . . .
. . . . . . . . . . . . . . . . . 378
Action Statement 15-16: Discharge and Follow-up . . . . . . . .
. . . . . . . . . . . . . . . . . . . . 385
Guideline Implementation Recommendations.. . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 387
Summary of Research Recommendations . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 388
ACKNOWLEDGMENTS, REFERENCES, AND APPENDICES
Acknowledgments.. . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 388
References . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 389
Appendix 1: ICF and ICD 10 Codes.. . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Appendix 2: Operational Definitions. . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
TABLES AND FIGURES
Figure 1: Referral Flow Diagram.. . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
353
Figure 2: Congenital Muscular Torticollis Classification Grades
and DecisionTree. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . 354
Table 1: Levels of Evidence.. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
351
Table 2: Grades of Recommendations for Action Statements . . . .
. . . . . . . . . . . . . . . . 351
Table 3: Measurement Evidence Table. . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Table 4: Passive Stretching Evidence Table. . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 380
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
350 Kaplan et al Pediatric Physical Therapy
-
L E V E L S O F E V I D E N C E A N D G R A D E S O F R E C O M
M E N D A T I O N S
This clinical practice guideline for physical therapymanagement
of infants with congenital muscular torticol-lis (CMT) is intended
as a reference document to guidephysical therapy practice and to
inform the need for con-tinued research related to physical therapy
management ofCMT. The methods of critical appraisal, assigning
levelsof evidence to the literature, and summating the evidenceto
assign grades to the recommended action statementsfollow accepted
international methodologies of evidence-based practice. The
document is organized to present thedefinitions of the levels of
evidence and grades for actionstatements (Tables 1 and 2), the list
of 16 action statements,followed by the descriptions of the aims,
methods, and eachaction statement with a standardized profile of
informationthat meets the Institute of Medicine’s criteria for
transpar-ent clinical practice guidelines. The 16 action
statementsare organized under 4 major headings: Identification
andReferral of Infants with CMT; Physical Therapy Examina-
TABLE 1: LEVEL OF EVIDENCE
LEVEL CRITERIA
I Evidence obtained from high-quality diagnostic studies,
prognostic or prospective studies, cohort studies or
randomizedcontrolled trials, meta-analyses or systematic reviews
(critical appraisal score >50% of criteria)
II Evidence obtained from lesser-quality diagnostic studies,
prognostic or prospective studies, cohort studies or
randomizedcontrolled trials, meta-analyses or systematic reviews
(eg, weaker diagnostic criteria and reference standards,
improperrandomization, no blinding,
-
S U M M A R Y O F A C T I O N S T A T E M E N T S
IDENTIFICATION AND REFERRAL OF INFANTS WITHCONGENITAL MUSCULAR
TORTICOLLIS (CMT)
A. Action Statement 1: IDENTIFY NEWBORNS ATRISK FOR CMT.
Physicians, nurse midwives, obstet-rical nurses, nurse
practitioners, lactation specialists,physical therapists (PTs), or
any clinician or family mem-ber must assess the presence of neck
and/or facial orcranial asymmetry within the first 2 days of birth,
usingpassive cervical rotation, passive lateral flexion,
and/orvisual observation as their respective training supports,when
in the newborn nursery or at time of delivery. (Ev-idence Quality:
I; Recommendation Strength: Strong)
B. Action Statement 2: REFER INFANTS WITHASYMMETRIES TO
PHYSICIAN AND PHYSICALTHERAPIST. Physicians, nurse midwives,
obstetricalnurses, nurse practitioners, lactation specialists,
PTs,or any clinician or family member should refer
infantsidentified as having positional preference, reduced
cer-vical range of motion, sternocleidomastoid masses, fa-cial
asymmetry and/or plagiocephaly to the primarypediatrician, and a PT
as soon as the asymmetry isnoted (Figure 1). (Evidence Quality: II;
RecommendationStrength: Moderate)
B. Action Statement 3: DOCUMENT INFANT HIS-TORY. Physical
therapists should obtain a general med-ical and developmental
history of the infant prior to aninitial screening, including 9
specific health history fac-tors: age at initial visit, age of
symptom onset, pregnancyhistory, delivery history including birth
presentation anduse of assistance, head posture/preference, family
his-tory of CMT, other known or suspected medical condi-tions, and
developmental milestones. (Evidence Quality:II; Recommendation
Strength: Moderate)
B. Action Statement 4: SCREEN INFANTS. When aclinician, parent,
or caretaker indicates concern abouthead or neck posture and/or
developmental progres-sion, PTs should perform a screen of the
neurological,musculoskeletal, integumentary, and
cardiopulmonarysystems, including screens of vision,
gastrointestinalfunctions, positional preference and the structural
andmovement symmetry of the neck, face, and head, spineand trunk,
hips, upper and lower extremities, consistentwith state practice
acts. (Evidence Quality: 22-15; Rec-ommendation Strength:
Moderate)
B. Action Statement 5: REFER INFANTS FROMPHYSICAL THERAPIST TO
PHYSICIAN IF REDFLAGS ARE IDENTIFIED. Physical therapists
shouldrefer infants to the primary pediatrician for
additionaldiagnostic testing when a screen or evaluation
identi-fies red flags (eg, poor visual tracking, abnormal
muscletone, extramuscular masses, or other asymmetries incon-
sistent with CMT), or when, after 4 to 6 weeks of initialintense
intervention, in the absence of red flags, littleor no progress in
neck asymmetry is noted. (EvidenceQuality: II; Recommendation
Strength: Moderate)
B. Action Statement 6: REQUEST IMAGES ANDREPORTS. Physical
therapists should obtain copies ofall images and interpretive
reports, completed for the di-agnostic workup of an infant
suspected of having or diag-nosed with CMT, to inform prognosis.
(Evidence Quality:II; Recommendation Strength: Moderate)
PHYSICAL THERAPY EXAMINATION OF INFANTSWITH CMT
B. Action Statement 7: EXAMINE BODY STRUC-TURES. Physical
therapists should document the initialexamination and evaluation of
infants with suspected ordiagnosed CMT for the following body
structures:
� Infant posture and tolerance to positioning insupine, prone,
sitting, and standing for body sym-metry, with or without support,
as appropriatefor age. (Evidence Quality: II;
RecommendationStrength: Moderate)
� Bilateral passive cervical rotation and lateralflexion.
(Evidence Quality: II; RecommendationStrength: Moderate)
� Bilateral active cervical rotation and lateral
flexion.(Evidence Quality: II; Recommendation
Strength:Moderate)
� Passive range of motion (PROM) and active range ofmotion
(AROM) of the upper and lower extremities,inclusive of screening
for possible hip dysplasia orspine/vertebral asymmetry. (Evidence
Quality: II;Recommendation Strength: Moderate)
� Pain or discomfort at rest, and during passive andactive
movement. (Evidence Quality: IV; Recom-mendation Strength:
Weak)
� Skin integrity, symmetry of neck and hip skin folds,presence
and location of an SCM mass, and size,shape, and elasticity of the
SCM muscle and sec-ondary muscles. (Evidence Quality: II;
Recommen-dation Strength: Moderate)
� Craniofacial asymmetries and head/skull shape.(Evidence
Quality: II; Recommendation Strength:Moderate)
P. Action Statement 8: CLASSIFY THE LEVEL OFSEVERITY. Physical
therapists and other health careproviders should classify the level
of CMT severity choos-ing 1 of 7 proposed grades (Figure 2).
(Evidence Quality:V; Recommendation Strength: Best Practice)
B. Action Statement 9: EXAMINE ACTIVITY ANDDEVELOPMENTAL STATUS.
During the initial andsubsequent examinations of infants with
suspected or
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
352 Kaplan et al Pediatric Physical Therapy
-
Fig. 1. Referral flow diagram. Solid lines represent initial
communication pathway; dashed lines indicate ongoing
communication.
diagnosed CMT, PTs should document the types ofand tolerance of
position changes, and examine motordevelopment for movement
symmetry and milestones,using an age-appropriate, valid, and
reliable standardizedtool. (Evidence Quality: II; Recommendation
Strength:Moderate)
B. Action Statement 10: EXAMINE PARTICIPA-TION STATUS. The PT
should document the par-ent/caregiver responses regarding:
� Whether the parent is alternating sides when breastor
bottle-feeding the infant. (Evidence Quality: II;Recommendation
Strength: Moderate)
� Sleep positions. (Evidence Quality: II; Recommen-dation
Strength: Moderate)
� Infant time spent in prone. (Evidence Quality:
II;Recommendation Strength: Moderate)
� Infant time spent in equipment/positioning de-vices, such as
strollers, car seats, or swings.(Evidence Quality: II;
Recommendation Strength:Moderate)
B. Action Statement 11: DETERMINE PROGNOSIS.Physical therapists
should determine the prognosis forresolution of CMT and the episode
of care after comple-tion of the evaluation, and communicate it to
the parents/caregivers. Prognoses for the extent of symptom
resolu-tion, the episode of care, and/or the need to refer formore
invasive interventions are related to the age of ini-tiation of
treatment, classification of severity (Figure 2),intensity of
intervention, presence of comorbidities,rate of change, and
adherence with home program-ming. (Evidence Quality: II;
Recommendation Strength:Moderate)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
Pediatric Physical Therapy Congenital Muscular Torticollis
Practice Guidelines 353
-
Fig. 2. Congenital muscular torticollis classification grades
and decision tree. Solid lines represent clinical reasoning paths;
dashed linesportray the less supported option of trying “first
choice interventions,” for a limited time, prior to referral for
more invasive interventions.
PHYSICAL THERAPY INTERVENTION FOR INFANTSWITH CMT
B. Action Statement 12: PROVIDE THE FOLLOW-ING 5 COMPONENTS AS
THE FIRST-CHOICEINTERVENTION. The physical therapy plan of carefor
the infant with CMT or postural asymmetry shouldminimally address
these 5 components:
� Neck PROM. (Evidence Quality: II; Recommenda-tion Strength:
Moderate)
� Neck and trunk AROM. (Evidence Quality: II; Rec-ommendation
Strength: Moderate)
� Development of symmetrical movement. (Evi-dence Quality: II;
Recommendation Strength:Moderate)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
354 Kaplan et al Pediatric Physical Therapy
-
� Environmental adaptations. (Evidence Quality:
II;Recommendation Strength: Moderate)
� Parent/caregiver education. (Evidence Quality:
II;Recommendation Strength: Moderate)
C. Action Statement 13: PROVIDE SUPPLEMEN-TAL INTERVENTION(S),
AFTER APPRAISINGAPPROPRIATENESS FOR THE INFANT, TO AUG-MENT THE
FIRST-CHOICE INTERVENTION.Physical therapists may add supplemental
interventions,after evaluating their appropriateness for treating
CMTor postural asymmetries, as adjuncts to the
first-choiceintervention when the first-choice intervention has
notadequately improved range or postural alignment, and/orwhen
access to services is limited, and/or when the in-fant is unable to
tolerate the intensity of the first-choiceintervention, and if the
PT has the appropriate trainingto administer the intervention.
(Evidence Quality: III;Recommendation Strength: Weak)
B. Action Statement 14: REFER FOR CONSUL-TATION WHEN OUTCOMES
ARE NOT FULLYACHIEVED. Physical therapists who are treating
in-fants with CMT or postural asymmetries should
initiateconsultation with the primary pediatrician and/or
spe-cialists about alternative interventions when the infantis not
progressing. These conditions might include whenasymmetries of the
head, neck, and trunk are not resolv-ing after 4 to 6 weeks of
initial intense treatment; after6 months of treatment with only
moderate resolution; orif the infant is older than 12 months on
initial exami-nation and either facial asymmetry and/or 10 to 15◦
of
difference persist between the left and right sides for
anymotion; or the infant is older than 7 months on
initialexamination and a tight band or SCM mass is present;or if
the side of torticollis changes. (Evidence Quality:
II;Recommendation Strength: Moderate)
PHYSICAL THERAPY DISCHARGE AND FOLLOW-UPOF INFANTS WITH CMT
B. Action Statement 15: DOCUMENT OUTCOMESAND DISCHARGE INFANTS
FROM PHYSICALTHERAPY WHEN CRITERIA ARE MET. Physicaltherapists
should document outcome measures and dis-charge the infant
diagnosed with CMT or asymmetricalposture from physical therapy
services when the infanthas full passive ROM within 5◦ of the
nonaffected side,symmetrical active movement patterns throughout
thepassive range, age-appropriate motor development, novisible head
tilt, and the parents/caregivers understandwhat to monitor as the
child grows. (Evidence Quality:II-III; Recommendation Strength:
Moderate)
B. Action Statement 16: PROVIDE FOLLOW-UPSCREENING OF INFANTS 3
to 12 MONTHS POST-DISCHARGE. Physical therapists who treat infants
withCMT should examine positional preference, the struc-tural and
movement symmetry of the neck, face and head,trunk, hips, upper and
lower extremities, and develop-mental milestones, 3 to 12 months
following dischargefrom physical therapy intervention, or when the
child ini-tiates walking. (Evidence Quality: II;
RecommendationStrength: Moderate)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
Pediatric Physical Therapy Congenital Muscular Torticollis
Practice Guidelines 355
-
I N T R O D U C T I O N
Purpose of CPGsThe Section on Pediatrics (SoP) of the American
Phys-
ical Therapy Association (APTA) supports the develop-ment of
clinical practice guidelines (CPGs) to assist pedi-atric physical
therapists (PTs) with the identification andmanagement of infants
and children with participation re-strictions, activity limitations
and body function and struc-ture impairments, related to
developmental, neuromuscu-lar, cardiorespiratory, and
musculoskeletal conditions, asdefined by the World Health
Organization’s (WHO) In-ternational Classification of Functioning,
Disability andHealth (ICF)
(www.who.int/classification/icf/en/).
In general, the purpose of a CPG is to help PTs knowwho, what,
how, and when to treat, and who and when torefer, and to whom.
Specifically, the purposes of this CPGfor congenital muscular
torticollis (CMT) are to:
� Describe the evidence supporting physical therapymanagement of
CMT, including screening, exami-nation, evaluation, diagnosis,
reasons to refer, prog-nosis, intervention, discharge, and
long-term assess-ment of outcomes.◦ Define and classify common CMT
impairments
of body functions and structures, activity limi-tations and
participation restrictions and, wherepossible, align descriptions
with ICF terminology(Appendix 1-ICF/ICD 9/10 Codes).
◦ Identify appropriate outcome measures for CMTto establish
baseline measures and assess changesresulting from physical therapy
interventions.
◦ Identify interventions supported by current bestevidence to
address impairments of body func-tions and structures, activity
limitations, and par-ticipation restrictions associated with
CMT.
� Create a reference publication for PTs, physicians,families
and caretakers, other early childhood orhealth care service
providers, academic instructors,clinical instructors, students,
policy makers, and pay-ers, that describes, using internationally
accepted ter-minology, best current practice of pediatric PT
man-agement of CMT.
� Identify areas of research that are needed to improvethe
evidence base for physical therapy managementof CMT.
Background and Need for a CPG on CongenitalMuscular
Torticollis
Physical therapy and conservative interventions arewell
documented in the literature for the treatment ofinfants with
torticollis.1,2 Earlier studies were primarily
written by physicians regarding the diagnostic process,incidence
and presentation, and surgical management ofCMT from an orthopedic
or biomechanical perspective.3-7
Subsequent studies of conservative care typically focusedon
passive stretching applied in a standardized manner fora specific
period of time,8-11 similar to experimental inter-ventions as
opposed to individualized clinical care plans.More recent
literature on the incidence of developmentaldelays in children
treated for CMT,12-14 and the apparentincrease in incidence of
CMT15 and plagiocephaly16
associated with the Back to Sleep campaign, and its
relatedreduction in time spent in prone12 suggest that a
broaderdevelopmental approach is needed for the managementof
CMT.
A pivotal study on physical therapy interventionsfor CMT by
Emery2 has been considered by many asthe standard for conservative
intervention.17,18 While heroutcomes focus on neck range of motion
(ROM), thestudy clearly establishes that conservative management
ofstretching and parent education on handling and home ex-ercises
can effectively reduce CMT, thus avoiding surgeryfor the vast
majority of infants. Karmel-Ross19 compileda comprehensive
collection of articles in a special editionof Physical &
Occupational Therapy in Pediatrics, providingfoundational and
clinical guidance for rehabilitation man-agement of infants with
CMT. Since that publication, manystudies have addressed selected
aspects of CMT identifica-tion and rehabilitation. The Cincinnati
Children’s Hospi-tal guideline on CMT20 is the first to use
evidence-basedprocesses to support recommendations on CMT
manage-ment; though it was updated in 2009,20 its levels of
ev-idence are unique to the institution, the literature is
ap-praised by consensus and expert opinion rather than byapplying a
systematic appraisal rubric, and the guidelinerecommendations are
hierarchically categorized but notgraded. Since that publication,
there have been numer-ous studies published on the diagnosis,
imaging, and careof infants with CMT, as well as advances in
evidence-based practice methods. The roles of PTs in the treat-ment
of CMT are clearly documented in survey resultsfrom Canada21 and
New Zealand22; though no studies de-scribe these roles in the
United States. Given the numberof newer publications, the SoP
initiated the developmentof this CPG to build on these earlier
foundational docu-ments and to create a document that would be more
con-sistent with evolving international evidence-based prac-tice
methodologies and ICF terminology. This guidelineaddresses CMT from
a broader developmental perspectiveconsistent with pediatric
physical therapy, but does notaddress plagiocephaly, nor is it
applicable to cases of sud-den onset, acquired CMT evidenced later
in infancy orchildhood.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
356 Kaplan et al Pediatric Physical Therapy
http://www.who.int/classification/icf/en/
-
The Scope of the GuidelineThis CPG uses literature available
through May 2013
to address the following aspects of PTs’ management ofCMT in
infants and young children. It is assumed through-out the document
that the PT has newborn and early child-hood experience. The CPG
addresses these aspects of CMTmanagement:
� Diagnostic and referral processes.� Reliable, valid, and
clinically useful screening and
examination procedures that should be documented.� Determination
of prognosis for intensity of interven-
tion and duration of care.� Effective first-choice physical
therapy interventions,
dosage guidance, and supplemental interventions.� Conditions
under which a child should be referred
for consideration of more invasive interventions.� The prognosis
if CMT is left untreated, treated with
conservative interventions, or treated with
invasiveinterventions.
� The important outcomes of intervention and
patientcharacteristics affecting outcomes.
Statement of IntentThis guideline is intended for clinicians,
family mem-
bers, educators, researchers, policy makers, and payers. Itis
not intended to be construed or to serve as a legal stan-dard of
care. As rehabilitation knowledge expands, clinicalguidelines are
promoted as syntheses of current researchand provisional proposals
of recommended actions un-der specific conditions. Standards of
care are determinedon the basis of all clinical data available for
an individ-ual patient/client and are subject to change as
knowledgeand technology advance, patterns of care evolve, and
pa-tient/family values are integrated. This CPG is a summaryof
practice recommendations that are supported with cur-rent published
literature that has been reviewed by ex-pert practitioners and
other stakeholders. These parame-ters of practice should be
considered guidelines only, notmandates. Adherence to them will not
ensure a success-ful outcome in every patient, nor should they be
con-strued as including all proper methods of care or ex-cluding
other acceptable methods of care aimed at thesame results. The
ultimate decision regarding a particularclinical procedure or
treatment plan must be made us-ing the clinical data presented by
the patient/client/family,the diagnostic and treatment options
available, the pa-tient’s values, expectations, and preferences,
and the clin-ician’s scope of practice and expertise. The
guidelinedevelopment group suggests that significant departuresfrom
accepted guidelines should be documented in pa-tient records at the
time the relevant clinical decisions aremade.
M E T H O D S
The guideline development group (GDG) was ap-pointed by the SoP
to develop a guideline to address PTroles in the management of CMT.
The procedures aredocumented in Pediatric Physical Therapy23 and
were de-rived from the review of selected guideline
developmentmanuals24-28 in order to meet the goals of the SoP and
toproduce guidelines that parallel international processes.
Determining Purpose, Scope, and Outlineof Content
In 2011, the GDG solicited topics from the SoP lead-ership and
members of its Knowledge Translation TaskGroup to identify what
clinicians expected a CPG on CMTto cover. Fifty topics were
organized into an online sur-vey. Fourteen members of the SoP
Knowledge TranslationTask Group and clinicians who expressed
interest in theCMT guidelines completed the survey, ranking the
impor-tance of each topic. These rankings influenced the scopeand
outline of the CPG content; 45 of the 50 topics areaddressed in
this document. (Survey results are availablefrom the authors.)
Literature ReviewThe GDG, volunteers from the SoP Knowledge
Trans-
lation Task Group, and clinicians from the SoP were in-vited to
conduct literature searches on CMT and sub-mit the search histories
and results to a dedicated e-mail account. This provided a range of
search strategiesand access to a wider range of databases. The
combinedcomprehensive literature search used these key
wordsseparately and in combination: congenital muscular
tor-ticollis, torticollis, plagiocephaly, infant asymmetry,
cer-vical ROM, physical therapy, physiotherapy, and exer-cise. The
databases include: MEDLINE(R), CINAHL, EBMReviews–Cochrane Database
of Systematic Reviews 2005to June 2010, EBM Reviews–ACP Journal
Club 1991 toJune 2010, EBM Reviews–Database of Abstracts of
Reviewsof Effects 2nd Quarter 2010, EBM Reviews–CochraneCentral
Register of Controlled Trials 2nd Quarter 2010,EBM Reviews–Cochrane
Methodology Register 3rd Quar-ter 2010, EBM Reviews–Health
Technology Assessment3rd Quarter 2010, EBM Reviews–NHS Economic
Evalu-ation Database 3rd Quarter 2010, EMBASE 1980 to 2010Week 32,
ERIC 1965 to July 2010, Health and PsychosocialInstruments 1985 to
July 2010, PsycINFO 1806 to AugustWeek 2 2010, PubMed Clinical
Queries, PEDro, GoogleScholar, and the Web of Science. Additional
sources wereidentified using the same key words by searching
specificjournals, manual searching of article and textbook
refer-ence lists, and through Google and Google Scholar.
Studies
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
Pediatric Physical Therapy Congenital Muscular Torticollis
Practice Guidelines 357
-
published through May 2013 were included in the CPG;a reference
librarian from the University of Southern Cal-ifornia validated the
search for the years 1990 to 2012.Operational definitions were
adopted for clarity of writing(Appendix 2).
Articles were included if they were written in Englishand if
they informed the diagnosis, examination, interven-tion, or
prognosis of CMT as related to physical therapy.Research designs
included RCTs, cohort, case-control, caseseries, and case studies.
Study outcomes included rangeof cervical motion, cervical muscle
strength, ROM andstrength measures, posture, motor development,
treatmentdurations, need for surgical intervention, and parent
sat-isfaction with physical therapy. Articles were excluded ifthey
focused only on plagiocephaly, did not report datadirectly related
to physical therapy diagnosis, interventionor prognosis for CMT, or
were poster or presentation ab-stracts. A total of 193 articles
were reviewed, and a total of167 articles informed this
document.
Critical Appraisal ProcessThe critical appraisal forms used for
diagnostic and
intervention literature are based on adaptations from Fet-ters
and Tilson29 and have been described previously.23
Selected diagnosis and intervention articles were
criticallyappraised by the GDG to establish the test standards.
Vol-unteers completed critical appraisals of the test articlesto
establish interrater reliability. Volunteers qualified tobe
appraisers with agreement of 90% or more. Appraiserswere randomly
paired to read each of the remaining diag-nostic or intervention
articles. Each dyad compared scoresfor agreement and submitted a
single critical appraisal formwhen complete. Discrepancies in
scoring were negotiatedby the readers. In the event that a score
could not be agreedon, a member of the GDG made the final
determination.
Levels of EvidenceThe levels of evidence evolved from the APTA
Section
on Orthopedics30 to incorporate critical appraisal scores.29
Recommendation grades are derived to be consistent withthe
BRIDGE-Wiz software deontics.31 BRIDGE-Wiz isdesigned to generate
clear and implementable recommen-dations consistent with the
Institute of Medicine rec-ommendations for transparency.28 The GDG
believes itis important to consider all controlled research
designs(randomized controlled trials, meta-analyses,
systematicreviews, diagnostic, prognostic, prospective, and
cohortstudies) to equalize their importance in rehabilitation
de-cision making. While it is recognized that experimentalstudies
are the only designs that suggest causality, the dif-ference
between level I and II evidence is based on method-ological rigor
within each design, rather than solely on thestudy design. Thus,
the score from the critical appraisal
process determines whether an intervention or diagnosisstudy is
a level I or II.
Theoretical/foundational (designated by D) and prac-tice
recommendations (designated by P) are not generatedwith BRIDGE-Wiz.
The former are based on basic scienceor theory, and the latter are
determined by the GDG tobe representative of current physical
therapy practice orexceptional situations that exist for which
studies cannotbe performed.
Research recommendations (designated by R) are pro-vided by the
GDG to identify missing or conflicting evi-dence, for which studies
might improve measurement andintervention efficacy, or minimize
unwarranted variation.
AGREE II ReviewThis CPG was evaluated by the third author and 2
ex-
ternal reviewers using AGREE II.32 AGREE II is an estab-lished
instrument designed to assess the quality of clinicalpractice
guidelines using 23 items in 6 domains (see Table,Supplemental
Digital Content 1, available at http://links.lww.com/PPT/A48). Each
item is rated using a 7-pointscale, with 7 representing the highest
score. Each item in-cludes specific criteria, although reviewer
judgment is nec-essary in applying the criteria. The AGREE II
appraisal pro-cess supported an iterative process to improve the
qualityof the guideline. Domain scores for the CMT CPG rangedfrom
98% to 67%. The 3 reviewers unanimously agreed torecommend the
Guideline for use. Scores were discussedby the GDG; where possible,
items were addressed in theCPG following the AGREE II reviews.
Thus, the percent-ages are likely higher in the final version of
the CPG.
External Review Process by StakeholdersThis CPG underwent 3
formal reviews. First draft re-
viewers were invited stakeholders representing medicine,surgery,
nursing, midwifery, PT clinicians and researchers,and a parent
representative. The second draft was postedfor public comment on
the APTA SoP website; notices weresent via email and an electronic
newsletter to SoP members,literature appraisers, and clinicians who
inquired aboutthe CPG during its development. Two Pediatric
PhysicalTherapy journal reviewers read the third draft.
Commentsfrom each round of reviews were considered for
successiverevisions.
Document StructureThe guideline action statements are organized
accord-
ing to the APTA Patient Management Model,33 beginningwith
recommendations for referral and screening, physicaltherapy
examination, evaluation, intervention, outcomemeasurement, and
concluding with follow-up and collabo-ration. References,
acknowledgments, and appendices areincluded at the end.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
358 Kaplan et al Pediatric Physical Therapy
http://links.lww.com/PPT/A48http://links.lww.com/PPT/A48
-
Each action statement is introduced with its
assignedrecommendation grade, followed by a standardized con-tent
outline generated by the BRIDGE-Wiz software. Ithas a content
title, a recommendation in the form of anobservable action
statement, indicators of the evidencequality, and the strength of
the recommendation. Theaction statement profile describes the
benefits, harms,and costs associated with the recommendation, a
delin-
eation of the assumptions or judgments made by theGDG in
formatting the recommendation, reasons for in-tentional vagueness
in the recommendation, and a sum-mary and clinical interpretation
of the evidence sup-porting the recommendation. An iterative
process wasused for discussion, literature review, and external
re-view to develop the content of action statements
andprofiles.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
Pediatric Physical Therapy Congenital Muscular Torticollis
Practice Guidelines 359
-
C O N G E N I T A L M U S C U L A R T O R T I C O L L I S
Incidence and Progression of Congenital MuscularTorticollis
Congenital muscular torticollis is a common pedi-atric
musculoskeletal condition, described as a posturaldeformity of the
neck evident at birth or shortly there-after. Synonyms include
fibromatosis colli for the masstype,34 wry neck,35 or twisted
neck.36 It is typically char-acterized by a head tilt to one side
or lateral neck flexion,with the neck rotated to the opposite side
due to unilateralshortening or fibrosis of the sternocleidomastoid
(SCM)muscle. It may be accompanied by cranial deformation37
or hip dysplasia,38 brachial plexus injury,39-41 distal
ex-tremity deformities, and less frequently, presents as a headtilt
and neck rotation to the same side. The incidenceof CMT ranges from
0.3 to 2%42 of newborns, but hasbeen reported as high as 16% (n =
102),37 and may occurslightly more frequently in males.17,43
Congenital muscu-lar torticollis may be present at birth when
selected mor-phologic and birth history variables converge, such as
inlarger babies, breech presentation, and/or the use of for-ceps
during delivery,44 or it may evidence during the firstfew
months,18,37 particularly in those with milder forms.
Congenital muscular torticollis is typically catego-rized as one
of 3 types: postural CMT presents as theinfant’s postural
preference15,45 but without muscle or pas-sive ROM restrictions and
is the mildest presentation; mus-cular CMT presents with SCM
tightness and passive ROMlimitations; and SCM mass CMT, the most
severe form,presents with a fibrotic thickening of the SCM and
passiveROM limitations.46 These presentations, in combinationwith
the age of initial diagnosis, are highly predictive of thetime
required to resolve ROM limitations. In general, in-fants
identified early with postural CMT have shorter treat-ment
episodes, and those who are identified later, after 3 to6 months of
age and who have SCM mass CMT, typicallyhave the longest episodes
of conservative treatment, andmay ultimately undergo more invasive
interventions.10,46
Pediatricians or parents may be the first to noticean asymmetry,
and pediatricians may provide the ini-tial instructions about
positioning and stretching to theparents.21 The American Academy of
Pediatrics, in itsBright Futures Guidelines For Health Supervision
of Infants,Children, and Adolescents publication, recommends
check-ing the newborn for head dysmorphia at 1 week and
skulldeformities at 1 month, but does not specify checking theneck
for symmetry until 2 months, when the term torticol-lis is first
mentioned.47 If the asymmetry does not resolveafter initial
exercise instructions by pediatricians, infantsare typically then
referred to physical therapy.21 While thispattern of identification
and eventual referral to physicaltherapy is described in the
literature, the GDG is in strongagreement that pediatricians should
be screening for CMTthroughout the first 3 to 4 months, such that
infants with
any persistent postural asymmetries are referred as early
aspossible for physical therapy intervention.
Typical physical therapy management of CMT is aconservative
approach that includes passive stretching, po-sitioning for active
movement away from the tightness, andparent education for home
programs.22,48 Earlier inter-vention is more quickly effective than
intervention startedlater. If started before 1 month of age, 98%
achieve nearnormal range within 1.5 months, but waiting until after
1month of age prolongs intervention to about 6 months, andwaiting
until after 6 months can require 9 to 10 monthsof intervention,
with progressively fewer infants achiev-ing near normal range49;
current CMT guidelines do notaddress the time of referral.
Reports of untreated CMT are rare,3,5 but there are
de-scriptions of unresolved or reoccurring CMT in older chil-dren
or adults, who later undergo Botox injections42,50,51
or surgery for correction of movement limitations and
con-sequent facial asymmetries.5,52,53 The incidence of
spon-taneous resolution is unknown, and there are no fool-proof
methods for predicting who will resolve and whowill progress to
more severe or persistent forms.
Finally, CMT has been associated with hip dysplasia,4
brachial plexus injury,39-41 distal extremity deformities,early
developmental delay,14,39 persistent developmentaldelays,13 facial
asymmetry, which may affect function andcosmesis,6 and
temporal–mandibular joint dysfunction.54
Thus, early identification and treatment is critical for
earlycorrection, early identification of secondary or concomi-tant
impairments, and prevention of future complications.
Early ReferralThe evidence is strong that earlier intervention
results
in the best outcomes11,49; thus, early referral is the ideal.
Areferral flow diagram is provided (Figure 1) that outlinesthe
possible referral and communication pathways basedon time of
observation, identification of “red flags,” priormodels, and
current literature.1,39,42,55-57
The referral flow diagram is divided into 2 distincttime frames:
birth to 3 days, representing the newborn pe-riod; and 3 days and
older, representing the typical timeafter discharge to home. During
the newborn period, manydifferent health care providers may observe
the infant be-cause they are involved in the birth and/or postnatal
care.These health care providers are in the ideal position
toobserve the symmetry of the head on the shoulders andscreen for
passive and active movement limitations, thoughscreening for CMT at
this point in development is not con-sidered the norm. After the
infant is at home, the mostlikely observers will be the primary
pediatrician and theparents or other caregivers. Regardless of who
performsthe initial screen, infants with asymmetry should
undergo
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
360 Kaplan et al Pediatric Physical Therapy
-
an evaluation to rule out nonmuscular causes of CMT. IfCMT or a
persistent postural preference is diagnosed, theinfant should be
referred to the PT.
Early referral to physical therapy translates to
earlierintervention and prevention of secondary
sequelae,2,8,18,58
and, by reducing treatment duration and avoiding addi-tional or
more invasive interventions, is cost-effective. Pre-liminary
evidence suggests that treatment by a PT maybe more efficient in
achieving symmetrical movementsthan when parents are the sole
providers of home ex-ercise programs,59 thus referral to the PT
should not bedelayed.
IDENTIFICATION AND REFERRAL OF INFANTS WITHCONGENITAL MUSCULAR
TORTICOLLIS (CMT)
A. Action Statement 1: IDENTIFY NEWBORN IN-FANTS AT RISK FOR
CMT. Physicians, nurse mid-wives, obstetrical nurses, nurse
practitioners, lactationspecialists, PTs or any clinician or family
member mustassess the presence of neck and/or facial or cranial
asym-metry within the first 2 days of birth, using passive
cervi-cal rotation, passive lateral flexion, and/or visual
obser-vation as their respective training supports, when in
thenewborn nursery or at site of delivery. (Evidence Quality:I;
Recommendation Strength: Strong)
Action Statement ProfileAggregate Evidence Quality: Level I.
Based on the
odds ratios (OR) and confidence intervals (CI) for predic-tion
of CMT from facial asymmetry (OR: 21.75; CI: 6.60-71.70) and
plagiocephaly (OR: 23.30; CI: 7.01-70.95).60
Benefits:� Early identification of infants at risk for CMT or
other
conditions that might cause asymmetries.� Early onset of
intervention for infants with CMT if
referred.� Reduced episode of care to resolve CMT, with con-
sequent reduction in costs.� Reduced risk of needing more
aggressive interven-
tions (Botox or surgery) in the future.
Risk, Harm, and Cost:� Potential of overidentification of
infants may increase
costs.� Potential of increasing parent anxiety.
Benefit–Harm Assessment: Preponderance of BenefitValue
Judgments: NoneIntentional Vagueness: NoneRole of Patient/Parent
Preferences: Although parents
may not be skilled in infant assessment, mothers who
arebreastfeeding may notice that the infant has greater dif-
ficulty feeding on one side, or may notice asymmetry
inphotographs, and these observations should trigger ROMscreening
by an attending clinician.
Exclusions: None
Supporting Evidence and Clinical InterpretationThe intent of
this action statement is to increase early
identification of infants with CMT for early referral tophysical
therapy. Newborns (up to the first 3 days of life)can be easily
screened by checking for full neck rotation(chin turns past
shoulder to 100◦)37 and lateral flexion(ear approximates
shoulder)37 while stabilized in supine61
during the first postnatal examination. Newborns are athigher
risk for CMT if their birth history includes a com-bination of
longer birth body length, primiparity and birthtrauma (including
use of instruments for delivery), facialasymmetry, and
plagiocephaly. Odds ratios from multiplelogistic regression for
these 5 factors are, from highest tolowest: plagiocephaly 23.30
(CI: 7.01-70.95), facial asym-metry 21.75 (CI: 6.60-71.70),
primiparity 6.32 (CI: 2.34-17.04), birth trauma 4.26 (CI:
1.25-14.52), and birth bodylength 1.88 (CI: 1.49-2.38). This
indicates that infantswith asymmetrical heads or faces have as much
a 22-foldincrease in abnormal sonogram for CMT; primiparity a
6-fold increase; birth trauma a 4-fold increase; and birth
bodylength an almost 2-fold increase.44 No one item predictsCMT
alone, but the presence of 2 or more of the above riskfactors
warrants referral for preventative care and parenteducation.
The importance of early identification of CMT iswell supported.
Pediatricians and PTs in Canada agreethat infants identified with
CMT should receive formalintervention.21 When intervention is
started at earlier ages,it results in shorter episodes of care11
that anecdotallyhave financial, psychological, and quality-of-life
implica-tions for the family.
R. Research Recommendation 1. Researchers should con-duct
studies to determine whether routine screening atbirth increases
the rate of CMT identification and/or in-creases false
positives.
B. Action Statement 2: REFER INFANTS WITHASYMMETRIES TO
PHYSICIAN AND PHYSICALTHERAPIST. Physicians, nurse midwives,
obstetricalnurses, nurse practitioners, lactation specialists,
PTs,or any clinician or family member should refer
infantsidentified as having positional preference, reduced
cervi-cal ROM, sternocleidomastoid masses, facial asymmetry,and/or
plagiocephaly to their primary pediatrician and aPT as soon as the
asymmetry is noted. (Evidence Quality:II; Recommendation Strength:
Moderate)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
Pediatric Physical Therapy Congenital Muscular Torticollis
Practice Guidelines 361
-
Action Statement ProfileAggregate Evidence Quality: Level II
evidence sup-
ports that when intervention is started earlier, it takes
lesstime to resolve the ROM limitations (P < .001),46,49
andthere is less need for subsequent surgical intervention (P
<.005).8,49 Authors suggest that stretching interventions
areeasier for parents to administer when infants are younger,before
the neck musculature strengthens and cooperationdeclines.2,49
Benefits:� Early differential diagnosis to confirm CMT.� Early
onset of intervention to resolve reduced ROM
and asymmetries.� Early parental education to facilitate
symmetrical de-
velopment.� Greater infant cooperation with intervention in
the
first few months of life.
Risk, Harm, and Cost:� Increased cost for treatment of
asymmetries that
some suggest may spontaneously resolve.
Benefit–Harm Assessment: Preponderance of BenefitValue
Judgments: Early referral to physical therapy
ensures early onset of intervention, which strongly cor-relates
with shorter episodes of care, greater success ofconservative
measures, and thus can lower overall costs ofcare. A pediatric PT
will also screen and follow the infantfor developmental delays,
feeding challenges, and environ-mental factors that may be
associated with or contributeto positional preference or CMT.
Intentional Vagueness: For infants suspected of othercauses of
asymmetries (ie, bony anomalies, fractures, neu-rological damage,
or extramuscular masses), the PT shouldcollaborate with the primary
pediatrician to make a defini-tive diagnosis of CMT prior to onset
of physical therapyinterventions. The focus and prioritization of
interventionsmay change depending on the type of limitations the
in-fant presents with (eg, neurological, musculoskeletal,
car-diopulmonary, integumentary, and/or gastrointestinal).
Role of Patient/Parent Preferences: Infant cooper-ation with
stretching is easier in the first 2 monthsthan when started after
the infant develops greater headcontrol,2,62 thus infant compliance
is greater and parentadherence to home programs may be
optimized.
Exclusions: Infants suspected of having nonmuscu-lar conditions
that might cause asymmetrical or torticollisposturing should be
fully examined by the appropriate spe-cialists to rule out
confounding diagnoses prior to initiatingphysical therapy.
Supporting Evidence and Clinical InterpretationClinicians
involved with the delivery and care of
infants are in the ideal position to assess the presence of
CMT. If screening for CMT occurs routinely at birth, in-fants
who are at high risk for CMT, or who have identifiedSCM tightness
or masses, can have physical therapy initi-ated when the infant is
most pliable. CMT may not appearuntil several weeks postdelivery;
thus, the 1-month wellbaby check-up by the pediatrician may be the
first point ofidentification. Early treatment for infants with
positionalpreference or confirmed diagnoses of CMT has
excellentoutcomes, with more than 95% to 100% only
needingstretching10,11 or techniques that facilitate functional
ac-tivation of weak neck muscles.62 The earlier interventionis
started, the shorter the duration of intervention10,46,49
and the need for later surgical intervention is
significantlyreduced.7,8,11 In contrast to recommendations to
providestretching instruction to the parents when CMT is
identi-fied at birth, and only refer to physical therapy at 2
monthsof age if the condition does not resolve,10 recent
studiessuggest that early physical therapy reduces the time
toresolution by approximately 1 month versus 3 monthsfor
parent-only stretching,59 that infants become moredifficult to
stretch as they age and develop neck control,2
and that earlier intervention can negate the need for
latersurgery.8
Physical therapists typically address a broad rangeof
developmental and environmental factors that influ-ence outcomes,
such as parental ability to comply withthe home exercise programs,
distance from the clin-ical setting,21 feeding positions, and the
infant’s mo-tor and developmental progression.21,22 Since
develop-mental delays are detectable at 2 months in infantswith
CMT,63 and the delays may be more related totime spent in the prone
position,63 instruction to par-ents and early modeling of prone
play time may helpto negate potential developmental lags that can
occurwith CMT.
R. Research Recommendation 2. Researchers should con-duct
studies to clarify the predictive baseline measuresand
characteristics of infants who benefit from immedi-ate follow-up,
and to compare the cost–benefit of earlyphysical therapy
intervention and education to parentalinstruction and monitoring by
physicians. Longitudinalstudies of infants with CMT should clarify
how the tim-ing of referral and initiation of intervention impact
bodystructure and functional outcomes, and overall costs
ofcare.
B. Action Statement 3: DOCUMENT INFANT HIS-TORY. Physical
therapists should obtain a general med-ical and developmental
history of the infant, including 9specific health history factors,
prior to an initial screen-ing. (Evidence Quality: II;
Recommendation Strength:B-Moderate)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
362 Kaplan et al Pediatric Physical Therapy
-
Action Statement ProfileAggregate Evidence Quality: IIBenefits:
A complete history of the pregnancy, deliv-
ery, known medical conditions, developmental milestones,and
daily management of the infant can provide informa-tion important
to the diagnosis by the PT, prognosis, andintervention.
Risk, Harm, and Cost: NoneBenefit–Harm Assessment: Preponderance
of BenefitValue Judgments: NoneIntentional Vagueness: NoneRole of
Patient/Parent Preferences: Parents/
caregivers can provide much of the history through in-terview
and preadmission information packets; however,obtaining medical
records may provide specifics that oralhistories may not.
Exclusions: None
Supporting Evidence and Clinical InterpretationIn addition to
documenting the standard intake infor-
mation (eg, date of birth, date of examination, gender,
birthrank, and reason for referral or parental concerns,
generalhealth of the infant, and other health care providers
thatare seeing the infant), the PT should specifically documentthe
following birth and health history factors:
� Age at initial visit.8,22� Age of onset of symptoms.18,22�
Pregnancy history including maternal sense of
whether the baby was “stuck” in one position duringthe final 6
weeks of pregnancy.61
� Delivery history including birth presentation(cephalic or
breech).18
� Use of assistance during delivery such as forceps orvacuum
suction.11,17,37,40
� Head posture/preference15,37,64,65 and changes in
thehead/face.7,17,18,37,66
� Family history of torticollis or any other congenitalor
developmental conditions.67,68
� Other known or suspected medical conditions.39,65�
Developmental milestones appropriate for
age.13,14,69
B. Action Statement 4: SCREEN INFANTS. Whena clinician, parent,
or caretaker indicates concern abouthead or neck posture and/or
developmental progression,PTs should perform a screen of the
neurological,musculoskeletal, integumentary, and
cardiopulmonarysystems, including screens of vision,
gastrointestinalfunctions, positional preference and the structural
andmovement symmetry of the neck, face, and head, spineand trunk,
hips, upper and lower extremities, consistentwith state practice
acts. (Evidence Quality: 22-15;Recommendation Strength:
Moderate)
Action Statement ProfileAggregate Evidence Quality: The benefits
of screen-
ing infants with suspected CMT are based on a com-bination of
level II-IV evidence and expert clinicalconsensus,15,42,65,70
within which selected proceduresused by PTs to identify red flags
have varying levels ofevidence.
Benefits:� Thorough screening can identify asymmetries and
determine if they are consistent with CMT or not.� Screening for
other causes of asymmetry (ie, hip dys-
plasia, scoliosis, clavicle fracture, brachial plexus in-jury,
congenital, and/or genetic conditions) facilitatesreferral to
specialists.
� For infants being treated for other conditions (ie,brachial
plexus injuries, reflux, and hip dysplasia)that are associated with
higher risks for developingCMT, parents can receive preventative
instruction forCMT.
Risk, Harm, and Cost: The cost of a PT screening ifthe infant is
not already being treated for other conditions.
Benefit–Harm Assessment: Preponderance of BenefitValue
Judgments: In some geographic locations or
practice settings, particularly where autonomous practiceis
permitted, PTs may be the first to screen an infantfor postural
asymmetries. Infants may present for reasonsother than head or neck
postures, but observing overallsymmetry is an element of a thorough
physical therapyscreen.
Intentional Vagueness: NoneRole of Patient/Parent Preferences:
NoneExclusions: None
Supporting Evidence and Clinical InterpretationIn situations
where infants present without physician
referral for CMT (eg, locations with direct access to phys-ical
therapy or infants who are being treated by a PT forother
conditions), the PT should conduct a systems screento rule out red
flags and other potential causes of observedasymmetrical
posturing.33,39,64,65 The screen is conductedthrough parent report
and observation of the infant in dif-ferent positions. The purpose
of the screen is to determinewhether the PT should continue with a
detailed examina-tion for CMT, or refer for consultations when red
flags aresuspected. Elements of the screen include:
History: per parent report as described in ActionStatement
3.
Systems Screen: Per the APTA Guide to PhysicalTherapist
Practice,33 a systems screen traditionallyincludes examinations of
the following 4 domains.For infants with CMT, a gastrointestinal
historyshould be added.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
Pediatric Physical Therapy Congenital Muscular Torticollis
Practice Guidelines 363
-
Musculoskeletal Screen: Screen for symmetricalshape of the face,
skull, and spine36,54; symmet-rical alignment of the shoulder and
hip girdles withparticular attention to cervical vertebral
anomalies,rib cage symmetry,56 and hip dysplasia66; symmet-rical
passive ROM of the neck; and palpation forSCM masses or restricted
movement.71
Neurological Screen: Screen for abnormal or asym-metrical tone,
retention of primitive reflexes, re-sistance to movement, cranial
nerve integrity,brachial plexus injury; temperament
(irritability,alertness); achievement of age-appropriate
devel-opmental milestones,39,42,56,65,69,71 inclusive of cog-nitive
and social integration within the familysetting.72 Perform a visual
screen comprised ofsymmetrical eye tracking in all directions,
notingvisual field defects and nystagmus as potential oc-ular
causes of asymmetrical postures.42,71,73
Integumentary Screen: Screen for skin fold symme-try of the
hips61,65 and cervical regions19,70; colorand condition of the
skin, with special attentionto signs of trauma that might cause
asymmetricalposturing.65
Cardiorespiratory Screen: Screen for symmetricalcoloration, rib
cage expansion, and clavicle move-ment to rule out conditions that
might causeasymmetrical posturing (eg, brachial plexus in-juries
and Grisel syndrome)65,68; check for acuteupper respiratory tract
distress.41,74 The infantshould be alert and appropriately vocal,
withoutwheezing.
Gastrointestinal History: Interview the parents for aninfant
history of reflux or constipation,41 or prefer-ential feeding from
one side,15 both of which cancontribute to asymmetrical
posturing.
Red Flags: The following are the basis for consultationwith the
primary pediatrician, referring physician, or otherspecialists:
� Suspected hip dysplasia.4,38,65,75,76� Skull and/or facial
asymmetry, including plagio-
cephaly and brachycephaly.36,37,44� Atypical presentations, such
as tilt and turn to the
same side, or plagiocephaly and tilt to the same side.� Abnormal
tone.41,65,71� Late-onset torticollis at 6 months or older,
which
can be associated with neurological conditions, tissuemass,
inflammation, or acquired asymmetry.41,65
� Visual abnormalities including nystagmus, strabis-mus, limited
or inconsistent visual tracking, and gazeaversion.65,71
� History of acute onset, which is usually associatedwith trauma
or acute illness.39,77
R. Research Recommendation 3. Researchers should con-duct
studies to identify the precision of screening proce-dures specific
to CMT.
B. Action Statement 5: REFER INFANTS FROMPHYSICAL THERAPIST TO
PHYSICIAN IF REDFLAGS ARE IDENTIFIED. Physical therapists
shouldrefer infants to the primary pediatrician for
additionaldiagnostic testing when a screen or evaluation
identi-fies red flags (eg, poor visual tracking, abnormal
muscletone, extramuscular masses, or other asymmetries
incon-sistent with CMT) or when, after 4 to 6 weeks of
initialintense intervention, in the absence of red flags, littleor
no reduction in neck asymmetry is noted. (EvidenceQuality: II;
Recommendation Strength: Moderate)
Action Statement ProfileAggregate Evidence Quality: Level II
evidence based
on cohort follow-up studies of moderate size.Benefits:
� Infants with red flags are identified and can be co-managed by
the primary pediatrician and other spe-cialists.
� Early coordination of care may resolve CMT morequickly and
with less cost, as well as initiate appro-priate intervention for
conditions other than CMT.
� Parent support starts earlier for effective home pro-gramming,
parent education, and the balance of in-tervention with parental
needs to enjoy and bondwith their infant.
Risk, Harm, and Cost:� Cost of care is increased in the cases
where red flags
are ruled out or the PT has misidentified red flags.� Additional
family stress due to concerns about the
infant having more serious health conditions.
Benefit–Harm Assessment: Preponderance of BenefitValue
Judgments: Level II evidence demonstrates that
earlier diagnosis of CMT is better, but there is no litera-ture
that documents the risks and consequences of a lackof immediate
follow-up for the 20% of infants who haveconditions other than
CMT.39 While the recommendationstrength is categorized as moderate
based on level II evi-dence, the GDG believes that referral to the
primary pedia-trician should be categorized as a must, when any red
flagsare identified to collaborate in the comanagement of careof
the infant who may have both CMT and other medicalconditions.
Intentional Vagueness: In settings with direct accessto physical
therapy services, parents may seek evaluationservices for an infant
with postural asymmetry withoutreferral from the primary
pediatrician. The GDG is
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
364 Kaplan et al Pediatric Physical Therapy
-
intentionally vague about the range of 4 to 6 weeks asthe amount
of time that a PT should treat an infant whois not responding to
intervention. Since younger infantstypically change more quickly
than older infants, the GDGrecommends that infants younger than 2
months who arenot responding to intervention should be referred to
theirpediatrician sooner than infants older than 2 months, whomay
require more time to respond to treatment. In eithercase, a PT
should initiate communication with the primarypediatrician when
there are red flags or when a child doesnot respond after 4 to 6
weeks of treatment.
Role of Patient/Parent Preferences: NoneExclusions: None
Supporting Evidence and Clinical InterpretationUp to 18% of
cases with asymmetrical head
posturing may be due to nonmuscular causes,39 in-cluding
Klippel–Feil,39 neurologic disorders,39,45 ocu-lar
disorders,39,73,78,79 brachial plexus injuries includingclavicle
fractures,39 paroxysmal torticollis that alternatessides,41 spinal
abnormalities,77 and SCM masses.45,70 It iswithin the scope of
physical therapy practice to screenfor neuromuscular and
musculoskeletal disorders, includ-ing testing for ocular cranial
nerve integrity and coordina-tion, abnormal tone, orthopedic
alignment, and develop-mental delay,33 and to screen for potential
nonmuscularcauses of CMT. Any red flags that are identified
shouldbe documented, and the primary pediatrician should
beconsulted.
B. Action Statement 6: REQUEST IMAGES ANDREPORTS. Physical
therapists should obtain copies ofall images and interpretive
reports, completed for the di-agnostic workup of an infant
suspected of having or diag-nosed with CMT, to inform prognosis.
(Evidence Quality:II; Recommendation Strength: Moderate)
Action Statement ProfileAggregate Evidence Quality: Level II
evidence based
on cohort and outcome studies of moderate size.Benefits:
� Images and imaging reports provide a comprehen-sive picture of
the infant’s medical status, includingcomorbidities.
� Images provide visualization of the SCM muscle
fiberorganization, and the location and size of fibrotictissue.
� Parents appreciate care that is coordinated and sharedacross
disciplines.
Risk, Harm, and Cost: NoneBenefit–Harm Assessment: Preponderance
of Benefit
Value Judgments: Per the APTA Guide to PhysicalTherapist
Practice,33 requesting relevant clinical reports onan infant’s
suspected or diagnosed condition is consideredappropriate gathering
of medical history.
Intentional Vagueness: NoneRole of Patient/Parent Preferences:
Parents need to
formally release information for reports to be forwarded tothe
PT; parents may arrive with reports and images in
theirpossession.
Exclusions: None
Supporting Evidence and Clinical InterpretationReports and
images from specialized examinations or
laboratory tests can rule out ocular, neurological, skeletal,and
oncological reasons for asymmetrical posturing.39,77
In particular, ultrasound images and/or reports may assistwith
describing the degree of fibrosis,80 visualizing thesize and
location of muscle masses, and determining anappropriate plan of
care and treatment duration.18,81,82
R. Research Recommendation 4. Researchers should con-duct
studies to determine who would benefit from imaging,at what time in
the management of CMT images are useful,and how images affect the
plan of care.
PHYSICAL THERAPY EXAMINATION OF INFANTSWITH CMT
B. Action Statement 7: EXAMINE BODY STRUC-TURES. Physical
therapists should document the initialexamination and evaluation of
infants with suspected ordiagnosed CMT for the following body
structures:
� Infant posture and tolerance to positioning insupine, prone,
sitting, and standing for body sym-metry, with or without support,
as appropriatefor age. (Evidence Quality: II;
RecommendationStrength: Moderate)
� Bilateral passive cervical rotation and lateralflexion.
(Evidence Quality: II; RecommendationStrength: Moderate)
� Bilateral active cervical rotation and lateral
flexion.(Evidence Quality: II; Recommendation
Strength:Moderate)
� Passive and active ROM of the upper and lowerextremities,
inclusive of screening for possible hipdysplasia or spine/vertebral
asymmetry. (EvidenceQuality: II; Recommendation Strength:
Moderate)
� Pain or discomfort at rest, and during passive andactive
movement. (Evidence Quality: IV; Recom-mendation Strength:
Weak)
� Skin integrity, symmetry of neck and hip skinfolds, presence
and location of an SCM mass, andsize, shape, and elasticity of the
SCM muscle and
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
Pediatric Physical Therapy Congenital Muscular Torticollis
Practice Guidelines 365
-
secondary muscles. (Evidence Quality: II; Recom-mendation
Strength: Moderate)
� Craniofacial asymmetries and head/skull shape.(Evidence
Quality: II; Recommendation Strength:Moderate)
Action Statement ProfileAggregate Evidence Quality:
Preponderance of level
II studies based on well-conducted prospective and
ret-rospective cohort follow-up studies of small to moderatesample
sizes.
Benefits:� Confirms the diagnosis of CMT and identifies
other problems such as hip dysplasia,
plagiocephaly,brachycephaly, scoliosis, brachial plexus injury,
orother orthopedic and medical conditions.
� Determines the extent of primary and secondary mus-cle
involvement, to estimate prognosis.
� Establishes baselines to measure progress of ROM,strength and
alignment, and infant’s ability to incor-porate movement through
available ranges.
� Facilitates systematic linking of interventions toidentified
impairments.
� Standardizes measurement and documentation ofbody structure
limitations from CMT to evaluategroup outcomes across clinical
settings.
Risk, Harm, and Cost:� Examination of passive cervical rotation
may result
in SCM snapping or a sense of “giving way” in ap-proximately 8%
of infants.46
� The infant may feel some discomfort or pain, and/ormay
cry48,74 due to restricted movement, discomfortwith ROM tests, or
intolerance of general handling.
� In infants with undiagnosed orthopedic conditions(eg,
osteogenesis imperfecta, hemivertebrae, or cer-vical instability),
there is a risk that overly aggressivetesting of passive ROM could
cause secondary injury,though this has not been reported.
Value Judgments: The evidence for selected measure-ment
approaches varies in strength; however, measures ofpassive and
active ROM, strength, and posture must bedocumented as part of any
physical therapy examinationand are consistent with current
standards of practice.33
For ROM measurement, the GDG recognizes that
clinicalpracticality has to be weighed against the desire for
themost reliable measures. Use of photography, head mark-ers, and
other devices to increase measurement reliabilitymay create undue
burdens for the infant, the family, andthe PT in daily clinical
practice. While there is only mod-erate to weak evidence to justify
the measurement of activecervical ROM, active ROM of the upper and
lower extrem-
ities, pain or discomfort, condition of the skin folds,
con-dition of the SCM and cervical muscles, and head shape,a lack
of evidence is not equated with a lack of clinicalrelevance.
Further, documentation of these initial exam-ination findings sets
the baseline for regularly scheduledobjective reassessment and
outcome measurement.
Intentional Vagueness: There is no vagueness as towhat should be
documented. There is variability as to howselected body structures
should be measured, due to thelimited number of valid tools or
methods.
Role of Patient/Parent Preferences: During testing,parents may
perceive that the baby experiences discomfortor that testing
positions could potentially harm the baby,resulting in requests to
stop testing if the baby is crying.The clinician must be aware and
responsive to the par-ents’ perceptions; it is incumbent on the
clinician to fullyexplain the importance of the measures and the
safety pre-cautions used, so that parents and infants can
comfortablyand accurately complete the testing procedures.
Cliniciansmay need to provide the infant with breaks during
testingto obtain the baby’s best performance and most
reliablemeasures. Including the parent in the test procedures
mayhelp elicit the infant’s best performance, calm the infant
ifunder stress, and generally assist with building trust be-tween
the PT and the infant.
Exclusions: NoneNote: Table 3 provides a summary of the evidence
on
measurement.
Supporting Evidence and Clinical InterpretationFollowing a
thorough history and screening to rule
out asymmetries inconsistent with CMT, the PT conductsa more
detailed examination of the infant. The followingitems appear as a
checklist, but in practice, the PT simulta-neously observes for
asymmetries throughout all examina-tion positions to reduce infant
repositioning and increaseinfant cooperation:
� General Posture: Document the infant’s posture andtolerance to
positioning in supine, prone, sitting,and standing when CMT is
suspected or diagnosed(dependent and independent) (Evidence
Quality: II;Recommendation Strength: Moderate)
Observe the infant in all positions, document-ing symmetrical
alignment and preferred positioning orposturing.14,15,22,37,89 In
supine, document the side oftorticollis,14,15,37,61 asymmetrical
hip positions,7,15,61,90
facial and skull asymmetries, restricted active ROM,
andasymmetrical use of the trunk and extremities,14,15,37,61
asthese are all typical of CMT.
In prone, document asymmetry of the spine orpresence of
scoliosis,5 the head on trunk, asymmetricaluse of the extremities,
and the infant’s tolerance to the
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
366 Kaplan et al Pediatric Physical Therapy
-
TABL
E3:
MEA
SURE
MEN
TEV
IDEN
CETA
BLE
MEA
SUR
EMEN
TO
FIN
TER
EST
TYPE
OF
MEA
SUR
EMEN
TTO
OL
CIT
ATI
ON
S
LEV
ELO
FEV
IDEN
CE,
VA
LID
ITY,
AN
DR
ELIA
BIL
ITY
POSI
TIO
NFO
RM
EASU
REM
ENT
(IN
FAN
TA
ND
EXA
MIN
ERS)
STR
ENG
THS
AN
DLI
MIT
ATI
ON
SW
HA
TN
OR
MS
AR
EU
SED
Pass
ive
sid
eb
end
ing
(S)/
late
ralfl
exio
n(L
)
Art
hro
dia
lp
rotr
acto
rC
hen
get
al,
1999
,17
2000
,18
2001
9
NA
for
late
ralfl
exio
nSu
pin
e:2
exam
iner
s;1
mea
sure
san
d1
stab
ilize
sth
esh
ou
lder
s
S—re
pro
du
cib
le;u
sed
inm
any
stu
die
sL—
no
esta
blis
hed
relia
bili
tyfo
rla
tera
lflex
ion
Co
mp
aris
on
of
valu
esto
rig
ht
and
left
Öh
man
and
Bec
kun
g,2
0088
3R
efer
ence
dK
lack
enb
erg
’sin
trar
ater
relia
bili
tyva
lues
,0.9
4-0.
98
Sup
ine:
2ex
amin
ers;
1m
easu
res
and
1st
abili
zes
the
sho
uld
ers
S—as
sig
ned
PRO
Mva
lues
L—in
fan
tsd
idn
ot
hav
eto
rtic
olli
s
70◦
mea
nPR
OM
Kla
cken
ber
get
al,2
0058
4In
trar
ater
relia
bili
ty0.
94-0
.98
Sup
ine
wit
hh
ead
and
bo
dy
sup
po
rted
.Th
ePT
mea
sure
s;th
ese
con
dex
amin
erst
abili
zes
the
sho
uld
ers
S—re
pro
du
cib
lew
ith
hig
hin
trar
ater
relia
bili
tyL—
no
ICC
for
inte
rrat
erre
liab
ility
ICC
hig
her
wh
enm
easu
rin
gth
eaf
fect
edsi
de
than
un
affe
cted
;60◦
,th
ein
fan
t’s
ear
reac
hed
the
sho
uld
er
Go
nio
met
erw
ith
the
leve
lad
apta
tio
n
Kar
mel
-Ro
ss,
1997
19N
ASu
pin
ean
dsi
ttin
gac
cord
ing
toth
ein
fan
t’s
dev
elo
pm
ent.
Insu
pin
eth
eh
ead
issu
pp
ort
edo
ffth
eed
ge
of
the
surf
ace
S—as
sig
nin
gR
OM
valu
esL—
ori
enti
ng
the
go
nio
met
erac
cura
tely
NA
Pho
tog
rap
hy
Kla
cken
ber
get
al,2
0058
4IC
C(0
.74-
0.90
)fa
irto
go
od
Sup
ine:
the
PTm
easu
res
and
the
seco
nd
exam
iner
stab
ilize
sth
esh
ou
lder
s.Th
ep
ho
tog
rap
his
take
nan
dth
eex
amin
erd
raw
so
nth
ep
ho
tog
rap
h
S—co
mp
aris
on
valu
esto
mea
sure
men
tw
ith
pro
trac
tor
L—to
om
any
vari
able
sto
con
tro
l.Ex
tra
step
s.A
uth
or
rep
ort
su
nfe
asib
le
NA
Pho
tog
rap
hy
Rah
linan
dSa
rmie
nto
,20
1085
Intr
arat
erre
liab
ility
0.80
-0.8
5,IC
C(3
.1)
inte
rrat
erre
liab
ility
0.72
-0.9
9,IC
C(2
.1)
Sup
ine:
1ex
amin
erp
lace
sth
ech
ildan
dp
rovi
des
visu
alst
imu
lus
inm
idlin
e
S—m
easu
res
the
infa
nts
rest
ing
po
stu
reL—
tim
e-co
nsu
min
gw
ith
seve
rals
tep
sto
mea
sure
the
ph
oto
gra
ph
Palp
atio
no
fex
ten
sib
ility
Emer
y,19
942
NA
2ex
amin
ers:
the
PTm
easu
res
and
the
seco
nd
exam
iner
stab
ilize
sth
esh
ou
lder
s
Sub
ject
ive
dat
a,n
od
efin
itio
no
fre
sist
ance
NA
,sym
met
ryo
fm
ove
men
tb
yfe
el
(co
nti
nu
ed)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
Pediatric Physical Therapy Congenital Muscular Torticollis
Practice Guidelines 367
-
TABL
E3:
MEA
SURE
MEN
TEV
IDEN
CETA
BLE
(con
tinu
ed)
MEA
SUR
EMEN
TO
FIN
TER
EST
TYPE
OF
MEA
SUR
EMEN
TTO
OL
CIT
ATI
ON
S
LEV
ELO
FEV
IDEN
CE,
VA
LID
ITY,
AN
DR
ELIA
BIL
ITY
POSI
TIO
NFO
RM
EASU
REM
ENT
(IN
FAN
TA
ND
EXA
MIN
ERS)
STR
ENG
THS
AN
DLI
MIT
ATI
ON
SW
HA
TN
OR
MS
AR
EU
SED
Pass
ive
cerv
ical
rota
tio
nA
rth
rod
ial
pro
trac
tor
Ch
eng
etal
,19
99,1
720
00,1
8
2001
9
Inte
rrat
erre
liab
ility
ICC
0.71
Un
pu
blis
hed
dat
a
Sup
ine
wit
hth
eh
ead
sup
po
rted
off
the
edg
eo
fth
esu
rfac
e;2
exam
iner
s,1
mea
sure
san
d1
stab
ilize
sth
esh
ou
lder
s
S—re
pro
du
cib
lean
du
sed
inm
any
stu
die
sL—
un
pu
blis
hed
dat
a
110◦
cerv
ical
rota
tio
n
Öh
man
and
Bec
kun
g,2
0088
3In
terr
ater
relia
bili
tyIC
C0.
71p
erC
hen
g’s
un
pu
blis
hed
dat
a
Ch
eng
’sm
eth
od
S—as
sig
ned
PRO
Mva
lues
L—in
fan
tsd
idn
ot
hav
eto
rtic
olli
s
110◦
mea
nPR
OM
Go
nio
met
erK
lack
enb
erg
etal
,200
584
Rig
ht
CM
TIC
C0.
82-0
.95
for
rota
tio
nan
dsi
de
for
rota
tio
nan
dla
tera
lflex
ion
.IC
C0.
58-0
.65
for
rota
tio
nan
dsi
de
for
rota
tio
nan
dla
tera
lfl
exio
nto
the
no
naf
fect
edsi
de
Sup
ine
wit
hh
ead
and
bo
dy
on
the
surf
ace.
The
PTm
easu
res
and
the
seco
nd
exam
iner
stab
ilize
sth
esh
ou
lder
s
S—es
tab
lish
ing
intr
arat
erre
liab
ility
L—ce
rvic
alro
tati
on
islim
ited
by
sup
po
rtin
gsu
rfac
e
ICC
hig
her
wh
enm
easu
rin
gth
eaf
fect
edsi
de
than
un
affe
cted
;70-
80◦
wh
enth
ein
fan
t’s
chin
tou
ches
the
sup
po
rtin
gsu
rfac
e
Go
nio
met
erw
ith
the
leve
lad
apta
tio
n
Kar
mel
-Ro
ss,
1997
19N
ASu
pp
ort
edsi
ttin
gac
cord
ing
toth
ein
fan
t’s
dev
elo
pm
ent.
The
seco
nd
exam
iner
stab
ilize
ssh
ou
lder
s
S—va
lues
can
be
assi
gn
edL—
acco
un
tin
gfo
rco
mp
ensa
tio
ns
of
tru
nk
and
sho
uld
ers
100-
120◦
of
cerv
ical
rota
tio
np
erEm
ery
valu
es19
94
Vis
ual
insp
ecti
on
Bo
ere-
Bo
on
ekam
pan
dva
nD
erLi
nd
en-K
uip
er,
2001
15
NA
Sup
ine
S—ea
syto
adm
inis
ter
NA
Palp
atio
no
fex
ten
sib
ility
Cam
ero
nan
dC
amer
on
,199
48N
ASu
pin
e:2
exam
iner
s,1
mea
sure
san
dth
ese
con
dex
amin
erst
abili
zes
the
sho
uld
ers
S—ea
syto
adm
inis
ter;
sub
ject
ive
Sym
met
ryo
fm
ove
men
tb
yfe
el;
gra
des
assi
gn
edb
ym
ild,m
od
erat
e,se
vere
(co
nti
nu
ed)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams
& Wilkins and the Section on Pediatrics of the American
Physical TherapyAssociation. Unauthorized reproduction of this
article is prohibited.
368 Kaplan et al Pediatric Physical Therapy
-
TABL
E3:
MEA
SURE
MEN
TEV
IDEN
CETA
BLE
(con
tinu
ed)
MEA
SUR
EMEN
TO
FIN
TER
EST
TYPE
OF
MEA
SUR
EMEN
TTO
OL
CIT
ATI
ON
S
LEV
ELO
FEV
IDEN
CE,
VA
LID
ITY,
AN
DR
ELIA
BIL
ITY
POSI
TIO
NFO
RM
EASU
REM
ENT
(IN
FAN
TA
ND
EXA
MIN
ERS)
STR
ENG
THS
AN
DLI
MIT
ATI
ON
SW
HA
TN
OR
MS
AR
EU
SED
Act
ive
late
ral
flex
ion
/sid
eb
end
ing
Mu
scle
Fun
ctio
nSc
ale
Öh
man
etal
,20
0912
Inte
r-an
dIn
trar
ater
relia
bili
tyka
pp
a>
0.9;
ICC
0.9
The
infa
nt
ish
eld
ina
vert
ical
po
siti
on
and
low
ered
toh
ori
zon
tal
S—va
lidan
dre
liab
lem
easu
reo
fla
tera
lflex
ion
stre
ng
thL—
late
ralfl
exio
no
nly
0-5
sco
res;
valid
ated
on
infa
nts
>4
mo
;5/5
isn
orm
alst
ren
gth
of
late
ralfl