As many as 1 in 300 babies are born with Congenital Muscular Torticollis (CMT). Torticollis occurs when the muscles on one side of the neck and jaw develop differently, tightness of this muscle results in a slightly tilted position of the head and limited neck movements. This causes the head to tilt to one side. Because of that tightness the infant then favors the more comfortable position and does not turn toward the other side. Plagiocephaly is the most common related condition to Torticollis. It is most generally seen in infants and is characterized by a flat spot on the back or one side of the head caused by remaining in one position for too long. If uncorrected, as the child grows, the head and face on the side affected may stay "flattened," so that facial asymmetry is common.
Torticollis more commonly it happens in infants of ordinary development who sleep in one position for long periods of time. Pediatricians have noted an increased incidence since 1992 when the American Academy of Pediatrics advised that healthy infants be positioned on their sides or backs while sleeping to prevent SIDS. Part of our therapy treatment and education revolves around teaching parents about "Safe Tummy Time".
The effect of CMT on posture and motor development is significant. The areas most affected in motor development including prone (lying on the belly) skills; visual tracking (sensory awareness toward the affected side); sitting balance skills; preferred use of one upper extremity, lack of creeping, use of scooting as primary means of mobility leading to gait disturbances. Other issues include the ability to weight-shift and midline development, which affects a child's power to move and explore surrounding environments; and limited forward reaching, to name just a few.
When to refer:
Physical therapy treatment with its relatively conservative measures, implemented as early as possible is imperative. It has been shown to be extremely effective in dealing with CMT. We encourage referrals when the child is 6 weeks to three months old. Older children are of course admitted, but tend to have a more difficult course of treatment.
Upon referral from your child's primary care physician or specialist, a pediatric physical therapist will evaluate your child's status in the following areas:
- Range of motion
- Resting posture
- Performance in age appropriate gross motor skills
- Stretches to improve muscle excursion and joint flexibility
- Myofascial techniques to increase muscle range
- Caretaker group/play sessions for children of like age groups
- Active range of motion exercises
- Strengthening exercises
- Use of orthotic devices
- Individualized home exercise programs that include: written parent education, recommendations for carrying techniques, positioning suggestions for crib, car seat, and other seats
Typical Course of Treatment
Children will usually be seen for 1 session per week for the first 1-3 months of treatment. Treatment will be decreased to 2 sessions per month when the child has full passive range of motion, and the focus of treatment has shifted to increasing opposing muscle strength and equality of movement on the left vs. right side of the body. Treatment will decrease to 1x/month when the child has achieved sufficient neck strength and transitional skills. Parents are encouraged to continue daily stretching until the age of 12-15 months to prevent regression during growth spurts.
Should a child require the use of a TOT collar to treat a severe tilt, the therapist is able to issue, size, and instruct parents in its use. A child with plagiocephaly will be monitored by an asymmetry index each month. The head asymmetry will be classified as minimal, moderate or severe and documented in the monthly note, which is sent to the primary care physician. While the therapist may make a recommendation for a helmet, the pediatrician will make the decision and generate the referral.