Congenital Muscular Torticollis Current Concepts And Review Of Treatment Pdf
- Microcurrent therapy for treatment of torticollis electrode placement. Full Text PDF PubMed. Congenital muscular torticollis: Current concepts and review.
- Congenital muscular torticollis: Current concepts and review of treatment. Current Opinion in Pediatrics, 18(1), 26 – 29. [Google Scholar]).
Figure 3 Intergroup comparison of the treatment duration according to US findings (A), Independent t-test, treatment duration was significantly shorter in US- group than US+ group ( ∗ P. Mean initial ΔROT and ΔLAT in US-abnormal (28.5°; 17.0°) were greater than in US-normal (7.9°, P. Congenital muscular torticollis (CMT) is a common disorder in neonates and infants with a tumor or tightness of the sternocleidomastoid muscle (SCM) caused by fibrotic changes ,. Numerous theories have been proposed, but the true etiology of CMT remains unclear. Various causes implicated for CMT include intrauterine crowding or vascular phenomenon, fibrosis from peripartum bleeds, compartment syndrome, primary myopathy of the SCM, and traumatic delivery 5.
The main clinical findings of CMT include a characteristic head tilt, passive neck motion limitation, and/or a palpable neck tumor ,. In the literature, patients with CMT have been classified on the basis of clinical findings into a SCM tumor group (those with a clinical tumor in SCM) or a muscular torticollis group (those with tightness of the SCM but no clinical tumor) ,. It is well known that clinical diagnosis group, initial limitation of passive neck motion, and age at presentation are the most important predictors of the outcome of physiotherapy 7; however, the clinical diagnosis is not always accurate. Thus, high-resolution ultrasonography (US) increasingly has received attention because of its diagnostic abilities to demonstrate a tumor or fibrotic lesion in the SCM ,. In terms of CMT with abnormal US findings, several studies have been conducted on the relationship between clinical features of CMT and relevant US abnormalities, which have found a close association of the severity of abnormal US findings with treatment course or prognosis ,. In particular, more severe fibrosis of the SCM on US is associated with greater neck motion limitation, longer treatment duration, and more likelihood of need for surgical intervention. In terms of CMT with normal US finding, one study by Tatli et al 12 reported that patients without a palpable mass and with normal US findings showed better conservative treatment outcomes than those with a clinically palpable tumor and any relevant US abnormalities of the SCM; however, they did not describe the severity of initial passive neck motion limitation before treatment and did not suggest protocol of the physiotherapy program, which also are associated intimately with the outcome of physiotherapy ,.
The review of systems was also. Congenital muscular torticollis: current concepts and review of. And outcome of treatment of congenital muscular torticollis in.
Not uncommonly, we find US-normal CMT with passive neck motion limitation (difference of passive neck motion between both sides) ≥10° in routine clinical practice, who are considered to need outpatient-based physiotherapy on the basis of previous studies , ; however, we still don't have much information about such patients. To our knowledge, no previous study has addressed patients with normal US finding but whose clinical finding shows clinical features of CMT considered to need outpatient-based physiotherapy: passive neck motion limitation ≥10°. Thus, the present study was undertaken to investigate the clinical features and outcome of outpatient-based physiotherapy (manual stretching program) in US-normal CMT group whose passive neck motion limitation were more than 10° and to conduct a comparative analysis with an US-abnormal CMT group whose passive neck motion limitation were more than 10°. A total of 318 patients with clinically suspected CMT visited the torticollis clinic at our hospital from 2007 to the first half of 2013 (boys: 182, girls: 136). Of these, a consecutive series of 149 infants (boys: 72, girls: 77) who met all study inclusion criteria were included in the study. These criteria were as follows: (1) an age younger than 6 months; (2) limitation of passive neck rotation (ΔROT) or lateral flexion (ΔLAT) ≥10°; and (3) completion of our outpatient-based physiotherapy program. ΔROT or ΔLAT was defined as difference of passive neck motion (rotation or lateral flexion) between both sides.
In addition, the following exclusion criteria were applied: (1) congenital anomaly of the cervical spine; (2) ocular torticollis; and (3) neurogenic or spasmodic torticollis. All patients underwent plain spine radiography. An ophthalmologist was consulted when an ocular problem was suspected.
A total of 162 patients that visited our torticollis clinic did not meet the study inclusion criteria. Of these patients, 27 patients presented after the age of 6 months and 36 patients showed both ΔROT and ΔLAT. The 149 patients were divided into the US-abnormal group and US-normal group on the basis of US findings. The US-normal group had normal findings on US but showed clinical features of CMT that were considered to need outpatient-based physiotherapy (passive neck motion limitation ≥10°) ( Figure 1A).
The US-abnormal group also had clinical features of CMT considered to need outpatient-based physiotherapy (passive neck motion limitation ≥10°) and had any relevant US abnormalities of the SCM, such as tumor, hypertrophy, heterogeneous echotexture, and hyperechoic lesion in SCM muscle ( Figure 1B-D). US evaluations were performed by 2 radiologists and 1 physiatrist using a HDI 5000 (Philips Medical Systems, Bothell, WA), a Voluson 730 (GE Healthcare, Zipf, Austria) or a LogiqE9 (GE Healthcare, Milwaukee, WI) equipped with a broadband linear-array transducer. Physiotherapy was conducted via a standardized protocol (manual stretching exercise for about 30 minutes 3 times per week) modified from Cheng et al , , which was performed by an experienced physical therapist a few days after diagnosis of CMT for all patients with a ΔROT or a ΔLAT of ≥10°. The manual stretching exercise consists of 4 directional neck motion exercises, including rotation, flexion, lateral flexion, and extension ( Figure 2).
Each directional motion exercise involved 3 repetitions of 15 manual stretches for 1 second with a rest period of 10 seconds between stretches. In addition, parents were educated to carry out only active symmetric neck positioning and not to do any passive stretching or manipulation at home. Clinical information, including gender, age at presentation, side of torticollis, and obstetrical data, was assessed. Treatment duration, which was defined as time between initial and final assessment, also was assessed. Patients were assessed on a monthly basis from initial visit to final assessment when end points were met. End points were determined when both ΔROT and ΔLAT normalized or were less than 5° or treatment was deemed to have failed, which was defined as no further improvement after more than 6 months of treatment, or a ΔROT of 6° or ΔLAT of 6° at 12 months of age.
One experienced physical therapist who was blind to the US group allocations routinely measured passive neck ROM and head tilt. Passive neck range of motion was measured with an arthrodial protractor with the patient in the supine position, the shoulder stabilized, and the head and neck supported by the examiner over the edge of the examination couch so that the neck was free to rotate and move in all directions 15.
The independent t-test was used to compare and analyze baseline characteristics, including birth weight, initial ΔROT and ΔLAT, and age at presentation between the US-abnormal and US-normal groups. Adjusted treatment duration was assessed by analysis of covariance (ANCOVA) to adjust for all clinically relevant factors that might influence outcome. Initial ΔROT, initial ΔLAT, and age at presentation that differed significantly between the 2 groups at baseline were included as covariates in the ANCOVA model. The Pearson correlation analysis was used to assess relationships between variables. The analysis was performed with PASW Statistics ver.
17.0 (SPSS Inc, Chicago, IL), and P values of. Table 1 shows baseline characteristics in the US-abnormal and US-normal groups. One hundred twenty-one patients (81%) were allocated in US-abnormal group and twenty-eight (19%) were in US-normal group. Birth weights, involved sides, and gender ratios were similar in the 2 groups; however, initial ΔROT and ΔLAT in US-abnormal group (28.5°; 17.0°) were significantly greater than those in US-normal group (7.9°, P.
Table 1 Basic characteristics according to ultrasonography findings Variable US+ (n = 121) US− (n = 28) Total (n = 149) P Value Gender ratio, M/F 60:61 12:16 72:77 Lesion side ratio, right/left 64:57 12:16 76:73 Birth weight, kg, mean (SD, range) 3.2 (0.5, 1.6-4.5) 3.3 (0.5, 2.2-4.2) 3.2 (0.5, 1.6-4.5).639 Age at presentation, mo, mean (SD, range) 1.8 (1.2, 0.5-5.9) 3.8 (1.4, 0.6-5.9) 2.2 (1.5, 0.57-5.9). Figure 3 Intergroup comparison of the treatment duration according to US findings (A), Independent t-test, treatment duration was significantly shorter in US- group than US+ group ( ∗ P. One hundred twenty-one of 149 patients (81%) showed US abnormalities in SCM and 28 (19%) normal US finding. The overall success rate of physiotherapy was 96%, and success rates in the US-abnormal and US-normal groups were 95% and 100%, respectively. These results show that if patients are first seen before the age of 6 months, outpatient-based physiotherapy provides a safe and effective treatment for CMT irrespective of US findings in approximately 96% of patients, which is consistent with the results of former studies 15. In comparative analysis between 2 groups, there was no treatment failure in US-normal group but there were 6 failures in the US-abnormal group. The independent t-test revealed mean treatment duration was significantly shorter in the US-normal (5.1 weeks) than US-abnormal group (14.9 weeks, P.
In patients with clinical features of CMT that is considered to need outpatient-based physiotherapy (passive neck motion limitation ≥10°), US-normal group showed less limitation of neck motion and older age at presentation than US-abnormal group. It seems that US-normal group showed shorter treatment duration irrespective of severity of initial neck motion limitation prior to treatment and age at presentation. Additionally, manual stretching program applied before 6 months of age appears to show generally good outcome no matter whether US finding of SCM is normal or abnormal. The authors compared the effectiveness of physiotherapy between infants with clinical signs of congenital muscular torticollis and either presence or absence of sternocleidomastoid tissue abnormality on ultrasound (US).
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PURPOSE OF REVIEW: The purpose of this review is to better understand the spectrum of disease in torticollis, which is the third most common pediatric orthopaedic diagnosis in childhood. Besides the benign muscular tightness of the sternocleidomastoid muscle leading to the classic head position, the differential diagnosis of the wry neck include sequelae to inflammatory, ocular, neurologic or orthopedic diseases.
Patients present with a stiff and tilted neck, and therefore require a thorough and systematic work-up, including a complete physical and neurologic examination and cervical spine radiographs. RECENT FINDINGS: Recent findings show that magnetic resonance imaging of the brain and neck is no longer considered cost-effective, or necessary, in congenital muscular torticollis. Observation and physical therapy, with or without bracing, is usually an effective treatment in most cases, especially if instituted within the first year of life.
Botox has recently been shown to be an effective intermediate method of treatment for more resistant cases of congenital muscular torticollis. In those presenting after the age of 1 year, there is an increased rate of sternocleidomastoid muscle lengthening. The lengthening may improve the range of motion, but not necessarily the plagiocephaly, facial asymmetry, or cranial molding.
SUMMARY: It is important to differentiate muscular from nonmuscular torticollis. Congenital muscular torticollis is benign; missing a case of nonmuscular torticollis could be potentially life threatening.