physical therapy management of congenital muscular torticollis: … · 2020. 5. 15. · ii;...

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


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



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



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)



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)



� 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)



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.



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



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.



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.



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



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)



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)



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.



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



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



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



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)



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)



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

physical therapy management of congenital muscular torticollis: … · 2020. 5. 15. · ii;...

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