torticollis · torticollis diagnosis, assessment, and treatment of infants and children krystle...
TRANSCRIPT
-
TORTICOLLISDiagnosis, Assessment, and Treatment of Infants and Children
Krystle Chilibecki, MScPT
PresenterPresentation NotesWelcome participantsTell them where bathrooms areTell no touching babiesSpeak about research issue: can find something to support every opinion so this is based on our clinical experience
-
Objectives
Provide an overview of the assessment and treatment of torticollis
Provide a brief introduction to common head shape abnormalities in infancy
-
Definition
Abnormal posturing of the neck
Lateral translation of the head on the trunk
Rotation and lateral head tilt
Most often affects sternocleidomastoid muscle
Not a diagnosis!
PresenterPresentation NotesNot a diagnosis-discribes a posture only
-
Let’s review: Anatomy of the Neck
PresenterPresentation NotesDiscuss that many muscles can be involved, does not only effect SCM
-
Types of Torticollis
Congenital
Acquired
-
Congenital Muscular Torticollis (CMT)
Etiology
Intrauterine crowding
Difficult labours and deliveries causing muscle damage
Ischemic injury due to abnormal vascular patterns (similar to compartment syndrome)
PresenterPresentation NotesDifficult labours in up to 30 - 60% casesMost cases no cause can be identified and that’s ok
-
CMT: A Three Dimensional Deformity
Affects growth and development of
Cranial facial system Vertebral column Shoulder girdle Pelvic girdle Extremities Visual perceptual system
PresenterPresentation NotesWhy our assessment is 3 pages long, needs to be extensiveTalk about new patient who has everything in pictureNo concept of midline
-
Congenital Torticollis
Four categories
Congenital torticollis with abnormal spinal x-rays Postural torticollis without muscle tightness or
pseudotumour Congenital muscular torticollis (CMT) with muscle
tightness and pseudotumour (aka fibromatosis colli or SCM tumour)
Muscular torticollis (MT) with muscle tightness and without pseudotumour
PresenterPresentation NotesAbnormal xrays: Klippel-Feil Syndrome, Scoliosis/Hemi-vertebrae, Unilateral atlanto-occipital fusions, Unilateral absence of C1 facet, Sprengle’s deformityWithout tightness or pseudotumour: will talk about what a pseudotumour is on next slide. Often due to muscle weakness or preference to look to one sideCan be impacted by vision problemsPotential Causes:Benign Paroxysmal Torticollis, Congenital absence of one or more cervical muscles, Congenital absence of transverse ligament, Contracture of scalenes, omohyoids, Chiari MalformationDescribe pseudotumour: normally size of pea, likely hard, tends to become less noticable as patient grows as it stays the same, typically diagnosed at birth and have US to rule out pathology
-
Non-Congenital (Acquired) Torticollis
Three types
Traumatic
Painful
Non-traumaticOcular torticollis
PresenterPresentation NotesClavical fractureManual manipulation of neck Painful: reflux, Sandifer Syndrome: haita hernia, abscess, infections, osteoblastoma: cancer of bone, neck injury Non traumatic: rotary subluxtion of c1 and c2 (caused by inflammation) often resolves as inflammation resolves
-
Ocular Torticollis
Tilt to maintain binocularity and/or to optimize visual acuity
Variety of conditions may be responsible Treatment may be surgical Referral to developmental
optometrist necessary
-
Torticollis
Now you know what it is….but how do you use that knowledge?
-
Assessment
Infant should be undressed
Occurs in various age-appropriate positions.
PresenterPresentation NotesSupine, prone, sitting etc.Reminder: infants should be able to hold head in midline in supine by 3-4 months of age. This is also when we expect to see righting reactions emerging.Make friends with baby and parent, establish a relationshipPull curtainsNeed a few fun toys or something to grab attention
-
Assessment Form
PresenterPresentation NotesTake it or leave itCan be altered to fit your clinic needssimple, fast and effectiveCan be done in approx ½ hour
-
Hemihypoplasia
Enlargement of one side of the body or part of the body
Can be whole body or isolated to one body part CMT: Decreased vertical dimension of face Can include: cheek, lip, nose, ear, eye, tongue, jaw,
roof of the mouth, or teeth
PresenterPresentation NotesImportant to do a scan of rest of body to ensure limbs are not affectedcan also affect internal organsIf severe - Referral back to Dr. for further investigations required, often need ortho consult
-
Hemihypoplasia
-
Using a Goniometer!
PresenterPresentation NotesNot necessary,We chart as a percentage of full range, most important things is that staff reports in the same way. Range is usually recorded as child will move from 0-15
-
Muscle Function Scale for Infants
Ohman et al./physiotherapy theory and Practice 25 (2009) 129-137
PresenterPresentation NotesBaby should be tipped all the way to vertical
-
Muscle Cording Upper Trap Tightness
Cording vs. Tautness
PresenterPresentation NotesDiscussion difference between cording vs. tautness
-
Birthmarks and Dimples
Why check for them? May be linked to neurological conditions
Which ones are important? Coarse long hair Dimples in midline where base is not easily visible Birthmarks in midline Webbing between fingers or toes
Unsure? Refer back to doctor or to head shape clinic
PresenterPresentation NotesNeuro conditions: spina bifida, tethered cord etc.
-
Birthmarks and Dimples
http://m1.wyanokecdn.com/0824c2d6499ca748a88aa1c6f638b568.jpghttp://m1.wyanokecdn.com/0824c2d6499ca748a88aa1c6f638b568.jpg
-
Now on to…
-
HEAD TILTPresent
↓ ROM
↓ PROMPreference: • games to
encourage rotation to opposite side
• environmental modifications
Weakness (↓ Righting Reactions)
Strengthening• diagonal
carry • righting rxns
↓ AROM
Improving
TOT Collar
Improving
Further Consults:• optometry• opthalmology• physician/
pediatrician• physiatry• request imaging• Neurosurgery• Orthotist referral
Other Causes• occular• reflux • spasmodic
Try:• core/postural
pelvic stabilization
• other splinting positioning (ie: foam wedge cushion, kentucky collar, over-correction with TOT collar)
Mild to Moderate (20o tilt or less or
75% – 100% PROM)
Stretches:• supine
stretches• sitting side
flexion• carry stretch• sub-occipital• 2 person
stretch
Improving
Severe (20o or more tilt or
less than 75% PROM)
Positioning:• foam collar• snug n’ go
Torticollis Flow ChartOctober 12, 2012
Examples of Improvement:
• equal righting reactions• active rotation to both sides• increased time in midline
DDX:
• DDH• Clubfoot• Reflux• Strabismus/Occular
Problems• Chiari Malformation• Hemi-Vertebraes• Other syndromes
NO
NO
YES
YES
YES
NO
NO
NO
YES
YESYES
Improving
Discharge
Discharge
Discharge
YES
NO
Criteria for Discharge:
• < 5o tilt• > 85% of time in midline• equal righting reactions• full AROM rotation to both
sides
PresenterPresentation NotesTalk through this chart
-
Stretching
PresenterPresentation NotesMost common stretch is for SCM, done in 2 separate stretches especially in young kids Too difficult to maintain control of child and do both movements at the same timeMention that we have lots of other stretches depending on what muscle is effected, didn’t include them in this presentation due to time but if you’d like more please email Krystle
-
Stretching Parameters
Hold 15-20 seconds Repeat 3 times; 5 times per day Ensure close contact with baby Use whole hand
-
Strengthening
Righting Reactions
-
Strengthening Exercises
-
Other strengthening options:
http://www.google.ca/url?url=http://www.123rf.com/photo_19203382_mother-doing-gymnastics-with-baby-on-fitness-ball.html&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjB_IyG2YbKAhWCLmMKHbxQCqsQwW4IHzAF&usg=AFQjCNFoQShWLeRSv2KEMf37xtpPi-AJSghttp://www.google.ca/url?url=http://fortheloveofpreschool.blogspot.com/2013/06/62-new-ways-to-play-with-exercise-ball.html&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjB_IyG2YbKAhWCLmMKHbxQCqsQwW4IFzAB&usg=AFQjCNF31MOaMKSYRSZq_mHDpSVsZOUzDAhttp://www.google.ca/url?url=http://www.123rf.com/photo_19203382_mother-doing-gymnastics-with-baby-on-fitness-ball.html&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjB_IyG2YbKAhWCLmMKHbxQCqsQwW4IHzAF&usg=AFQjCNFoQShWLeRSv2KEMf37xtpPi-AJSghttp://www.google.ca/url?url=http://fortheloveofpreschool.blogspot.com/2013/06/62-new-ways-to-play-with-exercise-ball.html&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjB_IyG2YbKAhWCLmMKHbxQCqsQwW4IFzAB&usg=AFQjCNF31MOaMKSYRSZq_mHDpSVsZOUzDA
-
Treatment
Emphasize Neck and trunk strength and mobility Midline postural control Symmetry of postural responses Symmetry of weight-bearing and transitional movements Age-appropriate motor skill
development
-
Additional Treatment Options
TOT collar Alternative bracing Custom bracing Kinesiotape Craniosacral therapy Myofascial therapy Osteopathy Massage Acupuncture/Acupressure Surgery
PresenterPresentation NotesStudies suggest surgery seldom necessary when treatment initiated early
-
Treating Older Children with Torticollis
Follow same general assessment and treatment
Thorough assessment is vital
Postural exercises Recognition of midline Consider cognitive
development Custom brace options
PresenterPresentation NotesPostural exercises, use visual feedback, lights, mirrors, pt can participate and understandMidline training, very important to reestablishOcular retrainingVestibular retrainingTends to be a lengthy process, pt needs to be dedicated.
-
Indicators for Surgical Intervention
Persistence of an intramuscular tumour Thickening of SCM muscle at 6 months of age Plateau of improvement Increase in the deformity Persistence of the deformity beyond 12 months of age
PresenterPresentation NotesDespite consistant intervention by parents and therapistWe refer to our plastic surgeons Bipolar release. Typically followed by TOT collar and stretches
-
Indications for Discharge
Full, symmetrical PROM of neck and trunk Active symmetrical head rotation Active midline head to trunk alignment during static
and dynamic play Head righting reactions present bilaterally Less than 5 degree tilt
PresenterPresentation NotesRoation of at least 80 degrees from midline in both directions (without compensations)Head righting reactions may be delayed to one side
Check midline during play in all positions
-
Post-Discharge
Infants are at risk for regression during Growth spurts Illness TeethingAcquisition of new motor milestones
Regression should resolve in 10-14 days May require short period of stretching
-
Normal Skull of the Newborn
-
Mal-Development
Primary = Synostotic Secondary = Positional Deformation
-
Positional Deformation
CausesProlonged external pressuresPositioning In-UteroDeliveryAAP “Back to Sleep”
Campaign
PresenterPresentation NotesBack to sleep is now safe sleep campaignPositioning: car seats, baby swings, bouncy
-
Plagiocephaly
FeaturesOne side of back of head is flatResults in ipsilateralForehead bulgeEar forwardAppearance of Larger eye
-
Plagiocephaly
High risk of skull deformation with CMT Typically flattening is on opposite side of tilt Treat with reposition strategies Improves as the neck improves
PresenterPresentation NotesMod to severe torticollis and mod to severe head shape may need helmet if repositioning does not work, need to be seen by headshape clinic if querying helmetWorking against a tight muscle
-
Plagiocephaly
-
Brachycephaly
Features Flatness across entire back of headBiparietal widening Increased cranial vault heightProminent ears
-
PresenterPresentation NotesSubjective measurementNo magic number that means they should have a helmet
-
Treatment of Plagiocephaly/Brachycephaly
Aggressive Repositioning Remodeling Helmet
-
Remodeling Helmet
Redistribution of forces to direct cranial growth
4 month commitment Wearing time: 23 hours/day Done by community orthotist Follow up with orthotist every
1-3 weeks to adjust helmet $2500- $2700 cost
-
Craniosynostosis
Non-Syndromic No developmental or brain abnormalities May be corrected with surgical intervention
Syndromic Associated anomalies Crouzon’s or Apert’s SyndromesMuenke’s syndrome
PresenterPresentation NotesAperts: characterized by malformations of the skull, face, hands and feet Muenke: early synostosis of coronals often no intellectual delay but can be
-
Sagittal Synostosis
Clinical features Triangular shaped or closed anterior fontanellePalpable ridging Long narrow headBilateral frontal bossingProminent occiput
PresenterPresentation NotesMost common synostosisForehead wider than back of headSurgical intervention then helmet
-
Coronal Synostosis
Can be unilateral or bilateral (rare) Clinical features
Same side as synostosis Palpable ridging Eye appears wider Flattening of forehead
Prominent forehead on opposite side of synostosis
-
Bilateral Coronal
Clinical features Eyes are high Ears low setBilateral frontal height Flattened foreheadPalpable ridging
bilaterally Eyes appear large
-
Metopic Synostosis
Clinical featuresNoticeable ridge
mid-forehead Eyes narrow set Triangular shaped
head when viewed from top
PresenterPresentation NotesIf not severe often not corrected surgically
-
Lambdoid Synostosis
Clinical features Palpable ridge On same side as synostosis Ear is back and down Prominent mastoid process Flattening in the occipital region
Opposite side of synostosis Frontal bossingOccipital bossing
PresenterPresentation NotesOften mistaken for torticollisRemember that flattening should push ear forward
-
Questions?
TorticollisObjectivesDefinitionLet’s review: Anatomy of the NeckTypes of TorticollisCongenital Muscular Torticollis (CMT)CMT: A Three Dimensional Deformity�Congenital TorticollisNon-Congenital (Acquired) Torticollis Ocular TorticollisTorticollisAssessmentAssessment FormHemihypoplasiaHemihypoplasiaUsing a Goniometer!Muscle Function Scale for Infants�Cording vs. Tautness�Birthmarks and DimplesBirthmarks and DimplesNow on to…Slide Number 22Stretching�Stretching ParametersStrengtheningStrengthening ExercisesOther strengthening options:TreatmentAdditional Treatment OptionsTreating Older Children with TorticollisIndicators for Surgical Intervention�Indications for DischargePost-DischargeSlide Number 34Normal Skull of the NewbornMal-DevelopmentPositional DeformationPlagiocephalyPlagiocephalyPlagiocephalyBrachycephalySlide Number 42Treatment of Plagiocephaly/BrachycephalyRemodeling HelmetCraniosynostosisSagittal SynostosisCoronal SynostosisBilateral CoronalMetopic SynostosisLambdoid SynostosisQuestions?