Sunday, March 13, 2011

Torticollis: Implications for Physical Therapy

Torticollis is a condition in which a baby’s neck muscles are tight, weak, or a
combination of both.  Babies with torticollis often have poor head control and delayed
gross motor skills. The primary treatment for babies with torticollis is a comprehensive
program designed by a skilled pediatric physical therapist. Physical therapy treatment is
essential in order to avoid surgical intervention, and/or several long-term effects that
torticollis will have if untreated (see below). The word torticollis means “wryneck” in
Latin. An infant or baby with torticollis will typically tilt their head/neck one way, and
look the opposite direction.

There are two very different types of torticollis: congenital muscular torticollis
(CMT) and acquired torticollis. CMT is caused directly by a tightness and weakness of
the neck muscles. The tightness is likely a result of damage to the muscles in utero, or at
some point during the delivery process. The sternocleidomastoid muscle is typically the
primary muscle injured. When the muscle(s) heals, it also shortens – just like a scar that
heals and tightens the skin in and around the scar. CMT is typically noticed when the
infant is 2-3 weeks old - when the healing process of the damaged muscle(s) is complete.
A small percentage of babies (8-10%) with CMT also have developmental dysplasia of
the hip.

Acquired torticollis is characterized by the same neck posture, however, the neck
tightness and weakness are secondary to something else. Potential causes of acquired
torticollis include: an ocular muscle impairment, a bony abnormality of the neck or spine,
poor head control or muscle imbalance from a neurological impairment, or neck
posturing to decrease esophageal pain and inflammation caused by gastroesophageal
reflux disorder. The onset of neck position varies depending on the primary cause.

A Total Approach offers a unique physical therapy evaluation and individualized
treatment program for an infant or baby with torticollis. The evaluation includes the
assessment of neck flexibility and strength; comprehensive assessment of arm, leg and
trunk flexibility and strength; and the assessment of gross motor skill development.
Without proper evaluation and early intervention, an infant or baby with torticollis is at
risk for developing permanent long-term effects.

Babies with torticollis have limited neck range of motion that, unless treated
appropriately will result in a permanent loss of flexibility.  Additionally, where there is
tightness in muscles, there is always weakness. The weak neck muscles result in poor
head control, and difficulty assuming upright and/or prone (belly) positions that are
integral in the development of gross and fine motor skills. Babies may also develop a
significant muscle strength imbalance that can cause an arm preference, or a preference
for attending to one side of the body more than the other. A muscle strength imbalance
will have immediate implications for a baby’s development of proper reaching, rolling,
sitting, crawling and walking skills.  A muscle strength imbalance can have later
implications that impact higher-level balance and bilateral coordination skills. Babies
with torticollis could also develop a permanent flattening of the head on one side and/or
asymmetrical facial features.

A skilled pediatric physical therapist will assist the family in carrying out appropriate
flexibility and strengthening exercises. Treatment often includes myofacial release
techniques in the neck and shoulder area, and/or transverse friction massage to the injured
muscle itself in conjunction with proper stretches. Strengthening exercises for infants and
babies include the facilitation of appropriate head control, arm strength, and gross motor
skill facilitation. Physical therapy will also focus on positioning the baby for play,
including techniques for increasing tummy time, and positions to prevent flattening of the

At times a baby’s primary physician will recommend a consultation with additional
medical specialists, including pediatric orthopedists, orthopedic surgeons,
opthamologists, neurologists, gastrointestinal physicians, and/or orthotists. Please consult
your doctor or physical therapist with any further questions.  


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