Physical Therapy Reviews

ISSN: 1083-3196 (Print) 1743-288X (Online) Journal homepage: https://www.tandfonline.com/loi/yptr20

The effectiveness of stretching for infants with

congenital muscular torticollis

Bradley Poole & Swati Kale

To cite this article: Bradley Poole & Swati Kale (2019): The effectiveness of stretching
for infants with congenital muscular torticollis, Physical Therapy Reviews, DOI:
10.1080/10833196.2019.1570704

To link to this article: https://doi.org/10.1080/10833196.2019.1570704

Published online: 17 Feb 2019.

Submit your article to this journal

Article views: 89

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=yptr20
PHYSICAL THERAPY REVIEWS
https://doi.org/10.1080/10833196.2019.1570704

The effectiveness of stretching for infants with congenital muscular

torticollis
Bradley Poole and Swati Kale
School of Health Sciences, University of East Anglia, Norwich, UK

ABSTRACT KEYWORDS
Introduction: Congenital muscular torticollis (CMT) is a neck deformity that involves unilat- Congenital muscular
eral shortening of the sternocleidomastoid (SCM). Conservative physiotherapy management torticollis; CMT; stretching;
of CMT is primarily focused on stretching the affected SCM. However, there is limited conservative management;
physiotherapy
research evidence on the use of stretching to improve the extensibility of SCM in infants
with CMT.
Aim: To investigate the effectiveness of stretching for infants with CMT.
Method: A systematic search of AMED, CINAHL, MEDLINE, EMBASE, Physiotherapy Evidence
Database (PEDro) and Cochrane Library was conducted during the period 2011–2018.
Results: Seven articles that met eligibility criteria were reviewed out of a total number of
415 articles that were screened; two articles were randomised control trials and five were
cohort studies. The studies typically reported statistically significant benefits of stretching for
the restoration of cervical range of movement and SCM thickness (p < 0.05). Appraisal of
the studies revealed varied quality.
Conclusion: The results suggest that stretching is an effective treatment intervention for the
management of infants with CMT and early physiotherapy referral can lead to decreased
treatment duration. However, due to a variation in study quality; additional high-quality
research is needed to help formulate more robust conclusions.

Introduction mass within the SCM and the muscular torticollis

Torticollis is a Latin term for ‘twisted neck’ and was
initially defined by Tubby [1] as a deformity that is
congenital or acquired, which is characterised by a
lateral inclination of the head to the shoulder, with
torsion of the neck and deviation of the face. The
term congenital muscular torticollis (CMT) denotes
a neck deformity that involves unilateral shortening
or a contracture of the sternocleidomastoid (SCM)
muscle due to partial or full fibrosis, that is detected
at birth or shortly after [2].
CMT is the third most common musculoskeletal
abnormality in infants, next to hip dysplasia and
club foot, with a reported incidence rate of 0.4–1.9%
[3]. Despite CMT being regarded as a common con-
dition in infants, the true etiology remains to be
clarified [4].
The clinical features of CMT typically include
reduced cervical range of movement (ROM) for
ipsilateral rotation and contralateral lateral flexion
and a head tilt in lateral flexion toward the affected
SCM [5]. A palpable mass may be present in the
muscle belly of the affected SCM [6]. Based on these
clinical features, Cheng et al. [7] divided CMT fur-
ther into subgroups including the sternomastoid
tumour group, in which there is a discrete palpable
group, in which there is tightness in the SCM but
no palpable mass present. Additionally, the postural
torticollis group describes a congenital torticollis
with all the clinical features of torticollis but with
no demonstrable SCM tightness or palpable mass.
However, the authors also stated that such distinc-
tion of these CMT subgroups has not been widely
adopted in the literature. Therefore, the term CMT
encompassed all three subgroups, in order to facili-
tate coherence with the literature.
Currently, the diagnosis of CMT in healthcare
practice is usually based upon clinical assessment,
incorporating a perinatal history and physical exam-
ination [8]. This typically includes measurement of
passive cervical ROM through the use of an arthro-
dial protractor, palpation of the affected SCM and
cervical muscle function assessment [9]. In addition,
ultrasonography may be used on the affected SCM
to screen the severity of fibrosis and help confirm
CMT diagnosis [10, 11].
Infants with CMT can have a range of impacts
such as a cervical muscle strength imbalance; weak-
ened lateral head righting on the contralateral side
[12]. As a result, infants with CMT are unable to
produce purposeful symmetric movements of the

CONTACT Bradley Poole brad_poole@hotmail.co.uk School of Health Sciences, University of East Anglia, Norwich, UK.
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 BRADLEY POOLE AND SWATI KALE

Table 1. Search terms.

Database Keywords
AMED (1) Congenital Muscular Torticollis; (2) CMT; (3) Muscular Torticollis; (4) Postural Torticollis; (5) Torticollis; (6) Wry
Neck; (7) Sternocleidomastoid pseudotumour; (8) Stretch
; (9) Exercis
; (10) Physiotherapy; (11) Conservative
Management; (12) no. 1 or 2 or 3 or 4 or 5 or 6 or 7; (13) no. 8 or 9 or 10 or 11; (14) 12 and 13.
CINAHL (1) Congenital Muscular Torticollis; (2) CMT; (3) Muscular Torticollis; (4) Postural Torticollis; (5) Torticollis; (6) Wry
Neck; (7) Sternocleidomastoid pseudotumour; (8) Stretch
; (9) Exercis
; (10) Physiotherapy; (11) Conservative
Management; (12) no. 1 or 2 or 3 or 4 or 5 or 6 or 7; (13) no. 8 or 9 or 10 or 11; (14) 12 and 13.
MEDLINE (1) Congenital Muscular Torticollis; (2) CMT; (3) Muscular Torticollis; (4) Postural Torticollis; (5) Torticollis; (6) Wry
Neck; (7) Sternocleidomastoid pseudotumour; (8) Stretch
; (9) Exercis
; (10) Physiotherapy; (11) Conservative
Management; (12) no. 1 or 2 or 3 or 4 or 5 or 6 or 7; (13) no. 8 or 9 or 10 or 11; (14) 12 and 13.
EMBASE (1) Congenital Muscular Torticollis; (2) CMT; (3) Muscular Torticollis; (4) Postural Torticollis; (5) Torticollis; (6) Wry
Neck; (7) Sternocleidomastoid pseudotumour; (8) Stretch
; (9) Exercis
; (10) Physiotherapy; (11) Conservative
Management; (12) no. 1 or 2 or 3 or 4 or 5 or 6 or 7; (13) no. 8 or 9 or 10 or 11; (14) 12 and 13.
Physiotherapy (1) Congenital Muscular Torticollis; (2) CMT; (3) Muscular Torticollis; (4) Postural Torticollis; (5) Torticollis; (6) Wry
Evidence Database Neck; (7) Sternocleidomastoid pseudotumour; (8) Stretch
; (9) Exercis
; (10) Physiotherapy; (11) Conservative
Management; (12) no. 1 or 2 or 3 or 4 or 5 or 6 or 7; (13) no. 8 or 9 or 10 or 11; (14) 12 and 13.
Cochrane (1) Congenital Muscular Torticollis; (2) CMT; (3) Muscular Torticollis; (4) Postural Torticollis; (5) Torticollis; (6) Wry
Neck; (7) Sternocleidomastoid pseudotumour; (8) Stretch
; (9) Exercis
; (10) Physiotherapy; (11) Conservative
Management; (12) no. 1 or 2 or 3 or 4 or 5 or 6 or 7; (13) no. 8 or 9 or 10 or 11; (14) 12 and 13.
Note:
: truncation.

head and cannot maintain midline alignment of the
head with the torso in static or dynamic postures.
Treatment options for CMT can incorporate con-
servative management or surgery. Physiotherapy is
the most frequently cited providers of first-line con-
servative management for infants with CMT in
healthcare practice [7]. Currently, most authors
advocate the use of conservative physiotherapy as an
effective management strategy for CMT [4, 13–15].
The evidence based guidelines for CMT developed
by the American Physical Therapy Association high-
light that although physical therapy and conservative
interventions for torticollis are well documented in
the literature, there is insufficient evidence for the
stretching dosage such as the duration, intensity,
frequency of stretching and rest periods [16].
Conservative physiotherapy management of CMT
is primarily focused on stretching the affected SCM,
which can be fulfilled through a range of therapeutic
strategies including manual stretching, active posi-
tioning, postural control exercises and strengthening
of the contralateral SCM [8]. The success of conser-
vative management for CMT is typically determined
when the infant achieves full cervical ROM, equal
SCM muscle function and normal fibrotic mass of
the SCM, relative to the unaffected side [13, 17].
The success rate of CMT from conservative manage-
ment is known to be correlated with the degree of
initial deficit in cervical rotation and the patient’s
age at initiation of treatment [4, 8, 19]. Clinical
studies have reported good-to-excellent results, if
conservative management is initiated before 12
months of age, with success rates ranging from
86–100% [7, 19, 21]. Hence, for the purposes of this
review, the focus will be on the age group 0–12
months only.
Christensen et al. [22] reviewed the literature
published from 1991 to 2011, to create an algorithm
as a guide for clinical decision making for the con-
servative management of infants with CMT.
However, stretching parameters were not based on
current CMT literature but healthy adult and paedi-
atric muscle tissue, as well as injured adult muscle
tissue; no studies were found investigating the ideal
frequency or duration of stretch for the SCM. This
was a limitation of this study which warrants
reviewing literature published after 2011 to identify
optimum stretching dosage based on studies done
on a CMT population.
Therefore, the aim of the review is to investigate
the optimal stretching parameters such as frequency,
duration of stretch and rest periods that are effective
as an intervention in improving outcomes for
infants aged 0–12 months with CMT.
Methodology
Search strategy
A search was conducted using six electronic databases
including AMED, CINAHL, MEDLINE, EMBASE,
Physiotherapy Evidence Database and Cochrane data-
bases in June 2018. A Boolean search strategy with
key terms and their synonyms was used (Table 1).
Inclusion and exclusion criteria
Articles published in peer reviewed journals and
published in English language from 2011 were
included, the rationale was that an earlier review
[22] has reviewed published literature until 2011.
Participants needed a diagnosis of CMT and the
intervention had to include stretching. Results from
the search were screened using inclusion and exclu-
sion criteria (Table 2).
Quality assessment
The methodological rigor of the selected studies was
independently assessed using two critical appraisal

Table 2. Inclusion and exclusion criteria.
Inclusion criteria
Studies where the participants had a diagnosis of CMT.
Studies carried out on human participants were included.
Participants aged between 0–12 months at initiation of treatment.
Studies using stretching as an intervention.
Studies using conservative treatment.
Studies published in the English language.
tools. Five studies were cohort studies and two were
randomised control trials. The STROBE tool was
used to assess the quality of cohort studies and the
CASP tool for evaluating the quality of randomised
control trials. The quality assessment scores can be
found in Appendix A.
Results
Studies included
The database search identified 415 articles, after
removal of duplicates, studies were screened for eli-
gibility at title level and re-assessed at abstract level
against inclusion and exclusion criteria. The refer-
ence lists of the identified studies were screened for
additional studies. Figure 1 illustrates the search
strategy presented via the PRISMA flow chart. A
summary of the included studies can be found in
Table 3. A total of eight studies were found to be
eligible for review. However, one of the articles [23]
was retracted by the publisher and was subsequently
removed from the review, reducing the total to
seven studies.
Sample population
A total of 540 participants were included in the seven
studies with sample size varying from 37–149. Six stud-
ies had a relatively small sample size of 50 [24–26,
28–30]. The mean ages ranged from 44(±14) days – 4.5
months. All included studies documented the male to
female ratios [24–30], incorporating 245 males and 219
females. The participants were often recruited from out-
patient paediatric clinics [24–27]. Studies were con-
ducted in South Korea, Italy, Sweden and China.
A number of studies used similar diagnostic
inclusion criteria consisting of palpable neck mass,
deficit in passive neck rotation and tilted head
€
[25–27]. Ohman et al. [28] and Ryu et al. [29] did
not state what clinical signs were present to diag-
nose CMT for inclusion. This information would
have been particularly useful, given the various sub-
types of CMT. With the exception of Carenzio et al.
€
[24] and Ohman et al. [28], all the included studies
had clear exclusion criteria [25–27, 29, 30], which
incorporated exclusion of participants with congeni-
tal anomalies of the cervical spine, ocular anomalies
PHYSICAL THERAPY REVIEWS 3
Exclusion criteria
Studies that had participants diagnosed with other pathological condi-
tions but not CMT.
Studies using stretching intervention with co-intervention or surgical
intervention.
and other types of torticollis such as acute, spas-
modic, neurogenic and bilateral.
Blinding
A number of studies blinded the outcome assessors
to the participant groups [26, 27, 30] and as a result
helped preserve the internal validity of the studies.
However, four studies [24, 25, 28, 29] explicitly
stated blinding was not completed or failed to docu-
ment if effort was made to achieve blinding.
Furthermore, none of the included studies reported
on whether the blinding process was successful.
Stretching interventions
A number of the included studies [25–27, 29] used
the Cheng et al. [7] stretching protocol. This incorpo-
rates manual stretching by a physiotherapist three
times a week, consisting of three repetitions of 15
manual stretches of the tight SCM, held for one
second with a 10 second rest period. The study out-
come measurements incorporated treatment duration
and passive cervical rotation and lateral flexion.
Lee et al. [27] concluded that the stretching
protocol resulted in good clinical outcomes regard-
less of whether the ultrasonography findings were
normal or abnormal. Another study found manual
stretching three times a week improves passive cer-
vical ROM [24]. The authors used ultrasonography
to assess SCM thickness and also used the modified
Cheng score, which encompassed measurement of
passive cervical rotation and lateral flexion deficits.
A statistically significant reduction in SCM thickness
which led to moderate clinical improvements in
SCM thickness and passive cervical ROM deficits.
Complete restoration of SCM thickness was
reported by Ryu et al. [29] which was statistically
significant (p = 0.047), with 79.4% (n = 80) of
infants achieving complete restoration. The authors
also stated that the age at diagnosis can have an
impact on restoration of SCM thickness (p = 0.001).
The authors therefore concluded that early referrals
can positively impact the success of treatment.
The Cheng et al. [7] stretching protocol used a
clinical classification criteria, whereas Lee et al. [26]
used infants with ultrasound confirmed diagnosis of
4 BRADLEY POOLE AND SWATI KALE
Figure 1. Flowchart depicting the inclusion studies for the review.
CMT, where the mild type 1 and type 2 showed a
mixture of proliferating fibroblasts with normal
muscle fibres and the severe type 3 and 4 showed
the entire muscle was replaced with fibrotic bands
without a normal muscle. For the stretching inter-
vention, this study used the Cheng et al. [7] stretch-
ing protocol and was found to be effective in
improving passive neck rotation. It also highlighted
that increased severity of fibrosis results in longer
€
treatment duration. Ohman et al. [28] evaluated dif-
ferent handling strategies to achieve symmetric head
posture and normal muscle function. Stretching
exercises were included for infants who had limited
ROM less than 90 in rotation and/or side differ-
ence in lateral flexion. Information on stretching
parameters such as duration, frequency of stretches
was not provided.
Carenzio et al. [24] concluded that infants with
CMT completely recovered in a short time, regard-
less of whether the stretching intervention was com-
pleted by a physiotherapist or parents/caregivers.
Increased frequency of stretching was shown to
be more effective by He et al. [30]. Infants were ran-
domly assigned to 100 or 50 times stretching group
by He et al. [30] with the 100 times showing greater
improvement in head tilt and cervical ROM.
The stretching interventions included in the
review were of different durations and intensities. A
more detailed summary of the stretching interven-
tions can be found in Appendix B.
 PHYSICAL THERAPY REVIEWS 5

Table 3. Summary table.

Authors and
publication Stretching Outcome
year Study design Participants intervention measure Results Conclusion
Lee Cohort N:50 (32 male, 18 Cheng et al. [7] Treatment Mean treatment dur- US severity is corre-
et al., (2011) prospective female) Mean age: stretching protocol
duration ation: US type 1: 3.2 lated with treatment
1.51 (±0.72) months implemented by a (±1.2) months US duration. However,
Infants were classi- physiotherapist. type 2: 3.8 (±1.4) stretching is still an
fied into three US Parents completed months US type 3: 5 effective treatment
types, based active positioning (±1.7) months strategy, even in
on severity. at home. Treatment duration infants with severe
was longer with US findings.
increased severity of
US (p < 0.001)
ROM Restoration of passive
cervical rota-
tion: 98%
€
Ohman Randomised con- N:37 (17 male, 20 Group 1: N:9. Treatment Mean treatment dur- Treatment duration
et al., (2011) trol trial girls) Mean age: Handling strategies, duration ation: 3.5 months. was similar between
4.5 months. Age implemented by Range 1–5.5 months groups. Early referral
range: parents. Group 2: Duration between and muscle function
1–10.5 months N:13. Handling strat- groups: (p ¼ 0.145) imbalance in lateral
egies and specific ROM Restoration of passive righting can shorten
strength exercises, cervical rotation and treatment duration.
implemented by lateral flexion: 31/33
parents. Group 3: ANCOVA ANCOVA: Muscle func-
N:11. Handling strat- tion scores and age
egies and specific at start of treatment
strength exercises, had significant influ-
implemented by ence on treatment
parents, with physio- time (p < 0.01 and
therapy 2-3 times p ¼ 0.04,
a week. respectively)
Park Cohort N:48 (17 male, 31 Cheng et al. [7] SCM thickness Mean affected SCM Stretching resulted
et al., (2013) retrospective female) Mean age: stretching protocol
thickness to normal in moderate clinical
3.9 (±3) months implemented by a SCM thickness ratio: improvements in
physiotherapist. Initial: 1.77 (±0.70) SCM ratio and
Parents completed cm Follow-up: 1.34 improved modified
active positioning (±0.5) cm (p ¼ 0.006) Cheng scores.
at home. ROM Mean modified Cheng
score: Initial: 3.38
(±2.46) Follow-up:
4.90 (±1.59)
Lee Cohort N:149 (72 male, 77 Cheng et al. [7] Treatment Mean treatment dur- US-normal group
et al., (2016) prospective female) US abnormal stretching protocol
duration ation: US-normal showed short treat-
group: 121 US nor- implemented by a group (5.1 weeks) ment duration.
mal group: 28 physiotherapist. US-abnormal group However, stretching
Age:6 months Parents completed (14.9 resulted in good
active positioning weeks) (p < 0.001) ROM outcome
at home. ROM Restoration of passive regardless of
cervical rotation and US findings.
lateral flexion:
Overall: 96% US-nor-
mal: 100% US-abnor-
mal: 95%
Carenzio Cohort N:50 (34 male, 16 Passive stretching Treatment Mean treatment dur- Stretching is effect-
et al., (2015) retrospective female) Mean age: was implemented by duration ation: Parent group: ive for recovering
10.2 (±6.66) weeks a physiotherapist or 72.8 (± 50.7) days cervical ROM in a
parents. Parent Physiotherapy group: short time, regard-
group treated 91.1 (± 77.4) less whether it is
infants whenever days (p > 0.05) completed by a
possible. ROM and Restoration of passive physiotherapist or
Physiotherapy group SCM cervical rotation and parents/caregivers.
treated infants thickness lateral flexion and
30 min a day. SCM thickness: 49/50
Parents completed
active positioning at
home for
both groups.
Ryu Cohort N:80 (49 male, 31 Cheng et al. [7] SCM thickness Restoration of SCM Stretching influenced
et al., retrospective female) Mean stretching proto- thickness: 79.4% complete restor-
(2016) age: 1.3 months col
implemented (p ¼ 0.047) Non-res- ation of SCM
Age range: by a physiother- toration of SCM thickness. Early
0–5 months apist. Parents thickness: Age at referral is import-
completed active diagnosis (p ¼ 0.001) ant for success
positioning of treatment.
at home.
(continued)
6 BRADLEY POOLE AND SWATI KALE

Table 3. Continued.
Authors and
publication Stretching Outcome
year Study design Participants intervention measure Results Conclusion
He Randomised con- N:50 (24 male, 26 Stretching session: Head tilt Restoration of head tilt, Stretching treatment
et al., (2017) trol trial female) Mean 10 manual and ROM passive cervical rota- of 100 times per day
age: 44 (± 14) stretches, held for tion and lateral flex- is likely to associate
days Age range: 10–15 seconds. ion: Significant with greater
21–76 days Ten or five ses- improvement for all improvement in
sions per day. infants (p < 0.05). head tilt and cervical
Performed by Hundred times range of movement.
parents. Group 1: stretching group
N: 26. 100-times showed greater
stretching. Group improvement com-
2: N 24. 50- pared with 50 times
times stretching. stretching
group (p < 0.05).
SCM thickness Restoration of SCM
thickness: SCM thick-
ness was significantly
decreased in all
infants (p < 0.05).
There were no sig-
nificant differences
in SCM thickness
between the groups.
Note: ANCOVA: analysis of covariance; N:number of participants; ROM: range of movement; US: ultrasonography;
:manual stretching for 30 min, three
times per week. Stretches consisted of 315 manual stretches of the affected SCM with a sustained force for 1 second and a rest period of 10 seconds
between each stretch.

Outcome measures resulted in moderate clinical improvements in SCM

The outcome measures used by the included studies
were cervical ROM comprising of passive lateral
flexion and cervical rotation, SCM thickness
assessed by ultrasonography and treatment duration.
Some studies also used the muscle function score in
the lateral flexor muscles of the neck.
Restoration of cervical lateral flexion and rotation
was frequently reported [24, 26–28, 30]. Muscle
function score and the age at initiation of treatment
significantly influenced treatment duration (p <
0.01 and p = 0.04, respectively) [28]. Increasing the
stretching frequency per day was shown to be asso-
ciated with greater improvement in head tilt and
cervical ROM [30]. Treatment duration was defined
as the time between initial assessment and final
assessment. The mean treatment duration was sig-
nificantly longer for the severe fibrotic changes as
noted by ultrasonography-abnormal group (p <
0.001) [27].
Restoration of SCM thickness was reported by a
number of included studies [24, 25, 29, 30]. A statis-
tically significant decrease in thickness of the SCM
was reported by He et al. [30] (p < 0.05). Park et al.
[25] found that the mean initial modified Cheng
score was 3.38 (±2.46) and the follow-up score
showed an improvement of 4.90 (±1.59).
Additionally, the protocol led to a statistically sig-
nificant reduction in SCM thickness (p = 0.006),
with an initial mean SCM thickness score of 1.77
(±0.70) cm and follow-up score of 1.34 (±0.5) cm.
The authors concluded that the stretching protocol
thickness and passive cervical ROM deficits.
The severity of fibrosis as detected by ultrasonog-
raphy can have an impact on the duration of
stretching. Lee et al. [26] found that treatment dur-
ation, ranging from 3–5 months, had a statistically
significant linear trend of association with ultrason-
ography severity (p < 0.001). Additionally, 49/50
infants achieved restoration of passive cer-
vical rotation.
Discussion
Stretching parameters
Several types of therapeutic interventions are used
by physiotherapists for the management of torticollis
however passive stretching is perceived to be effect-
ive and commonly used intervention by physio-
therapists. A survey carried out in New Zealand
[20] reported on the use of passive stretches for the
management of torticollis, however, these were not
performed if the infant resisted the stretch or
became upset. Another survey carried out in
Sweden [31] and a recent survey of physiotherapists
in Ireland [32] also confirmed that passive stretch-
ing was perceived to be one of the most effective
interventions along with handling, positioning and
neurodevelopmental facilitation. In all three surveys
passive stretching was dependent on the calm state
of the infant, modified as per the cooperation of the
infant to avoid stretching when the infant was
resisting. These parameters potentially pose a chal-
lenge in standardising the stretching parameters as

it needs to be modified in response to the tolerance
of individual infants.
A physiotherapy protocol outlined by Cheng
et al. [7] was utilised by many of the included stud-
ies [25–27, 29]. The studies that used the Cheng
protocol concluded stretching to be effective in
restoring SCM thickness and improving passive lat-
eral flexion and rotation of the cervical spine
[25–27, 29]. The studies that utilised the protocol by
Cheng et al. [7] consistently revealed a statistically
significant benefit in restoring passive cervical ROM
and SCM thickness, with a mean treatment duration
range of 1.5–5 months.
One study [24] did not provide detail on the
stretching protocol parameters implemented, other
than infants in the physiotherapy group were treated
30 min each day till discharge and parents/care-
givers were instructed to treat infants whenever pos-
sible. Therefore, due to a lack of clarity on the
duration of the stretching intervention dosage, the
extent to which the study findings can be used to
help ascertain optimal stretching parameters for
CMT is compromised.
Low intensity stretches sustained for 10–15 sec-
onds with a rest period of 10 seconds between two
stretches and a frequency of 10 stretches per session
repeated 10 times per day, depending on infant tol-
erance, resulted in improved head tilt and cervical
ROM as compared to a frequency of five times per
day [30]. Increasing the frequency of stretching
results in greater improvement of cervical ROM and
head tilt.
It is difficult to standardise the stretching dosage
due to variability in the stretching parameters in the
reviewed studies. However, one can conclude that
low intensity stretches held for 10–15 seconds with
a rest period of 10 seconds is shown to be effective
in restoring cervical ROM and head tilt. Increasing
the frequency of stretches from 3–5 times per day
to 10 times per day could be more beneficial.
Evidence-based clinical guidelines for physiotherapy
management of CMT published in 2013 [22] and
updated in 2017 by the paediatric section of the
American Physical Therapy Association [16] sup-
ports increased stretching frequency for bet-
ter outcomes.
Early referral and outcome
Factors such as thicker SCM, low birth weight and
history of breech delivery affect the rehabilitation
duration and outcomes in patients with CMT [33].
Early referral is known to have a favourable effect
on restoring cervical range of motion. Some studies
[28, 29] identified a statistically significant correl-
ation between age at initiation of treatment and
PHYSICAL THERAPY REVIEWS 7
success rate of CMT symptoms. Ryu et al. [29] rec-
ommended early referrals for successful outcomes.
This is coherent with previous research, which
stated age can have an impact on treatment dur-
ation and overall success rate of CMT symptoms [4,
18, 19]. The results from this review further outline
the importance of early physiotherapy referral, as it
appears to lead to increased success rates from
stretching, which could also help improve cost-
effectiveness in clinical services, through reducing
treatment duration and avoiding additional or more
invasive interventions such as surgery.
Implementing stretching interventions is easier
when infants are younger than six months, before
the neck musculature strengthens and infant cooper-
ation declines [34].
Parents/caregivers versus physiotherapist
In order to provide continual stretching, it is essen-
tial that parents/caregivers carry out active position-
ing/handling strategies at home. Two studies [24,
28] compared the effectiveness of stretching when
implemented by parents/caregivers only or by physi-
otherapists with a home treatment programme. The
studies found no statistical difference in treatment
duration between parents/caregivers and physio-
therapists with home treatment (p > 0.05). The
studies concluded that for as long as an appropriate
plan of care is in place, the use of stretching for the
management of CMT can be equally effective,
regardless whether it is completed by parents/care-
givers or by a physiotherapist with a home treat-
ment programme. This is in contradiction with
€
previous research. Ohman et al. [35] found statistic-
ally significant better outcomes in terms of treat-
ment duration for the restoration of cervical ROM
when infants were treated by a physiotherapist, as
opposed to a parent/caregiver (p < 0.001). These
contrasting findings suggest that further research in
this area is needed, in order to ascertain whether
stretching offered by physiotherapists is more effect-
ive than that offered by parents/caregivers is needed.
Limitations
Only English language articles were included due to
time constraints and lack of resources to achieve
accurate translation. Therefore, a number of non-
English articles were identified from the online
search and excluded at abstract level [36–38]. A pos-
sible limitation of this review was the exclusion of
gray literature, which could potentially help to iden-
tify articles not published in the standard databases,
this could have made the review more inclusive.
The small number of studies included limits the
8 BRADLEY POOLE AND SWATI KALE
generalisability of the findings of this review.
Stretching protocols varied between studies limiting
the ability to compare results from all studies.
Conclusion
This review suggests that stretching is an effective
form of management for infants with CMT in terms
of restoring cervical ROM and regaining normal SCM
thickness. Early physiotherapy referral can result in
decreased treatment duration. The review was not
able to identify the optimum dose of stretching, as the
quality of the studies varied. Increased frequency of
stretching was shown to be effective, future research
should be carried out on the establishing the duration
of stretch and optimum frequency that can be effect-
ive, to help further inform the management of CMT.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes on contributors
Bradley Poole was a student on the MSc (pre-registration)
physiotherapy at the School of Health Sciences, University
of East Anglia, Norwich, UK. He carried out this litera-
ture review as part of his research dissertation project. He
is currently practicing as a musculoskeletal physiotherap-
ist at Cossham Hospital, Bristol, UK.
Swati Kale is a lecturer in physiotherapy at the School of
Health Sciences, University of East Anglia, Norwich, UK.
Her research interests include interventions used in paedi-
atric physiotherapy, determining predictive validity of
processes used for selection of undergraduate students in
physiotherapy, social inequities in health and use of tech-
nology in health education.
ORCID
Bradley Poole http://orcid.org/0000-0002-0308-0427
Swati Kale http://orcid.org/0000-0002-9876-5209
References
1. Tubby, A. Deformities and diseases of bones and
joints. 2nd ed. New York: Macmillan; 1912.
2. Lee JY, Koh SE, Lee IS, et al. The cervical range of
motion as a factor affecting outcome in patients
with congenital muscular torticollis. Ann Rehabil
Med. 2013;37(2):183–190.
3. Cheng JCY, Tang SP, Chen TMK, et al. The clinical
presentation and outcome of treatment of congeni-
tal muscular torticollis in infants–a study of 1,086
cases. J Pediatr Surg. 2000;35(7):1091–1096.
4. Tessmer A, Mooney P, Pelland L. A development
perspective on congenital muscular torticollis: a
critical appraisal of the evidence. Pediatr Phys Ther.
2010;22(4):378–383.
5. Schertz M, Zuk L, Green, D. Long-term neurodeve-
lopmental follow-up of children with congenital
muscular torticollis. J Child Neurol. 2012;3(1):
28–55.
6. Suhr MC, Oledzka M. Considerations and interven-
tion in congenital muscular torticollis. Curr Opin
Pediatr. 2015;27(1):75–81.
7. Cheng JCY, Wong MWN, Tang SP, et al. Clinical
determinants of the outcome of manual stretching
in the treatment of congenital muscular torticollis
in infants: a prospective study of eight hundred and
twenty-one cases. J Bone and Joint Surg. 2001;83(5):
679–687.
8. Tatli B, Aydinli N, Caliskan M, et al. Congenital
muscular torticollis: evaluation and classification.
Pediatr Neurol. 2006;34(1):41–44.
9. Hwang JH, Lee HB, Kim JH, et al. Magnetic reson-
ance imaging as a determinant for surgical release
of congenital muscular torticollis: correlation with
the histopathologic findings. Ann Rehabil Med.
2012;36(3):320–327.
10. Lee SY, Park HJ, Choi YJ, et al. Value of adding
sonoelastography to conventional ultrasound in
patients with congenital muscular torticollis. Pediatr
Radiol J. 2013b;43(12):1566–1572.
11. Dudkiewicz I, Ganel A, Blankstein A. Congenital
muscular torticollis in infants: ultrasound-assisted
diagnosis and evaluation. J Pediatr Ortho. 2005;25
(6):812–814.
12. Lee KS, Chung EJ, Koh SE, et al. Outcomes of
asymmetry in infants with congenital muscular tor-
ticollis. J Phys Ther Sci. 2015;27 (2):461–464.
13. Petronic I, Brdar R, Cirovic D. Congenital muscular
torticollis in children: distribution, treatment dur-
ation and outcome. Eur J Phys Rehabil Med. 2010;
46 (2):153–158.
14. Burch C, Hudson P, Reder R, et al. Cincinnati
children’s hospital medical center: evidence-based
clinical care for therapy management of congenital
muscular torticollis. J Pediat. 2009;1(1): 1–13.
15. Nilesh K, Mukherji, S. Congenital muscular torticol-
lis. Ann Maxillofac Surg. 2013;3(2):198–200.
16. Kaplan SL, Coulter C, Fetters L. Physical therapy
management of congenital muscular torticollis.
Pediat Phys Thera. 2013;25(4):348–394.
17. Tomczak KK, Rosman NP. Torticollis. J Child
Neurol. 2013;28 (3):365–378.
18. Agarwal A, Verma I. Sternocleidomastoid pseudotu-
mor and congenital muscular torticollis. J Clin
Ortho Trau. 2011;5(2):82–84.
19. Celayir AC. Congenital muscular torticollis: early
and intensive treatment is critical. A prospective
study. Pediatr Int. 2000;42(5):504–507.
20. Luxford BK, Hake L, Piggot J. The physiotherapy
management of infants with congenital muscular
torticollis: a survey of current practice in New
Zealand. J Physiother Phys Rehabil. 2009;37(3):
127–135.
21. Wei JL, Schwartz KM, Weaver AL, et al.
Pseudotumor of infancy and congenital muscular
torticollis: 170 cases. Int J Pediat. 2001;111:688–695.
22. Christensen C, Landsettle A, Antoszewski S, et al.
Conservative management of congenital muscular
torticollis: an evidence-based algorithm and prelim-
inary treatment parameter recommendations. J Phys
Occup Thera Pediat. 2013;33(4): 453–466.
 PHYSICAL THERAPY REVIEWS 9

23. Lee IH. The effect of postural control intervention
for congenital muscular torticollis: a randomized
controlled trial. Clin Rehabil. 2015;29 (8):795–802.
24. Carenzio G, Carlisi E, Morani I, et al. Early
rehabilitation treatment in newborns with congeni-
tal muscular torticollis. Eur J Phys Rehabil Med.
2015;51(5):539–545.
25. Park HJ, Kim SS, Lee SY, et al. Assessment of fol-
low-up sonography and clinical improvement
among infants with congenital muscular torticollis.
Am J Neuroradiol. 2013;34(4):890–894.
26. Lee YT, Yoon K, Kim YB, et al. Clinical features
and outcome of physiotherapy in early presenting
congenital muscular torticollis with severe fibrosis
on ultrasonography: a prospective study. J Pediatr
Surg. 2011;46 (8):1526–1531.
27. Lee YT, Park JW, Lim M, et al. A clinical compara-
tive study of ultrasound-normal versus ultrasound-
abnormal congenital muscular torticollis. PM R.
2016;8(3):214–220.
28. €
Ohman A, Mårdbrink EJ, Stensby J, et al.
Evaluation of treatment strategies for muscle func-
tion in infants with congenital muscular torticollis.
Phys Theo Pract. 2011;27(7):463–470.
29. Ryu JH, Kim DW, Kim SH, et al. Factors correlat-
ing outcome in young infants with congenital mus-
cular torticollis. Can Assoc Radiol J. 2016;67(1):
82–87.
30. He L, Yan X, Li J, et al. Comparison of 2 dosages
of stretching treatment infants with congenital mus-
cular torticollis: a randomized trial. Am J Phys Med
Rehabil. 2017;96(5):333–340.
31. €
Ohman A, Mårdrink EJ, Orefelt C, et al. The phys-
ical therapy assessment and management of infants
with congenital muscular torticollis. A survey and a
suggested assessment protocol for CMT. J Nov
Physiother. 2013;3 (4):1–5.
32. Seager A. Assessment and management of torticollis
in infancy: a survey of current physiotherapy prac-
tice. Physiother Pract Res. 2017;38(1):59–66.
33. Jung AY, Kang EY, Lee SH, et al. Factors that affect
the rehabilitation duration in patients with congeni-
tal muscular torticollis. Annals Rehabil Med. 2015;
39(1):18–24.
34. Klackenberg EP, Elfving B, Haglund-Akerlind Y,
et al. Intra-rater reliability in measuring range of
motion in infants with congenital muscular torticol-
lis. J Austra Physiol Assoc. 2005;7(2):84–91.
35. €
Ohman A, Nilsson S, Beckung E. Stretching treat-
ment for infants with congenital muscular torticol-
lis: physiotherapist or parents? A randomized pilot
study. PM R. . 2010;2 (12):1073–1079.
36. Daentzer D, St€ uder D, Wirth C. Muscular torticol-
lis. J Operat Ortho Trauma. 2010;22(2):177–187.
37. Demirel AÇ, Umay E, Noyan S, et al. Konjenital
M€ usk€uler Tortikollis Tedavisinde Rehabilitasyonun
Yeri. Turki J Phys Med Rehab. 2010;56(1):11–17.
38. Kessomtini W, Chebbi W. Congenital muscular tor-
ticollis in children. Pan Africa Med J. 2014; 18(3):
190–204.

Appendix A. Quality Assessment Scores.

Critical Appraisal: STROBE Results for Retrospective and Prospective Cohort Studies.
Authors, publication
year 1a 1b 2 3 4 5 6a 6b 7 8 9 10 11 12a 12b 12c 12d 12e 13a 13b 13c 14a 14b 14c 15 16a 16b 16c 17 18 19 20 21 22
Carenzio et al. (2015)      ✘ ✘ ✘   ✘ ✘   ✘ ✘ ✘ ✘   ✘  ✘   ✘ ✘ ✘ ✘  ✘  ✘ ✘
Park et al. (2013) ✘       ✘   ✘ ✘   ✘ ✘ ✘ ✘ ✘ ✘ ✘  ✘   ✘ ✘ ✘ ✘    ✘ ✘
Ryu et al. (2016) ✘     ✘     ✘ ✘   ✘ ✘ ✘ ✘   ✘  ✘   ✘ ✘ ✘ ✘     ✘
Lee et al. (2011)            ✘    ✘ ✘ ✘   ✘  ✘   ✘ ✘ ✘      ✘
Lee et al. (2016)            ✘   ✘ ✘ ✘ ✘   ✘     ✘ ✘ ✘     ✘ ✘
¼Yes; ✘¼No.

Critical Appraisal: CASP Results for Randomised Control Trials.

Authors, publication year 1 2 3 4 5 6 7 8 9 10 11
€
Ohman et al. (2011)   ✘ Can’t tell Can’t tell   ✘   
He et al. (2017)    ✘    ✘  ✘ 
¼Yes; ✘¼No
10 BRADLEY POOLE AND SWATI KALE
Appendix B. Stretching Intervention Table
Authors, publication year
Lee et al. (2011) Park et al.
(2013) Lee et al. (2016) Ryu
et al. (2016)
Öhman et al. (2011)
Carenzio et al. (2015)
He et al. (2017)
Stretching Intervention
A physiotherapy protocol outlined by Cheng et al. (2001) was utilised. This involved manual stretching for
30 minutes, 3 times per week, and performed by a trained physiotherapist. Manual stretches consisted of 3 repe-
titions of 15 manual stretches of the affected muscle with sustained force for 1 second and a rest period of
10 seconds between each stretch.
Additionally, parents were educated to carry out a home program of active positioning.
Handling strategies group: Infants spent as much time as possible in a prone position when awake and super-
vised. When lifting or carrying the infant, he/she was held in a sideways position with the weaker wide facing
upwards. Additionally, parents were encouraged to stimulate rotation of the head towards the affected side.
Handling strategies and specific strength exercises group: Infants were tilted to an almost horizontal position
with the weaker side facing upward and held for 5-15 seconds, over a 15-minute period with breaks. With the
weaker side facing upward and when standing in front of a mirror, the infant was lowered to a horizontal pos-
ition and held for 5-10 seconds, over a 15-minute period with breaks. This was in addition to the aforemen-
tioned handling strategies.
Handling strategies and specific strength exercises with training by physiotherapist group: Underwent the
same exercises as group 2. However, extra guidance by a physiotherapist was given 2-3 times a week, to ensure
that at least one group did both the handling strategies and the specific strength exercises.
Individual stretching programmes were implemented in an outpatient clinic or by parents. For both groups, the
programmes incorporated stretching of the SCM to recover lateral flexion and rotation and education on active
positioning.
Parent group: Parents treated their infant with passive cervical rotation and lateral flexion whenever possible.
The physiotherapist demonstrated the exercises on the parent, if he/she was unsure how to perform.
Physiotherapy group: Infants underwent passive stretching to recover cervical rotation and lateral flexion in a
prone position. Infants were treated 30 minutes a day.
Each session consisted of 10 manual stretches of the tight muscle and held for 10 to 15 seconds per stretch,
with a rest period of 10 seconds between any 2 stretches. The stretching treatment was preformed every day at
home by parents who had learned the stretching techniques in a course provided by the hospital. The parents
were not allowed to implement the stretching at home until their performance was approved by a
physiotherapist.