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Early rehabilitation treatment in newborns with congenital muscular

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Article in European journal of physical and rehabilitation medicine · February 2015

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Early rehabilitation treatment in newborns with congenital

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Early rehabilitation treatment in newborns with Congenital Muscular

Torticollis
G. Carenzio 1, E. Carlisi 1, I. Morani 1 , C.Tinelli 2 ,, M. Barak 3, M. Bejor 4 , E. Dalla
Toffola 3

1
Physical Medicine and Rehabilitation Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy

2 Biometry and Statistics, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
Physical Medicine and Rehabilitation Unit, University of Pavia, Rehabilitation Unit, IRCCS Policlinico San
3
Matteo Foundation, Pavia, Italy
4
University of Pavia Rehabilitation Unit, Don Carlo Gnocchi Foundation Salice Terme, Italy

Corresponding author:
GABRIELLA CARENZIO
Unità di Medicina Fisica e Riabilitazione
piazzale Golgi 19 27100 Pavia Italy
E-‐mail:g.carenzio@smatteo.pv.it

Background. Congenital Muscular Torticollis (CMT) is the most common form of torticollis
in infants;; on clinical presentation it is classified into 3 types: (i) postural torticollis, with
postural deformity only in the neck, (ii) muscular torticollis, where neck deformity is
associated with muscle tightness and restricted passive range of motion (ROM), and (iii)
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sternomastoid tumor or pseudotumor, with a fibrotic, sternocleido-mastoid muscle mass

and passive ROM limitations.
Aim. The aim of this study was to evaluate the physical therapy outcome of infants with
CMT treated either by parents using a home exercise program, or by a physical therapist.
Design. Longitudinal study.
Setting. Outpatients with CMT at our Department of Physical Medicine and Rehabilitation.
Population. Fifty consecutive newborns with CMT, referred by the primary pediatrician:
Methods. In our study, 50 infants with CMT were evaluated and treated either by a
physical therapist or by parents using a home program.
Results. 16 females (32%) and 34 males (68%), aged 10.2 weeks (SD 6.66). 23 of the
infants (46%) presented with more severe articular limitations than the others (p=0.002)
and were therefore prescribed outpatient treatment by a physical therapist;; the remaining
27 less severe cases (54%) were prescribed a home therapy program. 49 infants achieved
full resolution after an average of 81.06 days (SD 64.05) of rehabilitation treatment. The
group of patients who were treated at home achieved resolution more quickly (72.8 vs
91.1 days), although statistical significance was not reached.

Conclusions. Infants with CMT who were treated early, either at home or in the outpatient
clinic, completely recovered normal neck movement in a short time. It is important not to
discharge patients until they have achieved full resolution of CMT symptoms to exclude
the minimal risk of relapse.
Clinical Rehabilitation Impact. This study demonstrates the importance of early
treatment in cases of Congenital Muscular Torticollis.

Key words: Congenital Muscular Torticollis –Newborn- Rehabilitation- Physical therapy

Introduction
Congenital Muscular Torticollis (CMT) 1,2,3,4,5,6,7 is a benign pathology mainly characterised
by the thickening and shortening of the sternocleidomastoid muscle (SCM), which results
in head tilt and limited head rotation. Torticollis may be present at birth, or may not appear
until 2-4 weeks postdelivery. 3,4 In addition to the characteristic head posture with lateral
neck flexion and rotation to the contralateral side, a mass or tightness may be felt in the
muscle belly of the affected SCM. 3,4,580% of torticollis cases in newborns are CMT 8 , with
a variable incidence of 0.084%-3.92%. 1,3,5 CMT is the third most common congenital
musculoskeletal disorder after hip dysplasia and clubfoot. 9,10,11 The condition occurs more
frequently on the left side 11 and is rarely bilateral 12,13;; it affects more males than females,
with a ratio of 3:2 4,9;; there is a positive family history in 10% of cases.14
CMT may be associated with metatarsus adductus, congenital hip dysplasia (0-29%
variation) 9,15,16, plagiocephaly 17, craniofacial asymmetry 18,19, and brachial plexus injury. 8
Since 1992 there has been an increase in cases of CMT and positional plagiocephaly
contribute to the application of the guidelines for the prevention of Sudden Infant Death
Syndrome by the American Academy of Pediatrics, who discourage the prone sleeping
position. 20,21,22

On clinical presentation, CMT may be classified into 3 types:7,23,24,

- postural torticollis, the mildest form, with postural deformity in the neck but without
restricted passive ROM or mass/tightness in the SCM. Short-term conservative
interventions are used to treat infants because resolution is quick and occasionally
spontaneous;; 25
- muscular torticollis, where neck deformity is associated with muscle tightness and
passive ROM restriction. About 3% of cases require invasive interventions if not
treated early;; 25
- sternomastoid tumor or pseudotumor, the most severe form, with a fibrotic mass
in the SCM, and passive ROM limitations. About 8% of cases require invasive
interventions if not treated early. 25

Although the etiology of CMT remains unclear, there are some well-substantiated
hypotheses, including intrauterine malposition that causes an ischemic event, fibrosis of
the SCM leading to a compartment syndrome, birth-trauma 11,26,27,28,29 hereditary
hypothesis 30, and neurogenic involvement or infection.
CMT may also be present in newborns delivered by cesarean section, and there is no
significant difference in the clinical severity of CMT based on type of delivery. 31

If CMT is developed prior to delivery, it may cause birth trauma or breech birth.
Oligohydramnios is thought to be a risk factor for the development of both torticollis and
hip dysplasia. 1
The diagnosis of CMT is clinical and involves assessment of the incorrect neck and head
movement, palpation of the SCM, and measurement of ROM in neck rotation (where 100°
is normal in infants) and lateral flexion (where 65° is normal). 6 Ultrasound imaging of the
SCM is currently considered to be the most reliable means of diagnosis. 32,33,34,35,36,37
More specialized diagnostic tests such as X-ray, MRI or CT scan can rule out the
presence of other pathologies that can cause torticollis: Klippel-Feil syndrome, posterior
fossa tumors, Sandifer syndrome, 38 spasmodic torticollis, atlas malformation, respiratory
tract infection,1 cervical adenitis. 5,8,39,40,41 Particular attention should be paid to certain ocular
diseases where asymmetrical posturing of the head is an effective mechanism for
compensating ocular defects. 42,43
Early diagnosis is essential in order to begin rehabilitation therapy as early as possible,
thus avoiding the thickening and shortening of the SCM that causes tilt and rotation of the
head, and deformation of the face and skull.
Parents are often the first to report the appearance of torticollis to the pediatrician, usually
when infants are between 2 and 4 months old.
Previous studies agree that if rehabilitation treatment is not carried out within the first year
of life, recovery of neck ROM is reduced. 3,4,6,7,13,21,26,32,44
The physical therapy management of CMT includes passive stretching and positioning
away from the tightness for active movements.
It is very important for parents/caregivers to be taught how to correctly implement the
home therapy program. 6,7,44,45
In severe cases, the use of an orthopedic collar or botulinum toxin injections 46 in addition
to physical therapy offers a 60-90% chance of resolution.
Surgical release is only used if infants do not respond to conservative interventions after
12 months of age. 13,24,47,48
The aim of this study was to evaluate physical therapy outcomes in infants with CMT
treated either by parents using a home exercise program or by a physical therapist.

Materials and methods

50 consecutive newborns with CMT, who had been referred by the primary pediatrician,
were assessed by a Physical and Rehabilitation Medicine (PRM) physician between
March 2006 and September 2013.
Data were collected over a 7-year period but no significant changes were detected in
nursery care or birth practices.

During clinical evaluation, the following health history factors were collected: sex, type of
delivery, weight at birth and age at initial visit.
The physical examination assessed:

- posture and shape of the head
- neuromotor development and musculoskeletal impairments
- condition of the SCM by means of bilateral palpation
- spontaneous motility
- rotation and lateral flexion of the cervical spine by means of goniometric measurement,
categorized into four distinct ranges: 6
- complete (100° rotation, 65° lateral flexion) 49
- mild limitation (<15°)
- moderate limitation (15-30°)
- severe limitation (>30°).
In the presence of severe neck limitation or muscle mass, ultrasound imaging was
performed on the neck muscles.

Rehabilitation program
On the basis of the severity of ROM limitations and parent compliance observed during
clinical evaluation, an individual r ehabilitation program was designed b
y PRM physician to
be implemented either by a physical therapist in the outpatient clinic, or by the
parents/caregivers at home. The parents/caregivers of infants who were prescribed home
therapy programs were taught how to perform the exercises, and were strongly
recommended to treat infants whenever possible using exercises and caregiving
maneuvers.
When parents seemed unsure of whether or how to carry out the necessary exercises, the
physician asked them to lie in a prone position and demonstrated the correct passive
rotation and lateral flexion movements on the parents themselves.
Outpatients were treated by a physical therapist for 30 minutes each day, until discharge.

The rehabilitation program included :

- stretching the SCM muscle to recover cervical lateral flexion and rotation with infants in
the prone position;;
- stretching the SCM muscle to recover cervical lateral flexion, with infants in thelateral
position supported with a pillow;;
- controlling posture in strollers, swings or car seats. W
e suggested using a pillow to
correct neck posture and toys/sounds etc. to encourage newborns to turn away from the
favoured side;;
- peforming active rotation exercises to recover cervical ROM, with infant in the supine,
sitting or prone position depending on age;;
- positioning newborns with the head inclined towards the affected side during breast or
bottle-feeding;;
- peforming environmental adaptations, i.e. positioning newborns and objects to
encourage the correct movement/position of the head.

Passive cervical rotation and lateral flexion could be peformed when infants were asleep
or awake depending on compliance, which is usually greater in newborns between 0 and 2
months old.
Active movements were encouraged during playtime by showing infants toys or attracting
their attention with sounds or lights.
Infants were assessed once a month during therapy and then one month after complete
resolution in order to verify outcome stability. Parents were actively encouraged to
continue performing the rehabilitation exercises for a few months to maintain recovery.

Statistical Analysis
Descriptive statistics were produced for demographic characteristics for this study sample
of patients. The Shapiro-Wilk test was used to test the normal distribution of quantitative
variables;; all variables were normally distributed and so the results were expressed as
mean values and SD (standard deviation);; qualitative variables were summarized as
counts and percentages. For quantitative variables, a t-test was used for independent data
to analyse differences between two groups, and chi-square or Fisher exact test, as
appropriate, was used for qualitative variables. All tests were two sides and p<0.05 was
considered statistically significant.
Data analysis was performed using the STATA statistical package (release 13.1, 2014,
Stata Corporation, College Station, Texas, USA).

Results
50 consecutive newborns with CMT were assessed in the outpatient clinic at the
Department of Physical Medicine and Rehabilitation: 16 female (32%) and 34 male (68%),
mean age 10.2 weeks (SD 6.66) at initial visit.
30 subjects (60%) were delivered vaginally (9 female and 21 male), 14 (28%) were
delivered with cesarean section (5 female and 9 male), 2 (4%) were delivered preterm (1
female and 1 male), and 4 (8%) were delivered with instruments following dystocia (1
female and 3 male).
The mean birth weight was 3239 grams (SD 529.6), without significant difference
(p=0.137) between female and male subjects (3076 grams, SD 677, and 3315 grams, SD
435, respectively).
The right side was affected in 26 subjects (52%), and the left side in 24 (48%).

Clinical evaluation

All the subjects had torticollis but met age-appropriate developmental milestones. None of
the subjects had hip dysplasia.
Plagiocephaly was present in 8 subjects (16%), 6 female and 2 male.

SCM palpation

19 subjects ( 38%) had no mass or tightness in the SCM.
13 subjects (26%) had mass and tightness in the SCM.
18 subjects (36%) had tightness but no mass in the SCM.

CERVICAL ROM
The results of the goniometric measurement of the rotation and lateral flexion of the
cervical spine, divided into 4 distinct ranges, were as follows:
- 25 subjects (50%) had complete passive ROM in rotation and lateral flexion, but
limitations in active ROM (postural torticollis),
- 15 subjects (30%) had mild limitation in lateral flexion (5 subjects) or rotation (3
subjects) or both (7 subjects),
- 6 subjects (12%) had moderate limitation in lateral flexion (2 subjects) or rotation (3
subjects) or both (1 subject),
- 4 subjects (8 %) had severe limitation in both rotation and lateral flexion.
Ultrasound imaging was performed for 28 subjects (52%) only in the presence of severe
limitation, muscle mass or severe tightness. It was not performed for newborns with
complete or mild limitation, or absence of muscle mass or tightness.
The ultrasound imaging results were as follows:
- 10 subjects (20%) showed no signs of mass or tightness in the SCM,
- 11 subjects (22%) had a fibrous SCM mass or increased thickness of the SCM,
- 7 subjects (14%) had muscle hematoma.

Rehabilitation treatment

Home e xercise program: in 27 cases (54%) a PRM physician taught parents/caregivers
how to perform the torticollis rehabilitation program at home, and planned monthly
follow-up visits that continued until one month after resolution.
Outpatient treatment: 23 subjects (46%) were treated by a physical therapist in the
outpatient clinic. 14 subjects (28%) only needed one cycle of physical therapy ( 1 cycle =
10 sessions of 30 minutes daily ), 4 subjects (8%) needed 2 cycles, 4 subjects needed 3
cycles and only 1 subject needed 6 cycles.
Considering the severity of ROM limitation i n rotation and lateral flexion (mild limitation
<15°, moderate limitation 15-30°, severe limitation >30°), the most serious cases of
torticollis (moderate plus severe) were treated in the outpatient clinic: 9/23 (39.1%) vs
home treatment: 1/27 (3.7%);; p < 0.001.

Outcome
All but one of the newborns included in our study achieved complete recovery of neck
posture and cervical motility in an average of 81.06 (SD 64.05) days. The data
demonstrate that lateral flexion was recovered more quickly (mean days 113, SD 90.3)
than rotation (mean days 128, SD 102.2), although statistical significance was not
reached.
Resolution was not correlated with sex, age at initial visit or type of treatment;; however,
the infants treated at home with less severe passive and active ROM limitations achieved
resolution more quickly than the infants treated in the outpatient clinic by a physical
therapist (72.8 days, SD 50.7 vs 91.1 days, SD 77.4).
The only infant who did not achieve complete resolution before the age of 12 months was
referred to the orthopedic surgeon. At the first evaluation he had severe limitation of
cervical ROM in rotation and inclination. He was given 60 sessions of physical therapy
with a therapist. He is most likely not to have recovered due to his severe f ibrosis of the
SCM, as shown by ultrasound imaging.
In 3 cases (2 infants with a hematoma and 1 with a fibrous mass in the SCM) there was a
relapse of torticollis after the follow up visit one month after full resolution, so the infants
needed further treatment in the outpatient clinic and a subsequent observation period until
resolution was stable. All 3 of these infants were 6 weeks old at their initial visit and
received a total of 3 cycles of physical therapy. They achieved resolution of CMT
symptoms in an average of 67.7 days (min 43, max 98).

Discussion

All but one of the infants in our study achieved full resolution of CMT symptoms. All the
infants were diagnosed early and treated, either in the outpatient clinic or at home, at
about 2.5 months. This age corresponds with the typical onset of torticollis reported in the
literature: 2-4 months. 39,50
Our study found that the duration of treatment before resolution was about 2.5 months
(mean 81 days, SD 64), whereas Petronic 44 had previously reported that when
rehabilitation began before 1 month of age, 98% achieved near normal ROM within 1.5
months, but when rehabilitation began after 1 month of age, treatment lasted about 6
months with fewer infants achieving near normal ROM.
Furthermore, there was a lower incidence of associated postural plagiocephaly in our
study than in others: 16% (8 cases) in our study group vs 20%-48% in previous
studies. 16,18
Our study also differs from the literature in terms of the side affected in CMT: we didn’t find
a statistically significant difference (52% right, 48% left), while the most commonly affected
side has been reported to be the left. 4
Based on the clinical evaluation, 27 (54%) of the infants in our study were prescribed a
home therapy program and parents/caregivers were taught how to conduct the exercises
by a physical therapist. It was sometimes necessary to demonstrate the passive lateral
flexion and rotation movements on the parents themselves to improve confidence and
convince them that they would not harm their child.
The remaining 23 (46%) infants were found to have more severe articular limitation than
those treated at home, with a statistically significant difference (respectively p: 0.0008, p:
0.002), so they were treated by a physical therapist in the outpatient clinic and parents
were encouraged to repeat the exercises at home.
Some authors suggest that treatment by a physical therapist may be more efficient in
achieving a normal range of motion and symmetrical movements than when
parents/caregivers are the sole providers of home exercises programs. 49
The infants in our study who were treated at home achieved resolution more quickly than
the infants treated in the outpatient clinic, respectively an average of 72.8 days compared
to 91.1, although statistical significance was not reached. This difference demonstrates
that we prescribed the correct type of treatment based on the severity of ROM limitations
in cervical rotation and lateral flexion.
Our study group achieved full resolution in a shorter time than has previously been
reported 44 , a difference that can probably be explained by the less severe articular
limitation present in our subjects: 25 infants (50%) had complete ROM at the initial visit
(postural torticollis), and only 4 infants (8%) had severe ROM limitation (>30°).
The earlier infants are treated, the better their outcome because their muscles have higher
elasticity and they are more pliable in the first 2 months of life. 6,7,50 This pliability leads to
higher infant cooperation, and, in turn, to better parent adherence to home programs.his
Our results show that ROM limitations in lateral flexion are resolved in a shorter time
(mean 113 days) than limitations in rotation (mean 128 days).
On the basis of our observation, infants seem to tolerate passive lateral flexion exercises
better than passive rotation exercises. We also noticed that active rotation is easily
encouraged by attracting infants’ attention with sounds or lights.
The three cases (6%) of torticollis relapse in our study, in which the infants needed further
treatment in the outpatient clinic, demonstrate the importance of instructing
parents/caregivers to continue implementing the rehabilitation plan and to check head
posture after the post-discharge monitoring period.

Conclusions

By correctly assessing the motility and range of motion of the cervical spine, infants can be
prescribed the appropriate plan of care: a home or outpatient rehabilitation program.
It is important to discharge infants after full resolution of CMT symptoms has been
achieved and to actively encourage parents/caregivers to monitor neck posture in order to
exclude the minimal risk of relapse.

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Early rehabilitation treatment in newborns with congenital muscular

Article in European journal of physical and rehabilitation medicine · February 2015

Ettore Carlisi Carmine Tinelli

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Maurizio Bejor Elena Dalla Toffola

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Early rehabilitation treatment in newborns with congenital

EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION

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Early rehabilitation treatment in newborns with Congenital Muscular

Matteo Foundation, Pavia, Italy

Unità di Medicina Fisica e Riabilitazione

piazzale Golgi 19 27100 Pavia Italy

sternomastoid tumor or pseudotumor, with a fibrotic, sternocleido-­mastoid muscle mass

Design​. Longitudinal study.

Key words:​ Congenital Muscular Torticollis –Newborn-­ Rehabilitation-­ Physical therapy

On clinical presentation, CMT may be classified into 3 types:​7,23,24,

Materials and methods

The physical examination​ assessed:

The rehabilitation program included :

The ultrasound imaging results were as follows:

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sternomastoid tumor or pseudotumor, with a fibrotic, sternocleido-mastoid muscle mass

Design. Longitudinal study.

Key words: Congenital Muscular Torticollis –Newborn- Rehabilitation- Physical therapy

On clinical presentation, CMT may be classified into 3 types:7,23,24,

The physical examination assessed: