Congenital Muscular Torticollis (CMT):

2018 Evidence-Based Clinical Practice Guideline

Clinician Self-Assessment

Purpose Instructions for Use

The purpose of this document is to provide
physical therapy clinicians with a self-assessment
tool related to knowledge and use of the 2018
Congenital Muscular Torticollis Clinical Practice
Guideline (CMT CPG). This self-assessment is
designed to assist clinicians in gauging
knowledge, skills, attitudes, and factors impacting
use of the CMT CPG.
The CMT CPG provides 17 action statements
within 4 domains including: Education;
Identification and Referral; Physical Therapy
Examination; Physical Therapy Intervention;
Discontinuation; Reassessment, and Discharge.
When using this self-assessment, individuals may select
all or some parts of the tool to meet their need. All
parts of the self-assessment may be completed at once
or in stages to meet the need of the user(s).
(4) parts to this CMT CPG Clinician Self-Assessment:
Within each of the (4) parts, this self-assessment is
designed to assess factors that impact an individual’s
use of the CMT CPG such as user knowledge, skill,
attitude, as well as availability of tools/resources within
his/her practice setting:
Part 1: Levels of Use
Part 2: Knowledge, skills, ability
Part 3: Availability of supports / tools
Part 4: User attitude

Suggested Uses Potential Outcomes

1. Clinician: Individual clinicians may use this tool as 1. Increased awareness of all domains of the CMT CPG
a measure to guide current and ongoing content as an initial step toward use of the guideline.
professional development in working with infants 2. Identification of needs and engage in planning
with CMT. The tool may be used as a baseline
professional development and necessary behavior
assessment and/or for reassessment following
implementation of a professional development plan. change related to knowledge, skills, and abilities in
caring for infants with CMT using the CMT CPG.
2. Groups and organizations: Groups and
organizations may use this tool with clinical staff to a. Targeted education for clinical staff to improve
guide discussion, education, orientation of new knowledge, skills and abilities in caring for
staff,and/or to develop standards for physical infants with CMT.
therapists who care for infants with CMT. b. Increased awareness by researchers and
3. Education providers: Education providers may knowledge brokers of potential barriers and
use this tool to assess the needs of learners and facilitators to use of the CMT CPG .
tailor educational content to meet identified needs. 3. Improved care and outcomes for infants with CMT.
.
Definition of Terms
Congenital Muscular Torticollis (CMT): CMT is a postural deformity evident shortly after birth, typically characterized by lateral
flexion of the head to one side and cervical rotation to the opposite side due to unilateral shortening of the sternocleidomastoid
muscle. CMT may be accompanied by other neurological or musculoskeletal conditions.
Clinical practice guideline (CPG): Clinical practice guidelines are systematically developed statements to guide clinicians in
using the best available evidence in patient care. CPGs are key to decreasing unwarranted variations in practice, decreasing the
knowledge translation gap, and optimizing movement.
For more information regarding CPG development: www.apta.org/EvidenceResearch/EBPTools/CPGs

For more info: APTA Pediatrics CMT Clinical Practice Guideline | pediatricapta.org/clinical-practice-guidelines
Users of this resource are strongly encouraged to read the full CMT CPG: Kaplan SL, Coulter C, Sargeant B, Physical
Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA
Academy of Pediatric Physical Therapy, Pediatr Phys Ther 2018; 30:240-290. Full text of the article is freely available at:
www.journals.lww.com/pedpt/Fulltext/2018/10000/Physical_Therapy_Management_of_Congenital_Muscular.2.aspx
Physical Therapy Management of Congenital Muscular Torticollis:
A 2018 Evidence-based Clinical Practice Guideline

Clinician Self-Assessment
Name: _______________________________________ Date: _____________ Location: ___________________________

PART 1: LEVEL OF USE

For each area (columns 1a/1b-4), select the best description of the present action you are taking with regard to
use of the CMT CPG. Select only one action for each area for a total of (5) responses.
Area 1a: Area 1b: Area 2: Area 3: Area 4:
Discontinuation,
Identification Examination/ NOTES:
Education Intervention Reassessment,
/ Referral Evaluation
Description of action: Discharge

I have little or no knowledge

and I am not taking any
action at this time to use the
CMT CPG for this area:
I am taking action to learn
more detailed information
from the CMT CPG for this
area:
I have established a routine
for applying the
recommendations from the
CMT CPG for this area:
Based on formal/informal
evaluation of outcomes for
my clients, I have changed
the way I practice by using
the CMT CPG in my setting
for this area:
Based on input and
coordination with colleagues
who are also using the CMT
CPG, I have started changing
the way I practice by using it
for this area.this area:
Adapted from: Hall GE, Loucks SF, Rutherford WL, Newlove BW. Levels of use of the innovation: a framework for analyzing innovation adoption. J
Teach Educ. 1975;26(1):52-56.

If you have not used the CMT CPG to guide your clinical practice decisions, please select from the following
statements to indicate why: (check all that apply)
__ Did not know guideline exists __ I do not see it as necessary
__ Did not know where to find the guideline __ Workplace productivity constraints
__ Takes too long to read the guideline __ Do not have necessary support(s)
__ Lack of time needed to plan and implement changes in my practice __ Other (specify): _________________________
__ Mentor or colleagues do not support use of the CMT CPG
______________________________________
__ Did not know where to start
______________________________________

2
Physical Therapy Management of Congenital Muscular Torticollis:
A 2018 Evidence-based Clinical Practice Guideline

Clinician Self-Assessment

Name: _______________________________________ Date: _____________ Location: ___________________________

PART 2: KNOWLEDGE, SKILL, ABILITY

Definition of terms for questions 1 through 4:

• Not confident: “I definitely need some additional information or support to implement this item.”
• Somewhat Confident: “I might need some additional information or support to implement this item.”
• Confident: “I am “good to go” to implement this item.”
• Not applicable (N/A): “This item is not applicable to my setting.”

1. How do you rate your knowledge, skill, and ability to complete the following CMT CPG actions for education /
identification / referral (CMT CPG p. 253):
Not Somewhat
Confident N/A
Confident Confident

A. As a provider, review with expectant parents and parents of newborns

A B C N/A
within the first 2 days of birth: (Action Statement 1, p. 253).

i. supervised prone/tummy play when awake > 3 times/day. A B C N/A

ii. full active movement throughout the body. A B C N/A

iii. prevention of postural preferences. A B C N/A

iv. the role of pediatric physical therapists in the comprehensive

A B C N/A
management of postural preference and optimizing motor outcome.

B. Assess newborn infants for asymmetries/CMT within first 2 days of life

A B C N/A
and document the presence of: (Action Statement 2, p. 255).
i. neck/facial/cranial asymmetry using: A B C N/A

a. comparing passive cervical rotation between left and right side

A B C N/A
and/ or visual observation.
C. Ability to assess infants for asymmetries /CMT and REFER to
Physician or physical therapist if the following are present:
(Action Statement 3, p. 256).

i. craniofacial asymmetry A B C N/A

ii. reduced active and passive cervical range of motion. A B C N/A

iii. to determine postural preference. A B C N/A

iv. identify SCM masses. A B C N/A

D. As a provider, I am comfortable contacting MD if signs of other causes

of asymmetry are suspected prior to initiation of PT intervention.
A B C N/A
(NOTE: Refer also to Action Statement 5, p. 258 for additional information
regarding comprehensive screening).
OTHER: A B C N/A

1. SUMMARY: List all items (A-C) marked “Not confident” and “Somewhat confident” in row A and row B. This
summary identifies potentially actionable items for your consideration.
3
Physical Therapy Management of Congenital Muscular Torticollis:
A 2018 Evidence-based Clinical Practice Guideline

Clinician Self-Assessment

2. How do you rate your knowledge, skill, and ability to complete the following CMT CPG actions for examination of
infants with asymmetries/CMT (CMT CPG p. 257-271):
Not Somewhat
Confident N/A
Knowledge, skills, ability to examine and evaluate: Confident Confident

A. Obtain infant’s general medical and development history: Knowledge of

(9) specific birth and health history factors related to CMT. A B C N/A
(Action Statement 4, p. 257).

B. Screen for non-muscular causes of asymmetry and conditions

associated with CMT that warrant referral of infant to medical
provider/pediatrician for additional diagnostic testing (Action Statement 5,
p. 258 - 259) including: (consistent with state practice act).
*detailed screening recommendations p. 258-259

i. Musculoskeletal screen:
a. postural preference
b. structural and movement symmetry:
i. neck
A B C N/A
ii. face and head
iii. trunk
iv. hips
v. upper and lower extremities
ii. Neurological screen (including vision) A B C N/A

iii. Integumentary screen A B C N/A

iv. Cardiopulmonary A B C N/A

v. Gastrointestinal history A B C N/A

C. Effectively refer infants to physicians if indicated by screening.

A B C N/A
(Action Statement 6, p. 259).
D. Effectively request and include in medical record all available images
A B C N/A
and interpretive reports. (Action Statement 7, p. 260).
E. Examine (7) body structures: (Action Statement 8, p. 261).
i. Posture and tolerance to positioning (as age appropriate in supine,
A B C N/A
prone, sitting, standing / with or without support).

ii. Passive cervical range of motion using arthrodial protractor to

determine PROM difference between left and right side:

a. Bilateral passive cervical rotation. A B C N/A

b. Bilateral passive cervical lateral flexion. A B C N/A

iii. Active cervical range of motion:

a. Bilateral active cervical rotation: (supine if < 3 mo / rotating

A B C N/A
stool (supported sit) if > 3 mo ).

b. Bilateral active lateral flexion (age appropriate use of the

A B C N/A
Muscle Function Scale).

4
Physical Therapy Management of Congenital Muscular Torticollis:
A 2018 Evidence-based Clinical Practice Guideline

Clinician Self-Assessment

Not Somewhat
Confident N/A
Confident Confident

iv. Pain or discomfort including use of FLACC (at rest / during passive
A B C N/A
ROM / during active movement).
v. Skin integrity/Musculature: Ability to examine/identify: A B C N/A

a. Symmetry of neck and hip skin folds. A B C N/A

b. Presence and location of SCM mass. A B C N/A

c. Size/shape/elasticity of SCM muscle and secondary muscles. A B C N/A

d. Secondary asymmetries or compensations of the neck and

A B C N/A
shoulder girdle.
e. Symmetry of limb use. A B C N/A

f. Symmetry/presence of protective and righting reactions

A B C N/A
(head/neck/trunk).
g. Presence of Trendelenburg (if ambulatory). A B C N/A

h. Presence of scoliosis. A B C N/A

vi. Craniofacial asymmetries and head/skull shape including use of

A B C N/A
Argenta’s classifications (p. 265).
F. Classify the level of CMT severity by choosing 1 of 8 proposed grades
A B C N/A
(ranging from “Early mild” to “Very late”). (Action Statement 9, p. 265).

G. Use of standardized tools to monitor for developmental delay:

(Action Statement 10, p. 268).
i. Test of Infant Motor Performance (TIMP)
A B C N/A
through 4 months corrected age.
ii. Alberta Infant Motor Scales (AIMS)
A B C N/A
from 4-18 months corrected age.
iii. Peabody Developmental Motor Scales-2 (PDMS-2)
A B C N/A
from 1-72 months of age.
H. Participation status: (Action Statement 11, p. 269).

i. Positioning when awake and asleep. A B C N/A

ii. Time spent in positioning devices/equipment (such as car seat,

A B C N/A
stroller, swing, Rock n’ Play).
iii. Positioning for feeding (same or alternating sides). A B C N/A

iv. Feeding difficulties (such as jaw position, preference for one side). A B C N/A

v. Time spent in prone position while awake. A B C N/A

I. Determine prognosis for resolution of CMT and the episode of care:

Including expected outcome in measurable terms + timeframe to achieve
A B C N/A
the expected outcome + potential courses if the condition is treated or not.
(Action Statement 12, p. 270).

5
Physical Therapy Management of Congenital Muscular Torticollis:
A 2018 Evidence-based Clinical Practice Guideline

Clinician Self-Assessment

ADDITIONAL EXAMINATION-RELATED CONSIDERATIONS:

J. Availability of tools/equipment in my setting:
i. Arthrodial protractor for measuring passive cervical ROM. No Yes

ii. Digital photography for documentation of preferred posture. No Yes

K. Availability of standardized tools in my setting to monitor for

developmental delay:
i. Test of Infant Motor Performance (TIMP)
No Yes
through 4 months corrected age.
ii. Alberta Infant Motor Scales (AIMS)
No Yes
from 4-18 months corrected age.
iii. Peabody Developmental Motor Scales-2 (PDMS-2)
No Yes
from 1-72 months of age.
L. Availability of additional person(s) to assist during the examination with
measuring passive cervical range of motion (while using measurement No Yes
tools such as an arthrodial protractor).

M. Access to comprehensive evaluation documentation template form OR

No Yes
modification and implementation of template to align with the 2018 CPG.
OTHER: A B C

2. SUMMARY: List all items (A-M) marked “Not confident” OR “No” and “Somewhat confident” in row A and row B.
This summary identifies potentially actionable items for your consideration.

3. How do you rate your knowledge, skill, and ability to complete the following CMT CPG actions for intervention
(CMT CPG p. 271- 277):
Not Somewhat
Confident N/A
Confident Confident

A. Awareness of the 5 components of first choice intervention (as detailed

A B C N/A
in Action Statement 13, p. 273).

B. Ability to document the 5 components as first choice intervention. A B C N/A

C. Ability to recommend intensity necessary to achieve complete

A B C N/A
resolution of CMT (as detailed in Action Statement 16).
D. Ability to perform passive range of motion intervention as
A B C N/A
recommended in the guideline (p. 272-273).
E. Ability to facilitate parent skill and ability to independently complete
passive range of motion stretches, AROM exercises, and symmetrical A B C N/A
motor skills.
F. Ability to facilitate parent knowledge, skill, ability to alter home
environment (alternating crib and changing table position, adapting car A B C N/A
seat, strategic toy placement, feeding positions, etc).

G. Ability to facilitate the development of symmetry in gross motor skills

A B C N/A
such as rolling, transitioning into sitting, and pulling to stand.

6
Physical Therapy Management of Congenital Muscular Torticollis:
A 2018 Evidence-based Clinical Practice Guideline

Clinician Self-Assessment

Not Somewhat
Confident N/A
Confident Confident

H. Ability to implement supplemental interventions, (microcurrent, TOT

collars, etc) if appropriate, in addition to the first-choice interventions. This
A B C N/A
includes access to tools/information and ability to implement. (as detailed
in Action Statement 14, p. 273).
I. Referring back to primary care or to the appropriate medical provider
when an infant is not making progress within the recommended guidelines
(as detailed in Action Statement 15, p. 276 - 277). This includes A B C N/A
awareness of general expectations of improvement and the numerous
other factors that contribute to this determination.
OTHER: A B C N/A

3. SUMMARY: List all items (A-I) marked “Not confident” and “Somewhat confident” in row A and row B. This
summary identifies potentially actionable items for your consideration.

4. How do you rate your knowledge, skill, and ability to complete the following CMT CPG actions for
discontinuation, reassessment, discharge: (CMT CPG p. 277- 280):
Not Somewhat
Confident N/A
Confident Confident

A. Knowledge about the discontinuation from direct service criteria

detailed in Action Statement 16, p. 277 including:
i. Full passive ROM within 5 degrees of non-affected side.
ii. Symmetrical active movement patterns throughout the passive
A B C N/A
range.
iii. Age-appropriate motor development.
iv. No visible head tilt.
v. Parent/caregiver understands what to monitor as the child grows.
B. Ability to meet reassessment guidelines as detailed in Action Statement
17, p. 278 including:
A B C N/A
i. Reassessment by a PT 3-12 months after discontinuation from
direct PT OR at the age of walking, then discharge as appropriate.

ii. Reassessment includes examination of:

a. Postural preference.
b. Structural and movement symmetry of the neck, face, head, A B C N/A
trunk, hips, upper and lower extremities.
c. Developmental milestones.
OTHER: A B C N/A

4. SUMMARY: List all items (A-B) marked “Not confident” and “Somewhat confident” in row A and row B. This
summary identifies potentially actionable items for your consideration.

7
Physical Therapy Management of Congenital Muscular Torticollis:
A 2018 Evidence-based Clinical Practice Guideline

Clinician Self-Assessment
Name: _______________________________________ Date: _____________ Location: ___________________________

PART 3: SUPPORT AND TOOLS

Given the details of the CMT CPG provided in Part 2 of this CMT CPG Clinician Self-Assessment, consider whether you
have both the support and the tools to use the CMT CPG for the following categories:

Discontinuation,
Prenatal and newborn
Identification / referral: Examination: Intervention: Reassessment and
parent education
Discharge:
Yes No Yes No Yes No Yes No Yes No

What supports/tools are needed in your current setting that would enhance your use of the CMT CPG? Consider time,
tools/equipment, documentation system etc.
_________________________________________________________________________________________________
_________________________________________________________________________________________________

What is the impact of other stakeholders on your use of the CMT CPG? Consider: Funding sources, parents/caregivers,
physicians/referral sources.
_________________________________________________________________________________________________
_________________________________________________________________________________________________

PART 4: ATTITUDE
The intent of this part is to foster clinician self-reflection regarding attitudes that may impact implementation of the CMT
CPG. This part may be used to prompt discussion with mentors or among group members if using with groups. For this
question, consider your attitude toward use of evidence and/or use of the CMT CPG:

Strongly Strongly
Disagree Neutral Agree
Disagree Agree
1. I feel it is important to apply published evidence
in my clinical practice.
2. I feel I can integrate parent/family preferences
with the CMT CPG recommendations.
3. I feel the CMT CPG guides my practice to
achieve outcomes in a timely manner.
4. I feel the CMT CPG helps to reduce unwarranted
variation in my practice.
5. I feel the CMT CPG informs my practice for
timely referrals to specialists.

Full text of the 2018 CMT CPG is freely available at:

https://journals.lww.com/pedpt/Fulltext/2018/10000/Physical_Therapy_Management_of_Congenital_Muscular.2.aspx. This document
along with other 2018 CMT CPG implementation resources are available at: https://pediatricapta.org/clinical-practice-guidelines/

©2018 by the APTA Academy of Pediatric Physical Therapy, 1020 N Fairfax Street, Suite 401-B, Alexandria, VA 22314-1488,
www.pediatricapta.org. Developed by the APTA Academy of Pediatric Physical Therapy Knowledge Broker Network. Co-Lead
Developers: Barbara Pizzutillo with Nicole Terrill and Melanie McKinney. The APTA Academy of Pediatric Physical Therapy provides
access to these member-produced fact sheets and resources for informational purposes only. They are not intended to represent the
position of the APTA Pediatrics or the APTA.
8