Medical Rehabilitation / Rehabilitacja Medyczna (Med Rehabil) 2019, 23 (3): 21-30 DOI: 0 eISSN 1896–3250 © AWF Krakow

Congenital muscular torticollis – a proposal for treatment

and physiotherapy
Wrodzony kręcz szyi – propozycje leczenia i fizjoterapii

Agata Michalska 1 (A,B,D,E,F), Zbigniew Śliwiński 1 (B,D,E), Justyna Pogorzelska 1 (B,D,E), Marek Grabski 1 (B,D,E),
Jolanta Dudek 1 (B,D,E), Małgorzata Szmurło 2 (B,D,E,F), Maciej Szczukocki 3 (B,D,E)

1
Institute of Physiotherapy, Jan Kochanowski University in Kielce, Poland
2
Małopolska Centre for Children’s Rehabilitation in Radziszów, St. Louis Regional Specialised Children’s Hospital in Kraków, Poland
3
Institute of Nursing and Midwifery, Jan Kochanowski University in Kielce, Poland

Key words
congenital muscular torticollis, conservative treatment, physical therapy, algorithm

Abstract
Congenital muscular torticollis (CMT) is a condition manifested by unilateral thickening and/or shortening of the sterno-
cleidomastoid muscle. It can lead to local or global consequences (i.e., forced position and limitation of mobility of the cervi-
cal spine and head, delay of motor development). Early recognition of CMT symptoms and the implementation of conserva-
tive treatment, considered effective in the majority of cases, are an important part of physical therapy in CMT. The aim of the
study is to review literature presenting the methods of physical therapy in CMT and to create the authors’ own proposals for
treatment, based on the results of this review. Based on subject-matter literature and our own experience, algorithms for the reha-
bilitation procedure have been proposed, presenting the general scheme of action in CMT and management depending on the clin-
ical form and age of the child in whom therapy was started (up to 5 months and after 6 months). The authors’ proposed algorithm
did not strictly specify the frequency of sessions with a physiotherapist, because this is the resultant of many factors. The main ones
include the child’s age on the day of initiation of therapy, the clinical form of torticollis, the presence of muscle tone disorders and/
or skull asymmetry, but also, the correctness of performing exercises proposed as part of the home-based programme, regularity of
therapy and compliance with postural programme principles.

Słowa kluczowe
wrodzony kręcz szyi, leczenie zachowawcze, fizjoterapia, algorytm postępowania

Streszczenie
Wrodzony kręcz szyi to stan objawiający się jednostronnym pogrubieniem i/lub skróceniem mięśnia mostkowo-obojczykowo
-sutkowego. Może prowadzić do powstania miejscowych i globalnych konsekwencji (tj. wymuszonej pozycji i ograniczenia
ruchomości odcinka szyjnego kręgosłupa i głowy, opóźnienia rozwoju ruchowego). Wczesne rozpoznanie jego objawów oraz
wdrożenie leczenia zachowawczego, które uznaje się za skuteczne u większości chorych są istotnymi elementami fizjoterapii
wrodzonego kręczu szyi. Celem pracy jest przegląd literatury dotyczącej postępowania fizjoterapeutycznego u dzieci z wro-
dzonym kręczem szyi oraz stworzenie w oparciu o jego wyniki własnych propozycji ich leczenia. W oparciu o literaturę przed-
miotu oraz własne doświadczenia zaproponowano algorytmy postępowania usprawniającego przedstawiające ogólny schemat
działania w CMT oraz postępowanie w zależności od postaci klinicznej i wieku dziecka, w którym rozpoczęto terapię (do 5
m.ż i po 6 m.ż). W proponowanym algorytmie własnym nie określono ściśle częstotliwości spotkań z fizjoterapeutą, ponieważ
stanowi ona wypadkową wielu czynników. Do głównych należy zaliczyć wiek dziecka w dniu rozpoczęcia terapii, postać kli-
niczną kręczu, obecność zaburzeń napięcia mięśniowego i/lub asymetrii czaszki, ale również poprawność wykonywania ćwi-
czeń zaproponowanych w ramach programu domowego, systematyczność prowadzenia terapii i przestrzeganie zasad progra-
mu posturalnego.

The individual division of this paper was as follows: a – research work project; B – data collection; C – statistical analysis; D – data interpretation; E – man-
uscript compilation; F – publication search
Article received: 13.12.2018; Accepted: 04.05.2019
Please cite as: Michalska A., Śliwiński Z., Pogorzelska J., Grabski M., Dudek J., Szmurło M., Szczukocki M. Congenital muscular torticollis – a pro-
posal for treatment and physiotherapy. Med Rehabil 2019; 23(2): 21-30. DOI: 10.5604/01.3001.0013.3728
Internet version (original): www.rehmed.pl
This article is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License CC BY-SA (http://creativecommons.org/licenses/by-sa/4.0/)

21
Medical Rehabilitation / Rehabilitacja Medyczna (Med Rehabil) 2019, 23 (3): 21-30
INTRODUCTION
Congenital muscular torticollis
(CMT) is a postural deformity man-
ifested in one–sided thickening and/
or shortening of the sternocleido-
mastoid muscle (SCM). The result of
shortening is forced position of the
head in lateral flexion in the frontal
plane, towards the shortened SCM
muscle and the rotation of the chin
in the transverse plane in the oppo-
site direction, accompanied by limi-
tation of mobility and often ipsilater-
al arm elevation. The effect of CMT
is imbalance in the muscular tension
of the neck area. Its prevalence is es-
timated at 0.3–2.0% of live births1.
STUDY AIM
The aim of the study is a review of
specialist literature related to physi-
otherapy in children with congenital
torticollis, and to present the authors’
own treatment suggestions.
THE ETIOLOGY OF
CONGENITAL TORTICOLLIS
Perinatal traumatic injuries, i.e. stretch-
ing (tearing of fibres) of the SCM
muscle as a result of manoeuvres per-
formed during delivery, are most often
considered to be the cause of congeni-
tal torticollis. The results of modern re-
search, however, emphasize the impor-
tance of prenatal factors, although the
etiology of CMT is still unexplained.
The hypotheses cited in the subject–
literature are based, among others, on
theories of SCM muscle fibrosis as a re-
sult of infectious myositis, long–term,
asymmetrical foetal positioning, com-
pression of soft tissues leading to the
development of fascial compartment
tightness syndrome or on the ischem-
ic mechanism secondary to fibrosis1–3.
Lee et al.2, comparing the occurrence
of CMT in children born by force of
nature and by caesarean section, found
no statistically significant differences
in the frequency and severity of CMT
in both these groups, which may sug-
gest prenatal etiology. Similarly, the re-
sults of other studies confirm the coex-
istence of various malformations with
22
DOI: 0 eISSN 1896–3250
CMT, such as congenital hip dyspla-
sia (up to 20% of CMT) or congenital
clubfoot. It has not yet been explained
why out of so many neck muscles, this
pathology only applies to sternocleido-
mastoid muscle2,4–6.
SYMPTOMS OF CONGENITAL
TORTICOLLIS
Congenital torticollis manifests itself
in the forced position of the head and
neck – lateral flexion and rotation of
the chin in the transverse plane in the
opposite direction, accompanied by
limitation of mobility. Forced head
position can be associated with uni-
lateral shoulder lift on the side of tor-
ticollis. In SCM palpation testing,
a soft, painless swelling of 1–3 cm in
size, referred to as a pseudotumor,
can be detected. It is made of fibrous
tissue and gradually disappears up to
the age of 11,7,8.
Forced positioning of the child’s
head results in asymmetry of posture
and motor activity. In normal psycho-
motor development, due to the sym-
metrical activity of the neck flexor
muscles, the head and neck are posi-
tioned in mid–line orientation, which
occurs in 3–4 months of life. Their
centre line position gradually reduc-
es the impact on the posture of asym-
metrical tonic reactions, enabling the
convergence of eyesight and promot-
ing symmetry of limb movements.
This position, thanks to the possibili-
ty of symmetrical contact of the hand
with the body, also affects the devel-
opment of body awareness. The lack
of symmetrical head and neck align-
ment due to CMT leads to psycho-
motor development disorders, which
may be manifested as:
– greater activity of the contralateral
upper limb,
– disorder of symmetrical upper
limb activity, including putting the
hand in the mouth (which may re-
sult in subsequent sensory hyper-
sensitivity of the mouth),
– inability to experience conver-
gence (which may result in visual
perception disturbances),
– incorrect distribution of body
mass in supine and prone positions
(shift in facial direction),
© AWF Krakow
– extension activity in the neck area,
– ipsilateral limitation of shoulder–
blade mobility (which may result
in a lack of stabilisation of the
shoulder girdle, incorrect support
in prone position and secondary
compensation in the form of ex-
cessive extension activity)9.
The influence of CMT on motor de-
velopment was studied by Watemberg
et al.10, Öhman et al.11, Schertz et al.12
as well as Cabrera–Martos et al.13.
Functional asymmetry was found
in every fourth child with congeni-
tal torticollis in mild postural form,
more frequent occurrence of plagi-
ocephaly and delayed motor develop-
ment10. The differences in motor de-
velopment compared to healthy chil-
dren are noticeable up to 10 months
of age11, and sometimes even up to
1 year of age12; they are not accom-
panied by a delay in cognitive devel-
opment. In children with cranial de-
formities (plagiocephaly), the coex-
istence of torticollis delays the ap-
pearance of rotation, creeping and
assuming a standing position13.
In addition to functional disorders,
congenital torticollis can cause struc-
tural disorders such as skull and face
deformities, and malocclusion. As
a result of the shortening of the SCM
muscle, torsional forces arise, shift-
ing the ipsilateral auricle, malar bone
and frontal bone backwards, causing
displacement of the lower jaw14–16.
Deformations can affect the entire
skull, assuming the form of plagi-
ocephaly, which occurs in 80–90% of
children with CMT17.
DIAGNOSIS OF CONGENITAL
TORTICOLLIS
The diagnosis of CMT is most of-
ten made by a paediatrician based on
clinical symptoms (abnormal head
and neck alignment) and usually con-
firmed by ultrasound. The presence
of symptoms of congenital torticol-
lis, i.e. the forced head position, is
most commonly found in the first 3
months of life, although asymmetri-
cal head positioning may be seen im-
mediately after birth or appear up to
4 weeks following birth17. Depend-
ing on the clinical form, only thick-
 Medical Rehabilitation / Rehabilitacja Medyczna (Med Rehabil) 2019, 23 (3): 21-30
ening of the SCM muscle or a tu-
mour–like fusiform–shaped lesion
located most often in its lower part
can be observed in ultrasound (USG)
(Figure 1). The change, in its echo-
genicity, usually exceeds muscle tis-
sue, which is observed in approxi-
mately 50% of those diagnosed, and
its echostructure is heterogeneous18,
including a hypoechogenic rim sepa-
rating it from the structure of mus-
cle fibres. Cheng et al.19 described
the correlation between the increase
in echogenicity of the lesion and
the severity of clinical course. Its in-
crease may be an expression of the
replacement of normal skeletal mus-
cles with fibrous and adipose tissue.
In the “Doppler colour” option of
the USG examination, the vascular
flow outside or throughout the lesion
is visible at the beginning of the dis-
ease. At advanced stages, vascularisa-
tion is usually not observable20. Ex-
tended diagnosis is required in chil-
dren whose lesions persist for longer
periods despite the implementation
of treatment. Forced positioning of
the head, in addition to changes in
the SCM muscle, may be the result
of the occurrence of the cuneiform
vertebra, multiple vertebral disor-
ders, Klippel–Feil syndrome, Sandif-
er’s syndrome, gastroesophageal re-
flux disease, retropharyngeal abscess,
lymphadenitis, tonsillitis, mastoidi-
tis, bone marrow inflammation, cer-
vical dystonia, sensory disorders (vi-
sion, hearing), or cancer or paraneo-
plastic changes1,17,21. Further diagnos-
tics may require consultations carried
out by a pediatrician, orthopedist,
neurologist, ophthalmologist, supple-
mented by extended diagnostic imag-
ing and laboratory tests (according to
the planned diagnostic procedure).
INITIAL ASSESSMENT OF
TORTICOLLIS REQUIRED
FOR EXAMINATION BY
A PHYSIATRIST OR PHYSICAL
THERAPIST
According to many authors, initial as-
sessment is carried out by a physia-
trist or physical therapist during the
child’s first visit. Initial CMT assess-
ment should consist of:
– head alignment evaluation (in-
cluding skull symmetry assess-
ment),
– evaluation of the passive range
of head and cervical spine move-
ment, assessment of the active
range of motion (using visual
tracking or sound stimulation),
– neck palpation examination (in-
cluding the SCM muscle), neck
skin assessment,
– evaluation of the lower limbs
(occurrence of congenital hip
dysplasia, congenital foot de-
fects),
– assessment of psychomotor de-
velopment (including posture,
muscle tone, symmetry assess-
ment of motor skills in the field
of the gross and fine motor
skills)22,23.
Palpation of the SCM muscle reveals
a 1–3–cm thickening, usually locat-
ed in the central or lower abdomen.
Cheng et al.17 estimated the frequen-
cy of its occurrence in a group of
1,086 children to be at 28.2%. It is
soft, painless swelling, formed mainly
of fibrous tissue (without extravasat-
ed blood, blood vessel pathology or
inflammatory features), which can in-
itially increase its dimensions and dis-
appear gradually, usually before the
age of 1. It should be borne in mind
that in not all children with torticol-
lis during initial examination is limit-
ed mobility of the head and cervical
spine found. In opthalmic torticollis,
the range of motion may be normal16.
About 80–90% of children with tor-
ticollis present plagiocephaly (unilat-
eral flattening of the occiput)17. Pla-
giocephaly leads to asymmetry of the
skull and face, prominence of the zy-
gomatic arch and temporal field, and
displacement of the mandibular con-
dyle. A child with CMT should be
routinely screened for developmental
hip dysplasia. In children with con-
genital torticollis, some authors do
not recommend ultrasound examina-
tion in routine procedures, limiting
themselves to physical examination
only4,24. Opinions regarding this issue
are divided6, although many authors
believe that ultrasound assessment fa-
cilitates clinical assessment. The as-
sessment is supplemented by analy-
sis of medical records and an inter-
DOI: 0 eISSN 1896–3250 © AWF Krakow
view with questions on ways to car-
ry, lay down and feed a child. Based
on the results of the preliminary ex-
amination, it is proposed to classify
a child with CMT into one of 3 clin-
ical forms5:
– mild postural form (forced posi-
tion of the head and neck, no re-
strictions on passive mobility, no
thickening in the SCM muscle),
– muscular form (forced head and
neck position, limitation of pas-
sive mobility, shortening of the
SCM muscle),
– severe form with SCM muscle
thickening (tumour presence,
SCM muscle fibrosis, limitation
of passive mobility).
Based on the classification given
above, it is possible to conclude the
duration of therapy and possible
complications. In children with the
mild postural form, short conserva-
tive treatment is expected, and spon-
taneous symptom relief is often no-
ticed. In muscular form, the progno-
sis is good, only about 3% of children
require surgical treatment, while in
severe form, about 8% of patients
must undergo surgery5. The prognos-
tic factor is also the degree of head
mobility restriction. Reducing the
range of rotation to 10° is considered
to be easily corriible17.
PHYSICAL THERAPY IN
CONGENITAL TORTICOLLIS
The treatment of torticollis can be
conservative and its main element is
physiotherapy. Ryu et al.25 made an
attempt to analyse factors affecting
the resolution of CMT symptoms,
defined as the absence of chang-
es in the SCM muscle found in ul-
trasound. They considered the use
of physical therapy as the only sta-
tistically significant factor, exclud-
ing the significance of other varia-
bles, including age, sex, and length
and thickness of the change in the
SCM muscle. Among the important
factors influencing therapeutic suc-
cess is also the age of the child un-
dergoing therapy. The results of re-
search by many authors confirm the
principle that the earlier the reha-
bilitative procedure is initiated, the
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Medical Rehabilitation / Rehabilitacja Medyczna (Med Rehabil) 2019, 23 (3): 21-30 DOI: 0 eISSN 1896–3250 © AWF Krakow

shorter its duration1,26–28. In physio-
therapeutic treatment of CMT, the
following are applied: among others,
manual stretching, postural manage-
ment, massage, kinesiotaping, physi-
cal treatments and the use of orthot-
ic equipment. In the absence of cor-
rection of head positioning, rehabili-
tation is supplemented with invasive
methods, including botulinum tox-
in injections (in Poland, non–refund-
able treatment, available as part of
clinical trials) and surgical interven-
tion1,16,22,28–30.
THE AUTHORS’ ORIGINAL
ALGORITHM FOR PHYSICAL
THERAPY IN CHILDREN WITH
CMT
Based on the subject–literature and
our own experience, algorithms pre-
senting the general scheme of rehabil-
itative treatment in CMT have been
proposed (Figure 1), as well manage-
ment depending on the clinical form
and age of the child undergoing ther-
apy (up to 5 months and above 6
months) (Figure 2). In children with
the mild form of CMT, with no re-
strictions regarding range of passive
mobility in both age groups, the sug-
gested therapeutic methods are: ac-
tive correction, the use of a postur-
al programme and adaptation of the
home environment. In the muscular
and severe forms, stretching preced-
ed by physical treatments and/or
massage are additionally introduced.
Their frequency depends on the se-
verity of torticollis and the child’s
age (a greater number of repetitions
are recommended for larger mobili-
ty deficits – above 15°, and for chil-
dren beginning therapy being above
the age of 5 months). In children
with the mild form, younger than 6
months old, management can only
be limited to a home programme,
others should be assisted by an out-
patient physiotherapist using neu-
rophysiological methods and phys-
ical procedures (according to med-
ical recommendations). Corrective
helmets may be considered for chil-
dren with severe cranial deformities.
In postoperative rehabilitation, cer-
vical collars (soft, semi–rigid or rig-
id) may be used. Their type, head po-
sition (correction level) and during
of usage (wearing time) are individ-
ually recommended by an orthopae-
dic doctor or surgeon. Our proposed
algorithm did not strictly specify the
frequency of meetings with a physi-
otherapist because it is the result of
many factors. The main ones include
the child’s age on the day of initia-
tion of therapy, the clinical form of
torticollis, the presence of muscle
tone disorders and/or skull asymme-
try, but also the correctness of per-
forming exercises proposed as part
of the home programme, regularity
of therapy and compliance with pos-
tural programme principles. The fre-
quency of therapy should be deter-
mined individually after the initial,
local condition assessment, taking
the above mentioned factors into ac-
count. A meeting every 2 weeks was
proposed as the minimum during the
initial period, assuming the simulta-
neous introduction of a therapy pro-
gramme performed by the parent.
The postural programme imple-
mented in children with CMT is based
on the selection of corrective positions
appropriate to age and condition of
the child (including muscle tone) and
modification of nursing activities per-
formed by parents/guardians. They al-
low for passive and active stretching
of the contracted SCM muscle as well
as its strengthening on the contralat-
eral side, preventing postural deformi-
ties, including plagiocephaly. The pos-
tural programme also includes adjust-
ment of resting positions, playing po-
sitions and appropriate carrying of the
child. Based on a review of literature,
including the American Physical Ther-
apy Association guidelines, it is rec-
ommended to use:
– position with a lateral tilt of the
trunk of approximately 45°, in
which the side with the contract-
ed SCM muscle is closer to the
ground; in this position passive or
active correction of the head posi-
tion in the frontal and transverse
planes,
– frequently assuming prone posi-
tion,
– playing lying down on one’s side
(the SCM muscle side is closer to
the ground),
– sleep in a lying position on the side
with and without a pillow (the side
with SCM muscle contracted is
closer to the ground),
– appropriate feeding strategies (se-
lection of positions promoting ro-
tation in the opposite direction to
the assumed pattern).
Positions suitable for carrying a child
are: carrying the child with his/her
back to the guardian with lateral tilt
(the side with the contracted SCM
muscle is closer to the ground), carry-
ing the child sideways to the guardian
in a seated position (“bean”) and an
upright position promoting head ro-
tation, carrying the child front to the
guardian, on the shoulder, promoting
head rotation22,27,28. The postural pro-
gramme is associated with the need to
adapt the child’s environment, which
consists of: positioning in cot, seat
selection, car seat selection, toy ar-
rangement and presentation. Simulta-
neously along with the postural pro-
gramme, active correction is applied,
including exercises strengthening the
contralateral SCM muscle. For cor-
rection, the starting positions are se-
lected, in which the side with the con-
tracted SCM muscle is closer to the
ground, these are, among others, lat-
eral deflections, leading to a horizon-
tal position. Head straightening reac-
tions in low and high positions, ap-
propriate to the child’s age are also
used, as well as responses to sensory
stimulation (visual conduct, response
to sound) (Figure 6). Both the postur-
al programme and the methods of ac-
tive correction should be adjusted to
the child’s age and abilities (Table 1).
The selection of positions and correc-
tive activities should be preceded by
detailed assessment of posture and
motor performance in terms of sym-
metry, taking the influence of head
positioning on motor activity into ac-
count. The introduction of asymmet-
rical work to therapy must not dis-
turb the child’s movement patterns
and lead to diversified activity of both
sides of the body. Stretching is also
an element of physical therapy used
in children with muscular and sever
form of CMT. This type SCM mus-
cle stretching is used to reduce its ten-
sion, lengthen the fibres and restore
the physiological range of motion of

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 Medical Rehabilitation / Rehabilitacja Medyczna (Med Rehabil) 2019, 23 (3): 21-30 DOI: 0 eISSN 1896–3250 © AWF Krakow

Initial evaluation:
– assessment of active range of
movement (using eye tracking or audio
stimulation)
– evaluation of passive range of
movement Analysis of documentation confirming Consultations
– neck skin evaluation diagnosis: Conducted according to needs resulting from
– palpation examination of the neck, – Imaging studies physiotheurapeutic evaluation (paediatric,
including MOS muscle – Paediatric, neurological and ophthalmological neurological and ophthalmological, surgical
– evaluation of posture, muscle tonicity, opinion and orthopaedic)
gross and fine motor skills
– evaluation of hip joints
– skull symmetry evaluation
– interview regarding care, carrying and
feeding positions, resting

Classification of torticollis, determining objectives and programme of therapy

Therapy: Repetition of physiotherapeutic evaluation in

– At physiotherapeutic office (stretching, work using order to assess progress in therapy
neurophysiological methods in a range appropriate for (in the first two months, every two weeks, later, once
physiotherapeutic evaluation, massage, physical treatments) a month)
– At home programme (stretching, postural programme, active – Verification of methods
correction, massage, adaption of home environment)
– Adjuvant therapy (using orthotics, in the case of skull deformations, Follow-up of home programme:
use of corrective helmets) – Correctness of performing stretching techniques
– Adherence to postural programme guidelines

Relief of symptoms:
Lack of progress after 6 months of therapy
– In the case of a child below the age of 1, follow-
or persistent limitations in motion in the form of
up once every month, then, every 3 months until
lumps in the muscle MOS mass – orthopedic,
the age of 2
neurological and surgical medical consultation
– In the case of children who achieved the skill of
walking before the completion of therapy, follow-
up every 3 months for one calendar year

Post-operative rehabilitation:
– Usage of orthotics Invasive treatment:
– Therapy aimed at restoring muscle balance in – Botolinum toxin*
the neck area – surgical treatment
– Scar therapy

* Botulinum toxin treatment is not a routine therapeutic procedure in Poland, it is not refundable from the National Health Fund (NFZ)

Figure 1
General scheme of evaluation and treatment of congenital torticollis

the cervical spine and head. This pro-
cedure should be multiple times a day,
the more often the greater the degree
of mobility restriction. Based on a re-
view of literature7 and our own ex-
perience, we suggest performing this
action 3–5 times a day. Stretching
can be preceded by massage or phys-
ical treatment; it should not provoke
pain. Longer stretching duration and
low intensity is recommended to pre-
vent pain and micro–injuries of the
SCM muscle. Its purpose is to increase
range of motion28. Our observations
lead to the use of stretching according
to the scheme described by Emery29,
i.e. performing a 5–fold rotation mo-
tion preceded by traction and a 5–fold
lateral flexion motion and rotation
preceded by traction and a slight head
bend. The head should be maintained
in the end position for 10 seconds,
this time should be gradually extend-
ed up to 30 seconds. Under optimal
conditions, stretching should be per-
formed by two people. One of them
holds the shoulders and stabilizes
the collarbone, the other makes pas-
sive head movements. Stretching can
also be done by one person. Howev-
er, we believe that this technique does
not provide sufficient control over the
position of the shoulders and head of
the child being treated. SCM muscle
stretching can also be performed in
prone position, with the head in a ro-

25
Medical Rehabilitation / Rehabilitacja Medyczna (Med Rehabil) 2019, 23 (3): 21-30 DOI: 0 eISSN 1896–3250 © AWF Krakow

Age of child < 6 months Age of child ≥ 6 months

Severe muscular type, with Severe muscular type, with

Mild postural type, without Mild postural type, without
MOS muscle thickening and MOS muscle thickening and
limitations in passive limitations in passive
limitations in movement limitations in movement
movement movement

Work with a Work with a

physiotherapist physiotherapist
Home programme: Home programme:
Home programme: Home programme:
– Active correction (2-3 – Active correction (2-3
– Preparation for stretching – Preparation for stretching
times a day) times a day)
(physical treatments, (physical treatments,
– Postural programme – Postural programme
massage) massage)
– Home environment – Home environment
– Stretching (2-3 times – Stretching (5 times
adaptation adaptation
a day) a day)
Follow-up: Follow-up:
– Postural programme – Postural programme
In the first two months, every In the first two months, every
– Home environment – Home environment
2 weeks, later, once a month 2 weeks, later, once a month
adaptation adaptation
Follow-up: Follow-up:
In the first two month, every In the first two month, every
2 weeks, later, once 2 weeks, later, once
a month a month

Lack of symptom relief

Invasive treatment:
– Botolinum toxin*
– surgical treatment

Modification of therapy, according Post-operative rehabilitation:

to medical recommendations taking – Usage of orthotics
potential causes of lack of progress in – Restoration of muscle balance in neck
therapy into account area
– Scar therapy

Relief of symptoms:
– In the case of a child below the age of 1, follow-up once every month until child learns how to walk, then, every 3 months until the age of 2
– In the case of children who achieved the skill of walking before the completion of therapy, follow-up every 3 months for one calendar year

* Botulinum toxin treatment is not a routine therapeutic procedure in Poland, it is not refundable from the National Health Fund (NFZ)

Figure 2
Therapy management of congenital muscular torticollis – algorithm

tation toward it. The choice of tech-
nique should be decided by a doctor
and/or physical therapist, taking, in-
ter alia, the child’s age, morphology
and advancement of the changes into
account.
SCM massage in children with CMT
Massage should be treated as prepa-
ration for stretching or active correc-
tion. Its task is to reduce the tension
and make the SCM muscle more flex-
ible. It is performed in a position that
ensures muscle relaxation. It can be in
supine position with the head in the
central line of the body and the chin
slightly near the chest or in a position
lying on one’s side. The selection de-

26
 Medical Rehabilitation / Rehabilitacja Medyczna (Med Rehabil) 2019, 23 (3): 21-30 DOI: 0 eISSN 1896–3250 © AWF Krakow

Table 1
Suggestions for care, holding position and corrective activities in CMT taking the age of the patient into account
(own elaboration)
0-3 months
Care – selection of feeding position
encouraging rotation towards
the shortened SCM muscle
(feeding „belly to belly” or from
under the armpit, provoking
rotation with the use of a teat,
bottle),
– use to correct the rooting reflex,
– adaptation of the environment
promoting active correction of
the head position (position of the
cot, positioning in the cot).
Corrective holding – position sideways to the carrier,
positions child in a seated position, in this
position, rotation of the head
towards the guardian or in the
opposite direction (observation
of the environment),
– lying position on the shoulder
of the carrier (both positions are
intended to promote rotation
towards the shortened SCM
muscle).
Activity – encouraging the head to move
in full range of rotation in supine
and prone positions (e.g.
following with the eyes),
– frequent lying on the stomach,
head rotation in this position,
– lying on the side (more often on
the side of the contracted SCM
muscle), in this position, joining
the hands
4-6 months above 6 months
– adaptation of the environment – adaptation of the environment
to promote active correction of to promote active correction of
the head position (position of the head position (position of
the cot, positioning in the cot, the cot, positioning in the cot,
seating position), seating position),
– extending the time of lifting – promoting rotation movements
a child from lower to higher toward the contracted SCM
positions, using this position muscle during spoon feeding.
for active correction (lifting
sideways, side with shortened
SCM muscle closer to the
ground).
– back position to the carrier with – position on the carrier’s hip
lateral deflection (promoting (promoting rotation towards the
lateral flexion in the opposite shortened SCM muscle)
direction to the shortened SCM
muscle),
– sideways position to the carrier,
the child in an upright position
with dissociation of the lower
limbs (promoting rotation
towards the shortened SCM
muscle).
– encouraging full-range head – using eye tracking and reaching
movements in low and higher for toys in sitting, kneeling, on
positions (compensation all-fours and standing positions
observation required, e.g. for head position correction,
replacement of the deficit of – using rotation around one’s
rotation with extension, axis, amphibious position and
– lying on the side (more often on slanting position to correct head
the side of the contracted SCM position,
muscle), – lateral deflection (promoting
– assisted rotation (more often lateral flexion of the head in
through the side on the side of the opposite direction to the
the contracted SCM muscle), shortened SCM muscle).
– rotation around its axis
(promoting rotation towards the
shortened SCM muscle,
– lateral deflection (promoting
lateral flexion in the opposite
direction to the shortened SCM
muscle).

pends on the child’s level of motor ac-
tivity and the ability to relax. Move-
ments are carried out from the mas-
toid insertion to the collarbone and
sternum. The main technique is gen-
tle longitudinal stroking and rubbing,
which should not provoke pain. The
massage should be performed careful-
ly and gently, without pressing the lar-
ynx and vascular bundle of the neck.
Kinesiotaping in the treatment of
children with CMT
Kinesiotaping, i.e. dynamic plaster-
ing, is a method supporting the re-
habilitation process. Its effectiveness
in children diagnosed with CMT has
been confirmed in research by Öh-
man et al.31,32. However, Giray et al.33
found no additional effects of kine-
siotaping on torticollis. Dynamic
plastering is a method, the effects of
which have recently been questioned,
especially in review papers34,35.
Physical agents in the treatment of
children with CMT
The use of physical methods (elec-
tro physical agents, EPA) is limited
in paediatric rehabilitation due to the
safety of the means/factors applied.
The most safe physical treatments
supporting the rehabilitation process
of children with CMT are: magne-
tostimulation, magnetoledotherapy,
microcurrents and the action of vis-
ible polarised light. The above–indi-
cated forms of energy cannot only
be easily applied, which is especially
important in infants, but also easily
select the appropriate treatment pa-
rameters. In the subject–literature,
magnetostimulation is defined as the
use of magnetic fields with low in-
duction values of 30–70μT36. Due to
the biological effects in tissues, the
indications for the use of magneto-
stimulation in CMT primarily in-
clude analgesia and peripheral circu-
lation improvement37. The procedure
should be performed at least once
a day before kinesiotherapy (it can
also be applied more often, at fixed
times, but these procedures should
not be performed in the evening). In
our opinion, our own observations
justify the P2 or P1 programme, M2
mode, intensity of 0.5–1, treatment

27
Medical Rehabilitation / Rehabilitacja Medyczna (Med Rehabil) 2019, 23 (3): 21-30
time 12 minutes, elliptical applicator
with a 5–cm diameter. The synergis-
tic effect of ledotherapy (quasimon-
ochroamtic, non–polarised, incoher-
ent radiation) and magnetostimula-
tion allows to achieve analgesic, va-
sodilatatory and metabolism enhanc-
ing effects38. Due to the greater depth
of action, it is suggested to combine
LED infrared light with magnetostim-
ulation. Prior to the procedure, pre-
liminary preparation of the irradiated
surface is required (washing and de-
greasing the skin). Light should fall
perpendicularly to the treated surface.
It is recommended to use protective
glasses for the child. Microcurrents,
referred to as MENS (microampera-
ture electrical nerve stimulation), Mi-
cro–TENS or LIDC (low–intensity
direct currents) are characterised by
the use of currents measured in mi-
croamps (10–800μA). The microcur-
rent amplitude is so small that it is not
sensed by the treated children during
stimulation39,40. The mechanism of
microcurrent operation restores the
biological and electrical tissue balance
necessary to stimulate tissue regener-
ation processes41. MENS therapy usu-
ally consists of two successive treat-
ment phases. During the first phase,
the main objective is to quickly reduce
pain (parameters: intensity of 300μA
or higher, pulse time 1–50 msec, fre-
quency 10–400Hz or higher), in the
second phase; the healing process of
tissues covered by the disease process
is to be accelerated (parameters: in-
tensity of 10μA–200μA, pulse dura-
tion 100 msec or longer, frequency
0.3–1.0 Hz). In children with CMT,
only the second phase can be used,
with a treatment time of 5 to 10 min-
utes. Treatments can be performed
once a day, prior to kinesiotherapy,
from several weeks to 1.5 months. Af-
ter achieving the intended therapeu-
tic effects, it is advisable to continue
the treatment for 5–10 days. During
the procedures, flat electrodes, pref-
erably self–adhesive with a small di-
ameter, can be used, which are placed
on the course of the SCM muscle or
point electrodes, using “spreading and
pinching” techniques39. Due to the
ease of application and a small num-
ber of contraindications, visible polar-
ised light is becoming a new form of
28
DOI: 0 eISSN 1896–3250
therapeutic effects complementary to
traditional methods. Absorbed visible
polarised light is converted into elec-
trochemical energy, which triggers the
chain of biochemical reactions inside
the cells, stimulating the proper me-
tabolism and strengthening the immu-
nity of the whole organism. The main
therapeutic influence of visible po-
larised light regards: acceleration of
metabolism, improvement of micro-
circulation, and analgesic as well as
anti–inflammatory effects42. In chil-
dren with CMT, SCM muscle irradia-
tion can be used with the entire visible
light spectrum (white) or with a se-
lected wavelength dimension spec-
trum (red light improves circulation).
Irradiation should be performed once
a day, before kinesiotherapy. The
treatment time depends on the used
lamp (6 minutes with Bioptron lamp
or 10 minutes with Qlight lamp, po-
lariser filter). The principle that the
light must fall onto the treated surface
perpendicularly should be observed,
and the use of protective glasses is rec-
ommended for the child.
EVALUATION OF THE
REHABILITATION
PROGRAMME IN CHILDREN
WITH CMT
In accordance with the proposed al-
gorithm (Figure 1), the effectiveness
of therapy should be evaluated every
2 weeks in the first 2 months of its
duration. In the third and each sub-
sequent month, a single meeting is
sufficient. This frequency of reassess-
ment was chosen on the assumption
of steady progress, and in the absence
of progress, the frequency of meet-
ings should go back to every 2 weeks.
The main purpose of evaluation is to
verify the effectiveness of the pro-
posed therapeutic methods. The tool
used for this purpose can be the 18–
point numeric scale proposed in the
study by Cheng et al.17. This scale al-
lows to evaluate the degree of defi-
cit of rotation and flexion measured
in degrees on a scale of 0 to 3 points,
face and skull asymmetry, head posi-
tion and subjective feelings of parents
regarding the child’s functioning and
the cosmetic effects of therapy. The
© AWF Krakow
total of points equal to 16–18 means
very good therapeutic effects, 12–15
points – good effects, 6–11 points –
weak effects, below 6 points – unsat-
isfactory effects16,17. During meetings,
the physical therapist should support
parents and encourage them to per-
form a home–based programme, but
also control the correctness of the
stretching technique and compli-
ance with the principles of the pos-
tural programme. When the symp-
toms disappear, the authors propose
a check–up once every month un-
til gait ability occurs, then, every 3
months until the age of 2. In children
who start to walk before the end of
therapy, a check–up is recommended
every 3 months for a whole year. This
is dictated by the high dynamics of
changes in the child’s psychomotor
development during the first year of
age, and the possibility of symmetry
disorders appearing after the child
achieves new, higher positions. Lack
of progress after 6 months of therapy
or persistent significant mobility re-
strictions are an indication for med-
ical consultation and extended diag-
nostics. In this case, the physical ther-
apist may be required to modify the
methods of conduct or, after consul-
tation with a surgeon, apply surgical
treatment consisting in extending the
SCM muscle to implement post–op-
erative rehabilitation. It includes the
use of orthotics, scar therapy and
functional therapy aimed at restoring
muscular balance and postural sym-
metry of the neck area.
The essence of the mobilisation of
the postoperative scar is to take ther-
apeutic measures in a situation when
the tissue is still immature, which will
affect the condition of the scar (its
structure and appearance). The treat-
ment and management of surgical
scars throughout the entire healing
process is aimed at restoring wound-
ed tissues to the structure before sur-
gery as closely as possible. The early
improvement process is aimed at pre-
venting the formation of contractures
and adhesions, the effects of which
are visible in the form of reduced tis-
sue sliding, muscular imbalance, and
weakness as well as loss of elastici-
ty. Then, scar mobilisation and mas-
sage are used, involving the use of
 Medical Rehabilitation / Rehabilitacja Medyczna (Med Rehabil) 2019, 23 (3): 21-30
various techniques using the appro-
priate depth and degree of touch43.
Scar mobilisation can begin even with
stitches. Then, the mobilisation tech-
niques concern the areas around the
forming scar, which is done to ensure
better blood supply and nutrition of
the scar areas, and thus, faster healing
and collagen production in the newly
formed structure. In the first phase of
scar formation (until the scab is com-
pletely healed), mobilisation should
take place in the direction of the
healing tissues, or “towards the scar”.
Subsequently, techniques for stretch-
ing the tissue around the scar – trans-
versely, obliquely along the scar it-
self can be included. After the scab
has healed, the technique of twisting
the scar, pulling the scar away from
internal tissues, and rolling the scar
can be applied. It is assumed, howev-
er, that soft scar tissue therapy only
begins after the wound has complete-
ly healed. It should be borne in mind
that unskilful mobilisation can pro-
long the healing process, and thus
stimulate scar hypertrophy; hence,
its techniques should be demonstrat-
ed by a physiotherapist. In scars with
advanced morphology, mobilisation
techniques are carried out to sof-
ten them, making the changed tis-
sue more elastic, reducing symphysis,
and improving muscle function44.
Piśmiennictwo / References
1. Cheng J.C., Wong M.W., Tang S.P., Chen
T.M., Shum S.L., Wong E.M. Clinical deter-
minants of the outcome of manual stretching
in the treatment of congenital muscular torti-
collis in infants. A prospective study of eight
hundred and twenty–one cases. J Bone Jo-
int Surg Am 2001; 83: 679–687.
2. Lee S.J., Han J.D., Lee H.B., Hwang J.H.,
Kim S.Y., Park M.C., et al. Comparison of cli-
nical severity of congenital muscular torticol-
lis based on the method of child birth. Ann
Rehabil Med 2011; 35: 641–647.
3. Suzuki S., Yamamuro T., Fujita A. The aetio-
logical relationship between congenital tor-
ticollis and obstetrical paralysis. Int Orthop
1984; 8: 175–181.
4. Kim S.N., Shin Y.B., Kim W., Suh H., Son
H.K., Cha Y.S., et al. Screening for the co-
existence of congenital muscular torticol-
lis and developmental dysplasia of hip. Ann
Rehabil Med 2011; 35: 485–490.
5. Carenzio G., Carlisi E., Morani I., Tinelli C.,
Barak M., Bejor M., et al. Early rehabilita-
tion treatment in newborns with congenital
muscular torticollis. Eur J Phys Rehabil Med
2015; 51: 539–545.
6. Joiner E.R., Andras L.M., Skaggs D.L.
Screening for hip dysplasia in congenital
muscular torticollis: is physical exam eno-
ugh? J Child Orthop 2014; 8: 115–119.
7. Michalska A., Szmurło M., Pogorzelska J.,
Szczukocki M., Szwilling Z. Wrodzony kręcz
szyi– przegląd metod leczniczych. Neurol
Dziec 2017; 26: 29–34.
8. Wei J.L., Schwartz K.M., Weaver A.L., Orvi-
das L.J. Pseudotumor of infancy and conge-
nital muscular torticollis: 170 cases. Laryn-
goscope 2001; 111: 688–695.
9. Bly L. Components of typical and atypical
motor development. Neuro–Developmental
Treatment Association. Laguna Beach: 2011:
31–33.
10. Watemberg N., Ben–Sasson A., Goldfarb R.
Transientm motor asymmetry among infants
with congenital torticollis–description, cha-
racterization, and results of follow–up. Pe-
diatr Neurol 2016; 59: 36–40.
11. Öhman A., Nilsson S., Lagerkvist A.L., Bec-
kung E. Are infants with torticollis at risk of
a delay in early motor milestones compared
with a control group of healthy infants? Dev
Med Child Neurol 2009; 51: 545–550.
12. Schertz M., Zuk L., Zin S., Nadam L., Schwar-
tz D., Bienkowski R.S. Motor and cognitive
development at one–year follow–up in in-
fants with torticollis. Early Hum Dev 2008;
84: 9–14.
13. Cabrera–Martos I., Valenza M.C., Valenza–
Demet G., Benítez–Feliponi Á., Robles–Viz-
caíno C., Ruíz–Extremera Á. Impact of tor-
ticollis associated with plagiocephaly on in-
fants’ motor development. J Craniofac Surg
2015; 26: 151–156.
14. Luxford B.K., Hale L., Piggot J. The phy-
siotherapy management of infants with con-
genital muscular torticollis: a survey of cur-
rent practice in New Zealand. New Zealand J
Physiother 2009; 37: 127–135.
15. Hollier L., Kim J., Grayson B.H., McCarthy
J.G. Congenital muscular torticollis and the
associated craniofacial changes. Plast Re-
constr Surg 2000; 105: 827–835.
16. Freed S.S., O’Berry C. Identification and tre-
atment of congenital muscular torticollis in
infants. JPO 2004; 16: 18–23.
17. Cheng J.C., Tang S.P., Chen T.M., Wong M.W.,
Wong E.M. The clinical presentation and out-
come of treatment of congenital muscular tor-
ticollis in infants–a study of 1,086 cases. J Pe-
diatr Surg 2000; 35: 1091–1096.
18. Haque S., Bilal Shafi B.B., Kaleem M. Ima-
ging of torticollis in children. Radiographics.
2012; 32: 557–571.
19. Cheng J.C., Metreweli C., Chen T.M., Tang
S. Correlation of ultrasonographic imaging
of congenital muscular torticollis with clinical
assessment in infants. Ultrasound Med Biol
2000; 26: 1237–1241.
20. Wang L., Zhang L., Tang Y., Qiu L. The va-
lue of high–frequency and color Doppler
ultrasonography in diagnosing congenital
muscular torticollis. BMC Musculoskelet Di-
sord 2012; 13: 209.
21. Burch C., Hudson P., Reder R., Ritchey M.,
Strenk M., Woosley M; Cincinnati Children’s
Hospital Medical Center: Evidence–based
clinical care guideline for Therapy Man-
agement of Congenital Muscular Torticol-
lis. [http://www.cincinnatichildrens.org/svc/
alpha/h/health–policy/ev–based/otpt.htm.
Guideline 33: 1–13, 11–19–09].
22. Kaplan S.L., Coulter C., Fetters L. Physical
therapy management of congenital muscu-
lar torticollis: an evidence–based clinical
practice guideline: from the Section on Pe-
diatrics of the American Physical Thera-
py Association. Pediatr Phys Ther 2013; 25:
348–394.
23. Cheng J.C., Tang S.P., Chen T.M. Sternocleido-
mastoid pseudotumor and congenital muscu-
lar torticollis in infants: A prospective study of
510 cases. J Pediatr 1999; 134: 712–716.
24. Minihane K.P., Grayhack J.J., Simmons T.D.,
Seshadri R., Wysocki R.W., Sarwark J.F. De-
velopmental dysplasia of the hip in infants
with congenital muscular torticollis. Am J Or-
thop 2008; 37: E155–E158.
25. Ryu J.H., Kim D.W., Kim S.H., Jung H.S.,
Choo H.J., Lee S.J., et al. Factors Correla-
DOI: 0 eISSN 1896–3250 © AWF Krakow
ting Outcome in Young Infants With Conge-
nital Muscular Torticollis. Can Assoc Radiol J
2016; 67: 82–87.
26. Celayir A.C. Congenital muscular torticol-
lis: early and intensive treatment is critical. A
prospective study. Pediatr Int 2000; 42: 504–
547.
27. Öhman A., Mårdbrink E.L., Stensby J., Bec-
kung E. Evaluation of treatment strategies
for muscle function in infants with congenital
muscular torticollis. Physiother Theory Pract
2011; 27: 463–470.
28. Lee I. The effect of postural control interven-
tion for congenital muscular torticollis: a ran-
domized controlled trial. Clin Rehabil 2015;
29: 795–802.
29. Emery C. The determinants of treatment du-
ration for congenital muscular torticollis.
Phys Ther 1994; 74: 921–929.
30. van Vlimmeren L.A., Helders P.J., van Ad-
richem L.N., Engelbert R.H. Torticollis and
plagiocephaly in infancy: therapeutic strate-
gies. Pediatr Rehabil 2006; 9: 40–46.
31. Öhman A. The immediate effect of kinesiolo-
gy taping on muscular imbalance in the late-
ral flexors of the neck in infants: a randomi-
zed masked study. PM R 2015; 7: 494–498.
32. Öhman A.M. The immediate effect of kine-
siology taping on muscular imbalance for in-
fants with congenital muscular torticollis. PM
R 2012; 4: 504–508.
33. Giray E., Karadag–Saygi E., Mansiz–Kaplan
B., Tokgoz D., Bayindir O., Kayhan O. A ran-
domized, single–blinded pilot study evalu-
ating the effects of kinesiology taping and
the tape application techniques in addition
to therapeutic exercises in the treatment of
congenital muscular torticollis. Clin Rehabil
2017; 31: 1098–106.
34. Parreira PdCS, Costa LdCM, Hespanhol Ju-
nior LC, Lopes AD, Costa LOP. Current evi-
dence does not support the use of Kinesio Ta-
ping in clinical practice: a systematic review.
Journal of Physiotherapy 2014; 60: 31–39.
35. Kalron A, Bar–Sela S. A systematic review
of the effectiveness of Kinesio Taping – fact
or fashion? Eur J Phys Rehabil Med 2013;
49(5): 699–709.
36. Sieroń A. Analiza skuteczności terapeutycz-
nej magnetostymulacji systemem Viofor JPS
w wybranych jednostkach chorobowych.
Acta Bio–Opt Inf Med 2001; 1–2: 1–8.
37. Pasek J., Mucha R., Sieroń A. Magnetosty-
mulacja–nowoczesna forma terapii w medy-
cynie i rehabilitacji. Fizjoterapia 2006, 4: 3–8.
38. Kwiecień–Czerwieniec I., Woldańska–Okoń-
ska M. Magnetoled therapy in comprehen-
sive pediatric rehabilitation. Pol Ann Med
2012; 19: 163–169.
39. Dudek J. Terapeutyczne zastosowanie sty-
mulacji wysokonapięciowej i mikroprądów,
Med Sport 2001; 17: 239–244.
40. Dudek J, Głąb G. Mikroprądy w praktyce fi-
zjoterapeutycznej. Rehabil Prakt 2012; 2:
40–3.
41. Fujiya H., Ogura Y., Ohno Y., Goto A., Naka-
mura A., Ohashi K., et al. Microcurrent Elec-
trical Neuromuscular Stimulation Facilitates
Regeneration of Injured Skeletal Muscle in
Mice. J Sports Sci Med 2015; 14: 297–303.
42. Dudek J. Widzialne światło spolaryzowane
i koloroterapia, Rehabil Prakt 2009; 2: 23–28.
43. Schleip R., Findley T., Chaitow L., Huijing
P. Badanie, profilaktyka i terapia dysfunkcji
sieci powięziowej. Elsevier Urban&Partner;
Wrocław 2012: 293–411.
44. Lewit K., Olsenska S. Clinical importanceof
active scars a cause of myofascial pain. J Ma-
nipulative Physiol Ther 2004; 27: 399–402.
Address for correspondence
Agata Michalska
Uniwersytet Jana Kochanowskiego w Kielcach
Instytut Fizjoterapii
al. IX wieków Kielc 19, 25–317 Kielce, Poland
e–mail: michalskaagata.reh@gmail.com
29