CONGENITAL MUSCULAR

TORTICOLIS (CMT)
5TH YR PT Pediatric 2022
Mrs. M M Simpamba
 INTRODUCTION
• The term torticollis is derived from the Latin words tortus, meaning “twisted” and
collum, meaning “neck.”

• Torticollis is also referred to as Wry-neck or twisted neck.

• Congenital Muscular Torticollis (CMT) is a postural deformity evident shortly after

birth.

• CMT is mainly due to unilateral shortening and thickening of the sternocleidomastoid.

• CMT may be accompanied by other neurological or musculoskeletal conditions.

 Definition

“Congenital muscular torticollis (CMT) is a common pediatric

musculoskeletal condition that is characterized by head tilted
to one side (lateral neck flexion to the affected) with neck
rotation to the opposite side due to unilateral shortening or
fibrosis of the sternocleidomastoid muscle (SCM)”.
 Relevant anatomy of the SCM

• Origin: The SCM has 2 heads, the sternal head medially and clavicular head laterally.

• Insertion: Lateral surface of the mastoid process through a strong tendon, and to the lateral
half of superior nuchal line of the occipital bone through an aponeurosis.

• Action: Unilateral contraction of the SCM flexes the head to the same side and rotates it to
opposite side (Ipsilateral flexion and contralateral rotation).

• When acting together, the two muscles flexes the neck forward and extends the head.

• Functions: Movements of the head. Serves as an accessory muscle of inspiration

STERNOCLEIDOMASTOID MUSCLE
 EPIDEMIOLOGY OF CMT
• The reported incidence of CMT ranges between 0.3% to 2% of all live
births.

• CMT has been reported to occur more frequently in males than female
infants.

• It is also reported to be more frequent in infants exposed to opioids (or

Narcotics).

• CMT may be accompanied by other congenital musculoskeletal

deformities.
 ETIOLOGY
The etiology of CMT is not clear, but the following theories have associated with CMT
in infants:

• Abnormal position of the head and neck in utero, during labour and delivery.

• Persistent positioning of the head on same side in utero or after birth

• Other risk factors include trauma during birth, oligohydramnios, breech presentation
and large baby.

• Congenital anomalies at the craniovertebral junction.

• Sternocleidomastoid muscle tightness, mass, tumour or fibrosis.

 PATHOPHYSIOLOGY
• Intrauterine malposition or perinatal flexion and rotation of head
and neck may cause ischaemia and oedema in SCM resulting in
compartment syndrome with subsequent fibrosis.

• SCM tear during delivery may result in hematoma formation leading

to fibrosis, atrophy and shortening of the muscle.

• Persistent positioning of head on same side may result in

shortening of the SCM muscle with asymmetry.
 Classification of CMT
CMT is categorized into 3 types:

• Postural CMT (20%): Presents as infants postural preference, with no muscle

tightness or mass, no restrictions in passive ROM. This is the mildest form of CMT.

• Muscular CMT (30%): Presents with tightness and thickness of the

sternocleidomastoid muscle but no mass present, with limitations in passive ROM.

• Sternocleidomastoid mass CMT (50%): Presents with fibrotic thickening of the

SCM muscle, with a palpable mass, and limitation in passive ROM. This is the most
severe form of CMT.
 Clinical presentation of CMT
• Unilateral shortening or fibrosis of the SCM muscle

• Head tilted to one side or lateral neck flexion to the same side of the
contracted muscle.

• Contra-lateral rotation of the neck, or face and chin turned to the opposite
side.

• The affected side seems to be excessively stronger than the contralateral side.

• The shoulder may be elevated on the affected side.

Clinical presentation of CMT
 Other clinical features of CMT
• A palpable, firm movable mass on the affected muscle.

• Limited range of motion in the neck (Neck rotation and side

flection).

• CMT may be accompanied by cranial facial asymmetry or

Plagiocephaly.

• CMT may also be due to Plagiocephaly.

 Plagiocephaly
• Plagiocephaly is a deformity of the head which is characterized by
prominence of one side and flattening of the other side of the
forehead.

• Occasionally, Plagiocephaly is accompanied by asymmetric

deformity of the ear or tugging of the mouth to the affected side.

• Plagiocephaly is usually caused by the asymmetric resting position

of the head during cranial development.
Plagiocephaly
 ASSOCIATED IMPAIRMENTS

CMT may be accompanied by:

• Cranial deformation,

• Hip dysplasia,

• Brachial plexus injury

• Distal extremity deformities (e.g club foot).

 COMPLICATIONS OF CMT
• Progressive limitation of cervical movements

• Facial asymmetry

• Plagiocephaly

• Compensatory scoliosis

• Delayed gross motor milestones

• Functional asymmetry similar to hemiplegia

 DIFFERENTIAL DIAGNOSIS

• Acquired torticollis

• Atlanto-Occipital Fusion: characterized by partial or total fusion of

the atlas to the occipital bone.

• Congenital fusion of 2 or more cervical vertebrae.

• Sternocleidomastoid tumor.

• Scoliosis
 DIAGNOSTIC PROCEDURES
• Physical inspection, palpation of the affected SCM and measurement of ROM
in neck.

• Ultrasound can clearly distinguish postural torticollis from SCM tumor

• MRI, X-rays and US can rule out other pathologies such as structural and
functional neurological causes.

• MRI is recommended when CMT does not resolve with 12 months.

• CMT can be a sign of an underlying pathology.

 PROGNOSIS
• Prognosis for CMT is determined by the type, age at initial diagnosis and
early intervention.

• Over 90% of infants have good-to-excellent outcomes with nonsurgical

management.

• Infants with postural CMT who are identified earlier (less than 3 months)
have shorter treatment period than those identified after 3 to 6 months.

• Infants with SCM mass CMT have longer treatment period of

conservative management and may ultimately undergo surgery.
 When to refer a patient for specialist opinion
• Poor visual tracking,

• Abnormal muscle tone,

• Extra-muscular masses and associated conditions such as cranial deformities.

• Other asymmetries inconsistent with CMT

• When, after 4 to 6 weeks of initial intense intervention, little or no reduction

in neck asymmetry is noted

• Infant 7 months old with an SCM mass.

 MANAGEMENT
• When diagnosed early, CMT can be managed conservatively
through Physiotherapy.

• Conservative management for CMT involves massage, passive

stretching, active positioning exercises and home programme for
parents.

• Botulinum toxin injections can sometimes be used in conjunction

with passive stretching in very tight muscles to relax them.
 SURGICAL MANAGEMENT
• Surgical intervention is usually recommended after failed conservative management.

• Surgical management is usually done after the age of 1 year.

• Indications for surgery include the clinical type (tumor or severe muscle tightness),
severe limitation in neck rotation and late presentation.

• Surgical procedures include excision of the mass/tumor and careful release of tight
fascia bands.

• Surgery should be followed up with intensive postoperative physiotherapy stretching.

 Physiotherapy management
• Aims of Physiotherapy management for CMT include:

1. Reduce muscle tightness

2. Strengthen neck muscles

3. Correct muscle imbalance

4. Gain pain-free movements (range of motion)

5. Improve postural control and symmetry

6. Improve body alignment by easing muscle tension

 Physiotherapy management cont.
The first choice of treatment for CMT physical therapy include:

• Gentle stretching and massage for the neck and back muscles

• Active and passive range of motion

• Strengthening exercises for the neck and back muscles

• Righting reactions and posture correction

• Kinesio-taping to elongate the muscles to facilitate stretching

• Parent/caregiver advice on correct positioning and handling

• A home-exercise program to continue gentle rehabilitation at home

 Physiotherapy assessment
History taking:

• Chronological age, age of onset of symptoms.

• Pregnancy history, delivery, birth presentation (Cephalic or breech)

• Head postures and preferences

• Family history of torticollis or other developmental anomalies

• Other known or suspected medical conditions

• Developmental milestones
 Physical examination
• Posture and positioning
• Assess for any pain or discomfort
• Bilateral passive range of movement during PROM and AROM
(PROM) for cervical lateral flexion and
rotation. • Examine skin integrity
• Bilateral active ROM for cervical lateral
flexion and rotation • Neurological examination

• PROM for upper and lower limbs • Check for any craniofacial
• AROM for upper and lower limbs
asymmetry.
 SUPPLEMENTAL INTERVENTIONS
• Micro-current (MC): A low intensity single channel alternating current applied
superficially below infants’ threshold of sensation.

• Soft tissue mobilisation (STM):

- Passive mobilisation phase

- Mobilisation with stretching

- Mobilisation with active cervical rotation.

• Evidence for MC and STM shows better outcomes.

• Kinesiological Tapping: Little or no evidence of added benefit

 PHYSIOTHERAPY TREATMENT TECHNIQUES
• Passive stretching is the most common treatment modality for torticollis with reported success rates
raging between 61% to 85%.

• Passive stretching involves two movements, neck rotation and side flexion.

• Rotation: Baby in supine, head in midline, then gently turn the head so that the face and chin face the
affected side (Hold and count to 10).

• Side flexion (ear to shoulder): Head in midline, flex the head to the unaffected side until the ear touches
the shoulder (Hold and count to 10).

• Repeat both stretches at every nappy change or 6 to 10 times a day. Time can be increased according to
cooperation level.
 Passive stretching for CMT
Neck rotation Side flexion
 Strengthening techniques
Tummy time in prone, on
pillow, wedge or therapy
ball

• Encourage head/neck
extension and rotation

• Encourage weight
bearing through the
upper limbs
Strengthening techniques cont.
1. Target muscles of the neck, trunk,
back and upper limbs
2. Practice prone position on therapy
ball
3. While support child on pelvis, rock
side to side and front to back
4. Use mirror in front to promote
alignment
5. Older child can sit on the therapy
ball and rock back, forward and
sides
 PHYSIOTHERAPY HOME PROGRAMS
Carrying technique:

For left side torticollis: Hold the baby against your body, with baby facing away from
you, head against your left shoulder, place your right arm between his/her legs and
reach his/her left shoulder.

• With your right hand, gently push his/her left shoulder downwards, and with your left
hand gently lift his/her head up till the right ear is in contact with the right shoulder.

• Hold the stretch from 20 seconds up to one minute, while you encourage parents to
play with the baby and distract him from pain.
 Carrying techniques for CMT

Right side CMT Left sided CMT

 PHYSIOTHERAPY HOME PROGRAMS cont.
Positioning:
• Positioning involves stimulating the child to actively turn the head.

• Side lying with affected side down, head on pillow to deviate the neck
towards the unaffected side.

• When child in stroller, car sit or resting, use rolled baby blanket or shaped
neck pillow to hold neck in neutral position.

• When in baby cot, position child in a way that will encourage looking to the
affected side.
Positioning techniques
 Positioning cont.
• In prone and supine, encourage active rotation of the neck by
stimulating the child with attractive bright toys, light or sound on the
affected side so that the baby can turn the head towards the
affected side.

• Strengthening the weaker side (unaffected side) by holding the

infant sideways or tilting him horizontally, with the weaker side up
HOME PROGRAMME FOR RIGHT SIDE TORTICOLLIS
More home based activities
 Outcomes of Physiotherapy management
• If PT is started before the age of 1 month: 98% of infants with CMT
achieve near normal ROM by 1.5 months.

• If PT is started after 1 month of age, physical therapy episodes are

prolonged by an extra 6 months.

• If PT is started by 6 months of age, PT intervention would take 9 to

10 months, with fewer infants achieving full ROM.
 REFERENCES
• Angoules, A.G., Boutsikari, E.C. and Latanioti, E.P., 2013. Congenital muscular torticollis: An
overview. Journal of General Practice.
• Cheng, J.C.Y., Tang, S.P., Chen, T.M.K., Wong, M.W.N. and Wong, E.M.C., 2000. The clinical
presentation and outcome of treatment of congenital muscular torticollis in infants—a study of
1,086 cases. Journal of pediatric surgery, 35(7), pp.1091-1096.
• Kaplan, S.L., Coulter, C. and Fetters, L., 2013. Physical therapy management of congenital
muscular torticollis: an evidence-based clinical practice guideline: from the Section on Pediatrics
of the American Physical Therapy Association. Pediatric Physical Therapy, 25(4), pp.348-394.
• Luther, B.L., 2002. Congenital muscular torticollis. Orthopaedic Nursing, 21(3), pp.21-29.
• Ohman, A.M., Mardbrink, E.L., Orefelt, C., Seager, A. and Tell, L., 2013. The Physical Therapy
Assessment and Management of Infants with Congenital Muscular Torticollis. A survey and a
Suggested Assessment Protocol for CMT. J Nov Physiother, 3(165), p.2.