Orthotics/Prosthetics

Torticollis, also known as the shortening of the sternocleidomastoid muscle (SCM), is typically correctable with early diagnosis and therapeutic intervention, but in severe cases, an orthosis that manages a triaxial range of motion may be added to the treatment protocol, according to Gerald Stark, MESM, CPO/L, FAAOP, of Fillauer Companies Inc., in Chattanooga, Tenn.

Stark discussed his literature review of torticollis management at the American Academy of Orthotists & Prosthetists Annual Meeting and Scientific Symposium, in Orlando, Fla., and called for more data that would guide management of torticollis with orthoses.

Torticollis is a physical symptom found in all ages in which the head tilts toward the affected side and the chin toward the opposite side. Congenital muscular torticollis (CMT) presents shortly after birth in about one in 300 births.

	Image: © iStockphoto.com/Beau Meyer

“One of the surprising things is that torticollis is actually the third most prevalent pediatric orthopedic diagnosis,” Stark told O&P Business News. “I did not realize the prevalence was that high when I first studied the subject.”

According to Stark, 53% to 75% of the patients with torticollis tilt toward the right side. This could be caused by birth posture or the way in which the baby was delivered. The diagnosis, which would include decreased movement for certain lateral head shifts and rotations, normally occurs in the first 2 to 3 months of life.

“An excellent overview of torticollis has been provided by Colleen Coulter-O’Berry and Susan Freed, but there needs to be more literature regarding management to guide orthotic componentry and design,” Stark said.

Correction of torticollis

In the congenital presentation, 90% to 95% of torticollis cases are correctable with stretching and orthotic care.

“Quite often, torticollis is related to other malformations of the head. There is also a need for cranial remolding — not in all cases — but often times there is,” Stark said. “Sometimes clinicians combine torticollis management with a cranial remolding helmet.”

A cranial remolding orthosis or helmet may be used to manage deformational plagiocephaly, also known as an asymmetric distortion of the skull, which is often associated with torticollis, according to Stark. Practitioners can create the orthosis using computer-aided design and manufacturing. According to Stark, there is an 80% to 90% greater prevalence of adult plagiocephaly if the torticollis is not corrected.

“It depends on severity, but primarily stretching is usually effective and this was correlated by a Chinese study of over 1,000 children,” Stark said.

In that study by Cheng, 1,086 patients showed that mulitphasic stretching was 91.6% effective. Only 5% to 10% of congenital patients need surgery after 18 months. In fact, the parents can manage the stretching themselves for deficits of 10° or less. Stark recommended avoiding cervical flexion in bouncy seats, car seats or forward-facing baby carriers.

“Low-impact exercise to increase stability and gentle manipulation of the neck should work,” Stark said. “Some advocated application of heat and massages. Botox has even been used, but that is potentially dangerous because you are injecting Botox in a sensitive area in the neck. Obviously, that would be difficult for orthotists to advocate.”

Underlying cases require different treatments

Although current treatment plans have a relatively good success rate, there are many underlying causes for torticollis with different solutions. There are a number of pathologies that present as pediatric torticollis. The literature divides congenital torticollis into three diagnostic areas: SCM swelling, tightness with no swelling or postural changes with no swelling. According to Stark, a correct clinical evaluation must be made to successfully resolve torticollis.

Torticollis is deceptive in that at the outset it seems like a simple issue of repositioning the head, Stark said. But there are a variety of nonmuscular causes, and practitioners need to be aware of that effect among pediatric patients. According to Stark, 18% of all torticollis presentations may be due to nonmuscular, osseous infections or neurologic causes.

“The diagnosis may present like torticollis due to ocular torticollis, which is cranial nerve palsy, or it could be where you have a malformation in the cerebellum,” Stark said. “The neurologic issue can be quite involved even though the presentation looks similar.”

The diagnosis can become complicated in some cases. Stark said that adult torticollis is often more difficult to understand than CMT. — by Anthony Calabro

For more information

• Cheng JCY, Tang SP, Chen TK, et al. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants — a study of 1,086 cases. J Pediatr Surg. 2000;35:1091-1096.
• Freed S, Coulter-O’Berry C. Identification and treatment of congenital muscular torticollis in infants. J Prosthet Orthot. 2004;16(48).
• Stark G. Clinical overview of torticollis. Presented at the American Academy of Orthotists and Prosthetists 27th Annual Meeting and Scientific Symposium. March 16-19, 2011. Orlando, Fla.
• Disclosure: Stark has no direct financial interest in any products or companies mentioned in this article.

The vast majority of patients resolve with a stretching program by 6 months to 1 year. Many patients do not use any orthosis at all. It is recommended to position the child in a crib so that they need to turn their head to the affected side in order to see the activity in the room.

Torticollis can be caused by more serious congenital deformities of the cervical spine, so if it does not resolve well or there are other congenital deformities present in the child, X-rays or other imaging such as CT scan or MRI may be needed. There is also an association with developmental hip dysplasia, so the child’s hips should be carefully examined by their pediatrician. If the case does not resolve adequately, a simple surgical procedure to release the contracted sternocleidomastoid tendon is usually effective.

‘Congenital’ means it is present at birth or at least recognized soon afterwards. Torticollis presenting in later childhood is different and usually due to atlantoaxial rotatory subluxation. It often follows a viral infection and usually resolves with a cervical collar and nonsteroidal anti-inflammatory drugs. Occasionally, traction is required if it does not resolve quickly.

Torticollis arising in children after 1 to 2 years of age may also be a sign of other more serious conditions and should be evaluated by an orthopedic surgeon if it does not resolve expeditiously.

— Wally Krengel, MD
Chief, Spine Program,
Department of Orthopedics and Sports Medicine
Seattle Children’s Hospital