Conservative management of congenital muscular torticollis: an evidence-based algorithm and preliminary treatment parameter recommendations

Infants With Congenital Muscular Torticollis: Demographic Factors, Clinical Characteristics, and Physical Therapy Episode of Care

PURPOSE

To describe demographic factors, baseline characteristics, and physical therapy episodes in infants with congenital muscular torticollis (CMT), examine groups based on physical therapy completion, and identify implications for clinical practice.

METHODS

Retrospective data were extracted from a single-site registry of 445 infants with CMT.

RESULTS

Most infants were male (57%), Caucasian (63%), and firstborn (50%), with torticollis detected by 3 months old (89%) with a left (51%), mild (72%) CMT presentation. Cervical range of motion (ROM) limitations were greatest in passive lateral flexion and active rotation. Sixty-seven percent of infants completed an episode of physical therapy, 25% completed a partial episode, and 8% did not attend visits following the initial examination. Age at examination, ROM, and muscle function differed significantly between groups.

CONCLUSIONS

Physical therapists may use clinical registry data to inform practice for timing of referral, frequency of care, and clinician training to manage infants with CMT.

Effectiveness of pediatric integrative manual therapy in cervical movement limitation in infants with positional plagiocephaly: a randomized controlled trial

BACKGROUND

Positional plagiocephaly (PP) is a cranial deformation frequent amongst children and consisting in a flattened and asymmetrical head shape. PP is associated with excessive time in supine and with congenital muscular torticollis (CMT). Few studies have evaluated the efficiency of a manual therapy approach in PP. The purpose of this parallel randomized controlled trial is to compare the effectiveness of adding a manual therapy approach to a caregiver education program focusing on active rotation range of motion (AROM) and neuromotor development in a PP pediatric sample.

METHODS

Thirty-four children with PP and less than 28 week-old were randomly distributed into two groups. AROM and neuromotor development with Alberta Infant Motor Scale (AIMS) were measured. The evaluation was performed by an examiner, blinded to the randomization of the subjects. A pediatric integrative manual therapy (PIMT) group received 10-sessions involving manual therapy and a caregiver education program. Manual therapy was addressed to the upper cervical spine to mobilize the occiput, atlas and axis. The caregiver educational program consisted in exercises to reduce the positional preference and to stimulate motor development. The control group received the caregiver education program exclusively. To compare intervention effectiveness across the groups, improvement indexes of AROM and AIMS were calculated using the difference of the final measurement values minus the baseline measurement values. If the distribution was normal, the improvement indexes were compared using the Student t-test for independent samples; if not, the Mann-Whitney U test was used. The effect size of the interventions was calculated using Cohen's d.

RESULTS

All randomized subjects were analysed. After the intervention, the PIMT group showed a significantly higher increase in rotation (29.68 ± 18.41°) than the control group (6.13 ± 17.69°) (p = 0.001). Both groups improved the neuromotor development but no statistically significant differences were found. No harm was reported during the study.

CONCLUSION

The PIMT intervention program was more effective in increasing AROM than using only a caregiver education program. The study has been retrospectively registered at clinicaltrials.gov, with identification number NCT03659032 . Registration date: September 1, 2018.

Development and Validation of a Uremic Pruritus Treatment Algorithm and Patient Information Toolkit in Patients With Chronic Kidney Disease and End Stage Kidney Disease

CONTEXT

Uremic pruritus (UP) affects up to half of all patients with kidney disease and has been independently associated with poor patient outcomes. UP is a challenging symptom for clinicians to manage as there are no validated guidelines for its treatment.

OBJECTIVES

The study aimed to develop and validate an algorithm and patient information toolkit for the treatment of UP in patients with kidney disease.

METHODS

The study involved a literature search and development of an initial draft algorithm, followed by content and face validation of this algorithm. Validation entailed three rounds of interviews with six nephrology clinicians per round. Participants assessed the relevance of each component of the algorithm and then rated a series of statements on a scale of 1-5 to assess face validity of the algorithm. After each round, the content validity index (CVI) of each algorithm component was calculated, and the algorithm was revised by the study team in response to findings. This process was followed by a second study that developed and validated a patient information pamphlet and video.

RESULTS

Algorithm validation participants were affiliated with three institutions and included seven physicians, four registered nurses, three nurse practitioners, three pharmacists, and a dietician. The average CVI of the algorithm components across all three rounds was 0.89, with 0.80 commonly cited as the lower acceptable limit for content validation. More than 78% of participants rated each face validity statement as "Agree" or "Strongly Agree". For the patient information tools, five clinicians and 15 patients were included in validation. The average CVI was 1.00 for both tools, and the average face validity was 92%.

CONCLUSION

A treatment algorithm and patient information toolkit for managing UP in patients with kidney disease were developed and validated through expert review. Further research will be conducted on implementation of the treatment algorithm and evaluating patient-reported outcomes.

Measurement properties of instruments for assessment of cervical spine function in infants with torticollis: a systematic review

The aim of this study was to systematically review the measurement properties of instruments which assess cervical spine function in infants with torticollis. Electronic searches were performed in MEDLINE, CINAHL, Embase, Web of Science and the Cochrane Library, combining three constructs ('torticollis', 'cervical spine assessment' and 'measurement properties'). Two reviewers independently rated the methodological quality and the quality of measurement properties of identified articles, using both the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist and quality criteria for measurement properties. Five studies, using six instruments, met the inclusion criteria and were analysed. Included instruments were the goniometer, electronic pendular goniometer, protractor, still photography, Muscle Function Scale and a range of motion limitation scale. All studies assessed reliability, and one study also assessed content validity and hypothesis testing. The methodological quality of the studies varied from poor to excellent according to the COSMIN checklist. Two instruments were found to have good measurement properties from high-quality studies: still photography for the assessment of habitual head tilt in supine and the Muscle Function Scale for the assessment of side-flexor muscle function in lateral head righting.Conclusion: This systematic review identified two reliable tools for the assessment of cervical spine function in infants with torticollis. Further research is required to assess the measurement properties of tools already described in the literature and to develop further tools for use in this population. What is known? • A thorough assessment of the infant presenting with torticollis is essential, in order to correctly diagnose, rule out 'red flags' and manage appropriately • Assessment tools need to have robust measurement properties in order to be of value for clinical practice and research What is new? • This systematic review identified two valid and reliable tools for the assessment of cervical spine function in infants with torticollis • Further research is required to assess the measurement properties of tools already described in the literature and to develop further tools for use in infants with torticollis.

Assessing the Cervical Range of Motion in Infants With Positional Plagiocephaly

PURPOSE

To determine if infants with positional plagiocephaly have limitations of active and passive cervical range of motion measured with simple and reliable methods.

METHODS

The examiners assessed bilateral active and passive cervical rotations and passive cervical lateral flexion. Cervical assessment was performed twice by 2 different physicians to assess intertester reliability. To assess intratester reliability the first investigator performed a second examination 48 hours after the first one.

RESULTS

One-hundred nine subjects were analyzed; 70.7% of the sample had head positional preference on the right, while 29.3% had head positional preference on the left (χ 35.52, P <0.001). Cervical rotations and lateral flexion showed reliable levels of agreement for intra and intertester reliability.

CONCLUSIONS

The most limited range of motion in infants with positional plagiocephaly was cervical active rotation which affected more than 90% of patients. Passive cervical rotations and lateral flexion were limited in more than 60% of patients.

Comparison of 2 Dosages of Stretching Treatment in Infants with Congenital Muscular Torticollis: A Randomized Trial

OBJECTIVE

To compare the short-term efficacy of 2 dosages of stretching treatment on the clinical outcomes in infants with congenital muscular torticollis.

DESIGN

This was a prospective randomized controlled study. Fifty infants with congenital muscular torticollis who were randomly assigned to 100-times stretching group and 50-times stretching group received stretching treatment for the affected sternocleidomastoid muscle. The outcomes including the head tilt, the cervical passive range of motion, and the muscle function of cervical lateral flexors determined by the muscle function scale were assessed at baseline and at 4 and 8 weeks after treatment. The sternocleidomastoid muscle growth analyzed by the thickness ratio of sternocleidomastoid muscles was measured using ultrasonography at baseline and 8 weeks after treatment.

RESULTS

Except the ratio of muscle function scale scores, the postintervention outcomes were all significantly improved in both groups compared with baseline (P < 0.05). The 100-times stretching group showed greater improvement compared with 50-times stretching group in head tilt and cervical passive range of motion at 4 and 8 weeks after treatment (P < 0.05).

CONCLUSIONS

Stretching treatment of 2 dosages may effectively improve head tilt, cervical passive range of motion, and sternocleidomastoid muscle growth in infants with congenital muscular torticollis. The stretching treatment of 100 times per day is likely to associate with greater improvement in head tilt and cervical passive range of motion.

A Clinical Algorithm for Early Identification and Intervention of Cervical Muscular Torticollis

Congenital muscular torticollis (CMT) is a common newborn pediatric muscular deformity of the neck. The purpose of this article is to suggest a clinical algorithm for pediatric clinicians to promote prompt identification and intervention for infants with CMT. Early intervention for a child with CMT at less than 1 month of age yields a 98% success rate by 2.5 months of age, with the infant achieving near normal range of motion. Intervention initiated at 6 months of age or later can require 9 to 10 months of therapy with less success in achieving full range of motion of the cervical musculature. The clinical algorithm proposed here incorporates the American Physical Therapy Association guideline for CMT to optimize outcomes for the child and reduce health care expenditures. Current evidence and guidelines demonstrate that primary care providers are the primary diagnostic clinicians, while physical therapists are the preferred provider for the treatment of CMT.

Custom neck orthosis in combination with onabotulinumtoxinA for the treatment of refractory congenital muscular torticollis: A case report

PURPOSE

This case report examines the use of a custom neck orthosis following onabotulinumtoxinA (BoNT-A) injections for the treatment of congenital muscular torticollis (CMT) that has not been responsive to conservative treatment or previous injections.

METHODS

The patient was fitted for a custom neck orthosis following BoNT-A injections for refractory CMT. Clinical outcomes were evaluated with head tilt, cervical rotation, and neck passive range of motion (PROM) measurements. Parental reports of patient tolerance of the orthosis and family satisfaction of results were obtained through survey.

RESULTS

With use of the orthosis following BoNT-A injections, the patient's head tilt improved from 45° to an intermittent tilt of 10° and neck PROM to the left improved from 70° to 90°. He wore the neck orthosis for 8 to 10 hours per day for 3 months, experienced no major complications, and tolerated it well. On follow-up survey, the family reported satisfaction with the results.

CONCLUSION

This case provides evidence that a custom neck orthosis after BoNT-A injection may be an effective treatment of refractory CMT before or replacing surgical intervention.

Considerations and intervention in congenital muscular torticollis

PURPOSE OF REVIEW

To present the current literature regarding congenital muscular torticollis (CMT) to promote the most effective and evidence-based intervention. CMT is a musculoskeletal deformity observed at birth or in infancy, characterized by persistent head tilt toward the ipsilateral side with the chin rotated toward the contralateral side. The incidence of torticollis is on the rise and as a result there has been a surge in the literature on the topic, however, until recently, there was little consensus on the treatment approach.

RECENT FINDINGS

Research on CMT has gone in several directions. One branch is looking at diagnostics, imaging, and attempting to understand the underlying disease behind torticollis, down to the cellular level. This information may be helpful in the other, more clinical research vein to determine prognosis, establish plan of care, and create guidelines for the treatment of infants with torticollis.

SUMMARY

CMT presents as a muscular imbalance. We know from the pediatric and adult literature, whether it is about cerebral palsy or anterior cruciate ligament reconstruction, that muscle imbalances can lead to skeletal changes, postural dysfunction, and impaired movement patterns. These can lead to functional limitations and limitations in participation. CMT, therefore, needs to be addressed. Although this article presents the current evidence and guidelines for treatment, there is still much to be learned regarding disease, optimal intervention, duration of treatment, and timing of follow-up.

VIDEO ABSTRACT

http://links.lww.com/MOP/A24.