The value of a head turn in neurolocalization

BACKGROUND

A head turn is a clinically relevant abnormality identified on neurological examination and historically has been an isolated or concomitant sign of ipsilateral forebrain dysfunction. Experimental studies in quadrupedal mammals suggest that changes in head posture may be identified as originating in other parts of the central nervous system (CNS).

OBJECTIVES

To identify whether other locations within the CNS could give rise to a head turn and whether the head turn identified is isolated or concomitant with other deviations in head and body posture.

ANIMALS

Forty-nine client-owned dogs with a presentation of a head turn, from 6 veterinary referral centers.

METHODS

Multicenter observational prospective study including dogs with photographic evidence of a head turn, full neurological examination, and advanced imaging.

RESULTS

Of the population, 15/49 had head turn only, 9/49 had head turn and head tilt only, 12/49 had head turn and body turn only, and 13/49 had head turn, head tilt, and body turn. Nearly all dogs with forebrain disease (23/24), and, all with brainstem and cerebellar disease, had an ipsilateral head turn and body turn (if present). In the cerebellar group, all head tilts were contralateral to the lesion location. In the cervical spinal cord group, all head turns, body turns and head tilts were contralateral to the lesion location.

CONCLUSION

A head turn, although most likely associated with, is not exclusively seen with forebrain disease. Certain combinations of head turn, head tilt and body turn suggest a neurolocalization other than the forebrain, with appropriate classification needed.

The usefulness, reliability, and quality of YouTube video clips on congenital muscular torticollis: A STROBE compliant study

This study aimed to evaluate the usefulness, reliability, quality, and related characteristics of YouTube video clips on congenital muscular torticollis (CMT). This cross-sectional study analyzed 47 YouTube video clips on CMT. They were classified as either useful or misleading by 2 rehabilitation doctors. The modified DISCERN tool and the Global Quality Scale (GQS) were used to evaluate their reliability and quality. An analysis was conducted using the characteristics, such as presenters, ownership of YouTube channel accounts, countries, contents, and the video popularity. Of the 47 YouTube video clips, 8 (17%) were evaluated as misleading, which indicated that they included at least one scientifically unproven piece of information on CMT or more. They were less reliable and of lower quality than the useful video clips. The video clips presented by healthcare professionals were more useful compared to those presented by others (P = .015). However, the video popularity was not related to its usefulness. The reliability and quality (3.70 ± 0.82 vs 0.75 ± 0.50 and 2.95 ± 1.21 vs 1.50 ± 1.00) assessed by the modified DISCERN tool and GQS, respectively, were significantly higher in the video clips presented by healthcare professionals compared to those presented by others. There were misleading YouTube video clips on CMT. Video clips presented by healthcare professionals could be more useful, reliable, and of better quality. The popularity of the video clips does not indicate more usefulness, reliability, and better quality. YouTube viewers should be aware of these findings. We recommend that the viewers preferentially choose video clips on CMT presented by healthcare professionals, not by the video popularity.

Effect of physical therapy intervention on thickness and ratio of the sternocleidomastoid muscle and head rotation angle in infants with congenital muscular torticollis: A randomized clinical trial (CONSORT)

BACKGROUND

Early diagnosis as well as treatment is important in management of congenital muscular torticollis (CMT). The purpose of this study was to find an effective physical therapy modality to improve the sternocleidomastoid (SCM) muscle thickness, the ratio of the SCM muscle thickness on the affected side to that on the non-affected side (A/N ratio), and head rotation in infant under 3 months of age diagnosed with CMT.

METHODS AND ANALYSIS

A single-blind, randomized clinical trial was conducted. Participants were assigned in one of the 3 study groups through randomization. The treatment was performed 3 times a week for 30 minutes until the head tilt was ≤5 degrees. Group 1 was treated by handling for active or active-assist movement, group 2 was treated with passive stretching, and group 3 was treated with thermotherapy. For general characteristics, a χ2 test and 1-way analysis of variance were used. Intragroup differences were analyzed using a paired t test, and intergroup differences were analyzed using an age-adjusted analysis of covariance.

RESULTS

After the intervention, there was no significant difference between groups in terms of SCM thickness on the affected side and A/N ratio (P > .05). Degree of head rotation on the affected side showed significant differences between groups (P < .05), with Group 2 showing significantly better results than group 1 and group 3 (P < .05, both).

CONCLUSION

Passive stretching treatment was more effective than other treatments of this study for improvement in degree of head rotation in CMT infants under 3 months of age.

TRIAL REGISTRATION

The trial is registered at the Institutional Review Board of Sahmyook University (IRB number, 2-7001793-AB-N-012019103HR) and the Clinical Research Information Service (CRiS; registry number, KCT0004862).

Shear wave sonoelastography in infants with congenital muscular torticollis

Congenital muscular torticollis (CMT) is characterized by shortening or excessive contraction of the sternocleidomastoid muscle (SCM). The main purpose of this study was to evaluate the feasibility of quantifying SCM stiffness using acoustic radiation force impulse (ARFI) sonoelastography in infants with CMT. Twenty infants with an SCM thickness greater than 10 mm with or without involvement of the entire SCM length (limitation of neck rotation passive range of motion [PROM]: group 1S >30°, group 1M = 15°-30°) and 12 infants with an SCM thickness smaller than 10 mm with or without involvement of any part of SCM (group 2) were included. The SCM thickness was measured using real time B-mode ultrasound, and the local SCM shear wave velocity (SWV) and subcutaneous fat layer using ARFI sonoelastography. The neck rotation PROM was significantly greater in group 1S (36.5° ± 5.3°) than in group 1M (18.8° ± 4.9°; P < .01); the SWV of the SCM in the affected side (2.96 ± 0.99 m/s) was significantly higher than that in the unaffected side (1.50 ± 0.30 m/s; P < .01) in group 1. The SWV of the SCM was significantly higher in group 1S than in group 1M. There was significant correlation between the degree of PROM deficit of neck rotation and the SWV of the affected SCM (r = .75; P < .01) in all infants. This study revealed a difference in the SWV of the affected SCM in relationship to the limitation of neck rotation PROM in infants with CMT, if there was no difference in SCM thickness among infants.

Effectiveness of Surgical Release in Patients With Neglected Congenital Muscular Torticollis According to Age at the Time of Surgery

Objective

To identify the correlation between change in spinal deformities after surgical release and age at the time of surgery, and the effectiveness of surgical release in patients with neglected congenital muscular torticollis (CMT).

Methods

This was a retrospective study of 46 subjects with neglected CMT who had undergone surgical release at age ≥5 years at a tertiary medical center between January 2009 and January 2014. Spinal deformities were measured on anteroposterior plain radiographs of the cervical and whole spine, both preoperatively and postoperatively, to assess 3 parameters: cervicomandibular angle (CMA), lateral shift (LS), and Cobb angle (CA). We analyzed the change in spinal deformities after surgical release in consideration of age at the time of surgery.

Results

The median age at the time of surgery was 12.87 years. All 3 parameters showed significant improvement after surgical release (median values, pre- to post-surgery: CMA, 12.13° to 4.02°; LS, 18.13 mm to 13.55 mm; CA, 6.10° to 4.80°; all p<0.05). There was no significant correlation between age at the time of surgery and change in CMA (R=0.145, p=0.341) and LS (R=0.103, p=0.608). However, CA showed significant improvement with increasing age (R=0.150, p=0.046).

Conclusion

We assessed the correlation between change in spinal deformities after surgical release and age at the time of surgery. We found that that surgical release is effective for spinal deformities, even in older patients. These findings enhance our understanding of the effectiveness and timing of surgical release in patients with neglected CMT.

Clinical Usefulness of Sonoelastography in Infants With Congenital Muscular Torticollis

Objective

To evaluate the clinical usefulness of sonoelastography in infants with congenital muscular torticollis (CMT).

Methods

The medical records of 215 infants clinically diagnosed with CMT were retrospectively reviewed. Fifty-three infants met the inclusion criteria as follows: 1) infants diagnosed as CMT with a palpable neck mass before 3 months of age, 2) infants who were evaluated initially by both B-mode ultrasonography and sonoelastography, and 3) infants who had received physical therapy after being diagnosed with CMT. We checked the thickness of the sternocleidomastoid (SCM) muscles in B-mode ultrasonography, strain ratio of the SCM muscles in sonoelastography, and treatment duration. We evaluated the correlation between the treatment duration and the following factors: SCM muscle thickness, ratio of SCM muscle thickness on the affected to unaffected side (A/U ratio), and strain ratio.

Results

Both the thickness of the affected SCM muscle and the A/U ratio did not show significant correlation with the treatment duration (p=0.66, p=0.90). The strain ratio of the affected SCM muscle was significantly greater than that of the unaffected SCM muscle (p<0.001), and the strain ratio showed significant correlation with the treatment duration (p=0.001).

Conclusion

Sonoelastography may be a useful adjunctive tool to B-mode ultrasonography for evaluating infants with CMT, especially when predicting their rehabilitation outcomes.

Threshold of Clinical Severity of Cervical Dystonia for Positive (18)F-FDG PET/CT

Objective

To examine whether the clinical severity of cervical dystonia (CD) significantly correlates with ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) findings as well as to determine the threshold of the clinical severity of CD for positive ¹⁸F-FDG PET/CT study findings.

Methods

Forty-seven subjects with torticollis as one of the symptoms of CD were included. The clinical severity of CD was evaluated with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) at the time of ¹⁸F-FDG PET/CT. The correlation between the clinical severity of CD and the highest SUVmax was examined. The threshold of the clinical severity of CD necessary for positive ¹⁸F-FDG PET/CT findings was determined using receiver operating characteristics curve analysis.

Results

Thirty-three of the 47 subjects (70.21%) showed positive ¹⁸F-FDG PET/CT findings. The ipsilateral splenius capitis/cervicis, oblique capitis inferior, and longus colli/capitis were the rotators most frequently involved. The highest SUVmax of ¹⁸F-FDG PET/CT was significant correlated with the TWSTRS. Subjects with a total TWSTRS exceeding 39 showed positive ¹⁸F-FDG PET/CT findings, with those having a total TWSTRS ≤22 showing negative ¹⁸F-FDG PET/CT results. The cutoff value of the total TWSTRS for positive ¹⁸F-FDG PET/CT findings was set at 27.5 with 90.9% sensitivity and 64.3% specificity.

Conclusion

A significant correlation was evident between the clinical severity of CD and ¹⁸F-FDG PET/CT findings, providing a threshold of the clinical severity of CD for acquisition of positive ¹⁸F-FDG PET/CT findings.

Integrative analysis of congenital muscular torticollis: from gene expression to clinical significance

Background

Congenital muscular torticollis (CMT) is characterized by thickening and/or tightness of the unilateral sternocleidomastoid muscle (SCM), ending up with torticollis. Our aim was to identify differentially expressed genes (DEGs) and novel protein interaction network modules of CMT, and to discover the relationship between gene expressions and clinical severity of CMT.

Results

Twenty-eight sternocleidomastoid muscles (SCMs) from 23 subjects with CMT and 5 SCMs without CMT were allocated for microarray, MRI, or imunohistochemical studies. We first identified 269 genes as the DEGs in CMT. Gene ontology enrichment analysis revealed that the main function of the DEGs is for extracellular region part during developmental processes. Five CMT-related protein network modules were identified, which showed that the important pathway is fibrosis related with collagen and elastin fibrillogenesis with an evidence of DNA repair mechanism. Interestingly, the expression levels of the 8 DEGs called CMT signature genes whose mRNA expression was double-confirmed by quantitative real time PCR showed good correlation with the severity of CMT which was measured with the pre-operational MRI images (R² ranging from 0.82 to 0.21). Moreover, the protein expressions of ELN, ASPN and CHD3 which were identified from the CMT-related protein network modules demonstrated the differential expression between the CMT and normal SCM.

Conclusions

We here provided an integrative analysis of CMT from gene expression to clinical significance, which showed good correlation with clinical severity of CMT. Furthermore, the CMT-related protein network modules were identified, which provided more in-depth understanding of pathophysiology of CMT.

Usefulness of (18)f-fluorodeoxyglucose positron emission tomography/computed tomography in management of cervical dystonia

Objective

To evaluate the usefulness of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in the management of cervical dystonia (CD) with botulinum toxin type A (BoNT-A) injection.

Method

Thirty two subjects with CD were included. A BoNT-A injection was provided either by clinically targeting method (group 1) or by ¹⁸F-FDG PET/CT-assisted, clinically targeting method (group 2). In group 2, selection of target muscles and dosage of BoNT-A were determined according to the increased ¹⁸F-FDG uptake, in addition to physical examination and functional anatomy. The outcomes of BoNT-A injection was compared between the two groups, in terms of the number of subjects who had reinjection before and after 6 months, the number of reinjections, the interval of reinjections, the duration to the minimal Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), the number of adverse events, the reduction rate of TWSTRS at 1-3 months and 3-6 months after injection, and the probability of reinjection-free living.

Results

The number of subjects who had reinjection within 6 months was significantly lower in group 2 than in group 1 (10 in group 1 vs. 3 in group 2). The reduction rate of TWSTRS after 3-6 months (37.8±15.7% of group 1 vs. 63.3±28.0% of group 2) and the probability of reinjection-free living were significantly higher in group 2 than in group 1.

Conclusion

These findings suggest that ¹⁸F-FDG PET/CT study could be useful in management of CD in terms of the identification of dystonic muscles if there is an increase in the ¹⁸F-FDG uptake in the cervical muscle of the images.

Magnetic resonance imaging as a determinant for surgical release of congenital muscular torticollis: correlation with the histopathologic findings

OBJECTIVE

(1) To present the magnetic resonance imaging (MRI) findings of congenital muscular torticollis (CMT) of subjects who underwent surgical release and subjects who showed a good prognosis with stretching exercises and (2) to correlate the MRI findings with the histopathologic findings of CMT for subjects who underwent surgical release in order to examine the hypothesis that the MRI findings of CMT can be used as a determinant to perform surgical release of CMT.

METHOD

The neck MRI findings of 33 subjects who underwent surgical release for CMT were compared with those of 18 subjects who were successfully managed only with conservative management. The MRI findings were correlated with the histopathologic sections of the CMT mass.

RESULTS

All 33 subjects (100%) who underwent surgical release showed one or more low signal intensities within the involved sternocleidomastoid muscle (SCM) on the T1- and T2-weighted images of neck MRI. The eighteen non-surgical candidates showed only enlargement of the SCM without low signal intensity within the SCM. The histopathologic findings showed interstitial fibrosis and/or the presence of aberrant tendon-like excessive dense connective tissue that was either well-arranged or disorganized.

CONCLUSION

The histopathologic findings and MRI findings showed good correlation in terms of the amount of fibrosis and aberrant dense connective tissue within the SCM. If multiple or large low signal intensities within the SCM are noted, we think that surgical release should be considered.

Comparison of clinical severity of congenital muscular torticollis based on the method of child birth

OBJECTIVE

To compare the clinical severity of congenital muscular torticollis (CMT) based on the method of child birth.

METHOD

Children diagnosed with CMT and who were < 6-years-of-age at the time of their first visit at the Center for Torticollis, Ajou Medical Center, were included in this study. The medical records were retrospectively reviewed with reference to the method of child birth and the clinical severity of CMT. The clinical severity of CMT was determined either by whether stretching exercises were needed for the children <6-month-of-age or whether surgical release was required for the children ≥6-months-of-age at the time of the first visit.

RESULTS

One hundred seventy eight subjects with CMT were enrolled. There was no significant difference in the rate of surgical release according to the method of child birth. For 132 patients <6-month-of-age there was also no significant difference in the rate of stretching exercises.

CONCLUSION

There was no significant difference in the clinical severity of CMT based on the method of child birth. This finding suggests that prenatal factors alone could be a cause of CMT and that the clinical severity of CMT in children delivered by Cesarean section is not different when compared with the severity of CMT in children born through vaginal delivery.

The thickness of the sternocleidomastoid muscle as a prognostic factor for congenital muscular torticollis

Objective

To examine whether the thickness of the sternocleidomastoid muscle (SCM) could be used as a prognostic factor for congenital muscular torticollis (CMT).

Method

This was a retrospective study conducted in a pediatric rehabilitation service at a tertiary medical center. Fifty-two children who met the following inclusion criteria were included: 1) children who were 3 month-old or younger, 2) children diagnosed with CMT, 3) passive rotation of the face toward the shoulder of the tilted side ≤60°, 4) children who had been managed according to the clinical pathway for CMT, 5) children who had been followed up for 6 months or more after the end of treatment. The duration and total number of stretching exercise sessions were reviewed with reference to the thickness of the SCM.

Results

Among the 52 children with CMT, 46 children were successfully managed with only stretching exercise of the SCM for 1-6 weeks (group 1: 88.5%) and 6 children were managed with botulinum toxin A injection, surgical release or both in addition to stretching exercise (group 2: 11.5%). The difference in the SCM thickness between the affected and normal sides was significantly greater in group 2 than that in group 1 (p=0.026). A strong correlation was found between the total duration of stretching exercise and the difference in the SCM thickness in group 1 (Pearson' γ=0.429; p=0.003).

Conclusion

Children with a thicker SCM seem to require a longer duration of stretching exercise and other therapeutic interventions in addition to stretching exercise for CMT. Therefore, the thickness of the SCM may be one prognostic factor for CMT treatment.