Torticollis is a clinical sign or symptom that could be the result of a variety of underlying disorders. Congenital muscular torticollis (CMT) is a postural deformity detected at birth or shortly after birth, primarily resulting from unilateral shortening and fibrosis of the sternocleidomastoid muscle (SCM). Over 80% of all infants presenting with a torticollis posture will be found to have CMT. The remaining 20% may represent a sign of a more serious underlying condition (neurological or vision condition).
In 1992, the American Academy of Pediatrics formally introduced the recommendation that all infants be positioned on their backs for sleeping with a “Back to Sleep” campaign. The following decade saw a dramatic increase in the number of infants referred to physical therapy for treatment of CMT and the associated plagiocephaly (changes in skull shape and symmetry).
With Congenital muscular torticollis, the infant presents with limitation of active and passive neck motion, a positioning of the neck to tilt to the same side and rotate to the opposite side causing the chin to point to the opposite shoulder.
About 85% of babies diagnosed with torticollis or tight neck muscles also have craniofacial asymmetry and deformational plagiocephaly. Torticollis can also lead to gross motor delays if not treated early on.
Infants position during pregnancy or delivery (e.g. breech position)
Difficult or prolonged labor and delivery
Deformities of the bones or muscles in the neck
Low amniotic fluid
Imbalance of the eye muscle
Signs and symptoms may include:
Preference to tilt head towards one side and turn/rotate chin towards the opposite shoulder
Lack of full neck range of motion towards non-preferred side
A detectable lump (smaller than pea-size) in SCM muscle belly on the shortened side
Plagiocephaly: Flattening or bulging on the back or side of the head
Favors one side when reaching for toys or when playing
Asymmetrical facial features (i.e. ear, eye, jaw line and/or cheek on one side of face is smaller or shifted forward)
Frustration when not able to turn head completely
Physical Therapy Comprehensive Evaluation may include:
Parent report of child's birth history
Assess primitive reflexes
Observations: skin screen, facial features, resting posture, motor development
Clinical measurements of head shape, neck motion, and postural tilt (establishing a baseline is important to monitor the efficacy of exercises and rate of progress)
Palpation of SCM, Trapezius, Scalene muscles
Establish goals and treatment plan
Instruction on home exercise program
Referrals to specialists if needed (e.g. neurologist, ophthalmologist)
Research indicates that babies who begin treatment earlier resolve faster and with better outcome than those who begin later. Early treatment is important because it can be a big challenge to effectively perform the exercises on a child as they become older, stronger and more mobile. Treatment can begin as early as the first signs of torticollis are detected.
Early treatment is also critical in preventing negative effects on growth and development such as asymmetric alignment of head and body, musculoskeletal imbalances, poor protective responses, scoliosis, and delayed motor development.
Over 90% of children achieve a good to excellent outcome with conservative treatment when therapy is initiated during the first 12 months of life.
Physical therapy interventions include positioning, environmental adaptations, passive and active stretching of the tight muscle, strengthening of the weak neck and trunk muscles, play therapy, kinesio taping, and massage. It is also important to educate the child’s caregiver and implement a consistent therapy program at home.
Treatment Ideas for Left sided Torticollis (Perform the opposite if your child has right sided torticollis):
For the massage, the parent sits with the back against the wall and knees bent.
Place the child in your lap, with the child on their back and knees tucked. Massage by using your thumb or middle/index fingers to press into the sternocleidomastoid muscle.
Hold the child’s LEFT shoulder down with your RIGHT hand.
Place your LEFT hand on top of the LEFT side of the child’s head, and slowly bend child's head towards the RIGHT shoulder.
Hold the position for 15 seconds. Repeat 5 times, 4 times a day.
Place your LEFT forearm against the child’s RIGHT shoulder, and cup the child’s head with the same hand.
Use your RIGHT hand to hold the child’s chin.
Slowly rotate the child’s face to her LEFT.
Hold the position for 15 seconds. Repeat 5 times, 4 times a day.
Playing on stomach: When the child is on their stomach, position all toys in the crib so that the child has to turn their face to the LEFT.
Hold the child facing away from you, in a side-lying position, with the child’s LEFT ear resting against your LEFT forearm.
Place your RIGHT arm between the child’s legs and support the child’s body.
Carry the child in this position as much as possible.
6) Tummy Time
Practice tummy time as much as possible to help strengthen the neck, arms, and upper back muscles.
Click here to read our post on the importance of tummy time.
Click here to read out favorite toys to make tummy time fun!
Hold toys so that the child has to look up and out to the LEFT.
Position child in crib so that activities in the room encourage them to look to the LEFT.
While bottle feeding the child, position child to face LEFT.
While holding the baby across the shoulder, position child to face LEFT.
How is the baby positioned in his/her car seat? If the child’s head is consistently tilting to one direction, put a towel roll on the side the head is tilting toward to help support the neck in a more neutral position.
1) Ballock, R. T., and Song, K. M.: The prevalence of nonmuscular causes of torticollis in children. J Pediatr Orthop, 16(4): 500-4, 1996.
2) AAP: American Academy of Pediatrics AAP Task Force on Infant Positioning and SIDS: Positioning and SIDS. Pediatrics, 89(6 Pt 1): 1120-6, 1992.
3) Cheng, J. C.; Tang, S. P.; Chen, T. M.; Wong, M. W.; and Wong, E. M.: The clinical presentation and outcome of treatment of congenital muscular torticollis in infants--a study of 1,086 cases. J Pediatr Surg, 35(7): 1091-6, 2000.
4) Freed, S.: Identification and treatment of congenital muscular torticollis in infants. Journal of Prosthetics and Orthotics, 16(4s): 18, 2004.
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