MUSCULAR TORTICOLLIS PEAD Conditions.pptx

About congenital muscular torticolis

1. CONGENITAL MUSCULAR TORTICOLLIS GROUP 5 COURSE- MUSCULOSKELETAL DISODERS INCLUDING ORTHOPAEDIC CONDITIONS (PHT 404) LECTURER- DR. ABDULRAHMAN

2. GROUP 5 MEMBERS FOLORUNSHO AYOMIDE ALIU- 19/46PT027 IBIKUNLE ABDULHAMEED FERANMI- 19/46PT028 IYAOGEH MERCY ANUOLUWAPO- 19/46PT029 JEGEDE HOPE OHUNENE- 19/46PT030 JIMOH FATHIA AJOKE- 19/46PT031 KOLAWOLE OLANIKE FAITH- 19/46PT033

3. OUTLINE INTRODUCTION EPIDEMIOLOGY AETIOLOGY PATHOPHYSIOLOGY CLINICAL PRESENTATION DIAGNOSIS PROGNOSIS MANAGEMENT MEDICAL, SURGICAL, PHYSIOTHERAPY

4. INTRODUCTION Congenital muscular torticollis (CMT) is a condition in infants commonly diagnosed at or soon after birth. The term torticollis is derived from the Latin word tortus , meaning ‘’twisted’’ and collum meaning ‘’neck.’’ This condition is, therefore, also known as twisted neck or wry neck.

5. INTODUCTION CONT… CMT occurs when there is reduced length and increased tone of sternocleidomastoid (SCM) on one side. Infants present with lateral flexion on the ipsilateral side (i.e. the side where the SCM is affected) and contralateral rotation The exact cause of CMT is not always clear, but it is believed to result from the abnormal positioning of the baby in the womb or trauma to the muscles during birth. Factors such as breech presentation, large birth weight, or a difficult delivery may increase the risk of developing CMT.

6. EPIDEMIOLOGY The worldwide incidence rate of congenital torticollis varies between 0.3% and 1.9 %; other studies indicate a ratio of 1 in 250 new borns being the third congenital orthopaedic anomaly. There is a preponderance to male sex and first pregnancy .   A 2% incidence of congenital torticollis in traumatic deliveries and 0.3% in non-traumatic deliveries. In pelvic presentations, about 19.5%, forceps, suction cup represent 56 %.Other data reported an incidence of 53% in children whose mother was primiparous , and there was a high occurrence of traumatic childbirth. It is usually identified in neonates by age 2 to 3 weeks and can persist until the age of 1 year. It is typically unilateral, but rarely can be bilateral. There is a visible, palpable swelling known as a sternomastoid tumor , which appears in 50% of cases.   Congenital muscular torticollis categorizes into three types: Postural (20%) – Infant has a postural preference but no muscle tightness or restriction to passive range of motion Muscular (30%) – Tightness of the sternocleidomastoid muscle and limitation of passive range of motion Sternocleidomastoid mass (50%) – Thickening of the sternocleidomastoid muscle and restricted passive range of motion

7. AETIOLOGY 1. Intrauterine Positioning : Abnormal positioning of the fetus in the uterus, such as breech presentation or crowding, can lead to compression or stretching of the neck muscles, including the sternocleidomastoid muscle (SCM), increasing the risk of CMT. 2. Birth Trauma : Trauma during delivery, such as prolonged labor, forceps delivery, or birth through a narrow birth canal, can result in injury to the neck muscles or nerves, contributing to the development of CMT.   3 . Muscle Fibrosis : In some cases, there may be abnormal development or fibrosis of the SCM muscle during fetal development, leading to muscular imbalance and torticollis. 4. Genetic Factors : Although rare, there may be genetic predispositions or syndromes associated with CMT, such as Klippel-Feil syndrome or congenital anomalies of the cervical spine, which can affect muscle development and function. 5. Environmental Factors : Environmental factors, such as maternal smoking during pregnancy or exposure to certain toxins, may increase the risk of CMT by affecting fetal development and muscle function. 6. Neurological Factors : There may be underlying neurological conditions or abnormalities affecting muscle tone and coordination, leading to the development of CMT. 7. Idiopathic : In many cases, the exact cause of CMT is unknown (idiopathic), suggesting a combination of factors or a complex interplay of genetic and environmental influences.

8. PATHOPHYSIOLOGY 1. Muscular Imbalance : Congenital muscular torticollis often involves an imbalance in the sternocleidomastoid muscle (SCM) of the neck. This imbalance can result from factors such as abnormal intrauterine positioning, birth trauma, or developmental abnormalities .   2. Tightening and Weakness : The SCM may experience tightening (contracture) on one side and weakness on the other, leading to asymmetrical muscle tension and neck posture. 3 . Fibrosis and Contracture : Prolonged imbalance and abnormal muscle tension can lead to fibrosis (formation of excess fibrous tissue) and contracture (shortening and tightening) of the affected muscles. This further limits the range of motion of the neck and exacerbates the head tilt. 4 . Altered Muscle Function : Muscular fibrosis and contracture can impair the normal function of the SCM and surrounding muscles, affecting proprioception (awareness of body position) and muscle coordination. This can perpetuate the abnormal head posture and limit functional movement. 5 . Compensatory Mechanisms : In response to the head tilt, individuals may develop compensatory strategies to maintain balance and vision, which can further reinforce the abnormal posture and muscle imbalances. 6. Secondary Effects : Congenital muscular torticollis can lead to secondary effects such as craniofacial asymmetry, torticollis-associated plagiocephaly (flattening of the head), and developmental delays if left untreated.

9. CLINICAL PRESENTATION 1). Unilateral contraction of the SCM causing a lateral flexion towards the affected side with slight rotation of the chin to the contralateral side. 2). Affected side may seem excessively stronger than the contralateral side a)this causes an imbalance in the neck muscles b)The lateral head righting on the contralateral side is weaker than the affected side. c)In some cases, the shoulder may be elevated on the affected side . d)Can be accompanied by plagiocephaly When CMT is left untreated, it can cause : * fibrosis of the cervical musculature - this is associated with progressive limitations in head movements * asymmetry of craniofacial structures * compensatory scoliosis- this tends to get worse with age

10. CONT… There are three types of congenital muscular torticollis: 1 . Postural - occurs in 20% of cases - the infant will have a postural preference, but they do not have any muscle restrictions or reductions in passive range of motion 2 . Muscular - occurs in 30% of cases - the infant will have SCM tightness and a reduction in passive range of motion 3 . Sternocleidomastoid mass - occurs in 50% of cases - the infant will have thickening of SCM and restricted passive range of motion Postural CMT is the mildest form of CMT. If identified early, postural CMT is associated with shorter treatment times. Infants with sternocleidomastoid mass and who are identified later (after 3-6months) tend to require longer intervention and may need more invasive management

11. DIAGNOSIS Differential Diagnosis * Acquired Torticollis : Adult torticollis, also referred to as cervical dystonia or spasmodic torticollis. * Occipitoatlantal fusion : Congenital Atlanto -occipital fusion (AOF) involves the osseous union of the base of the occiput (C0) and the atlas (C1 ). * Klippel - Feil Syndrome : Klippel-Feil syndrome (KFS) is a rare skeletal disorder characterized by the congenital fusion of two or more vertebrae of the cervical spine within the neck. * Sternocleidomastoid tumour : palpable mass on the sternocleidomastoid muscle, this must be confirmed with ultrasonography * Scoliosis : Scoliosis is an abnormal lateral curvature of the spine

12. Diagnostic Procedures Diagnosis of CMT can usually be made based on the clinical presentation. The following clinical features may be present: * reduced neck range of motion * palpable SCM mass * head position preference * plagiocephaly However, some cases will require complementary diagnostic tests. In 50% of cases, infants are diagnosed before two months of age. Parents are often the ones to identify CMT. * Ultrasonography (US) is the most frequently used form of imaging, especially for neonates * it is useful for assessing neck masses, pseudo-tumour * useful for monitoring/evaluation post-treatment * Magnetic resonance imaging (MRI) may be used to rule out non-muscular cause

13. PROGNOSIS There is no standardized treatment for CMT, however it has been proven that 98% of infants that have access to physiotherapy interventions before the one month of age, achieve normal range of motion within 1.5 months. 90 to 95% of infants will improve before the age of 1 year if treatment is commenced before 6 months.

14. MANAGEMENT Medical management ● Medical management of torticollis involves conservative treatment . SCM fibrosis spontaneously resolves in the vast majority of infants. A large prospective study demonstrated that controlled manual stretching is safe and effective in the treatment of congenital muscular torticollis when a patient is seen before the age of 1 year. ● Educate caregiver on infant positioning during feeding, sleeping and playing ( including the importance of supervised prone positioning) and making environmental modifications to encourage head and neck movement ● Passive stretching exercises 4–5 times a day ● GP follow up within 4 weeks for monitoring ● Consider referral to physiotherapy when there is: ○ no improvement with home exercises by 4–6 weeks ○ severe torticollis: limited ROM at diagnosis (e.g. <30 degrees rotation) ○ a child older than 3 months at diagnosis with more than minimal torticollis ○ associated moderate to severe plagiocephaly ● Botulinum toxin (BTX) type A has been injected into the SCM for treatment of congenital muscular torticollis in pediatric and adult patients. Modest benefit with improved range of motion (ROM) has been reported, but studies have been relatively few and follow-up relatively short. A majority of cases will resolve after four to five months. If no significant improvement by 6 months of age, re-consider the diagnosis or refer to paediatric orthopaedic surgeon

15. CONT… SURGICAL MANAGEMENT If conservative treatment is not successful, botox or surgical options may be considered. Surgical may be indicated for the following: ● no improvement after six months of manual stretching ● there is a deficit of more than 15 degrees in passive rotation and lateral bending ● tight muscular band is present ● there is a tumour in sternocleidomastoid ● Persistent sternocleidomastoid (SCM) contracture limiting head movement ● Persistent SCM contracture accompanied by progressive facial hemihypoplasia ● Torticollis in children older than 12 months Surgical options for torticollis include: a). unipolar / bipolar sternocleidomastoids muscle lengthening ; "Z" lengthening, and b). radical resection of sternocleidomastoid . Surgical management of congenital muscular torticollis is generally avoided until the child is aged at least 1 year, until conservative methods ( eg , physiotherapy) are unsuccessful, and until other differential diagnoses are excluded.

16. PHYSIOTHERAPY MANAGEMENT Physiotherapy (stretching, strengthening and developmental facilitation) and aggressive repositioning are first-line treatments. Helmet therapy may be considered for infants with moderate to severe and persisting asymmetry.

17. CONT.. How Can a Physical Therapist Help?   * Before birth, physical therapists work with expectant parents on prevention of torticollis in their newborn.   *After birth, they screen newborns for muscle, bone, joint, and movement problems and provide needed treatment.   *Physical therapists use play to engage infants in activities and hands-on therapy to improve neck posture in a gentle, fun way. They understand how a baby communicates their tolerance for treatment and adjust treatment as needed.   *They also work with caregivers to create an environment that promotes development.   *As movement and developmental experts, pediatric physical therapists have the education, expertise, and experience necessary to screen, evaluate and diagnose postural asymmetries and should do so from birth.

18. CONT… Your child's physical therapy treatment plan will depend on their exam and may include: Education Education, guidance and support can reassure and help parents. It is important to educate parents/caregivers on positioning and handling skills to encourage active neck rotation towards the affected side and to discourage side flexion to the affected side (e.g. during feeding).   Manual Stretching Manual stretches are an important part of treatment. Manual stretches include side flexion and lateral rotation. It is necessary to show the caregiver how to stabilise and correctly position their hands for each stretch. Please note that stretching techniques are contraindicated in infants diagnosed with Klippel-Feil syndrome.

19. CONT… Passive ROM Lateral Neck Flexion   The following stretch is useful to encourage lateral flexion of the neck:   1. Hold infant's shoulder   2. Perform side tilt until you feel a gentle stretch   3. Never force the stretch   4. Infant should not be crying, but might be fussy, so try to keep them distracted   5. Can perform supine, or lying on your lap   6. Hold stretch for 30 seconds   7. Perform this 3-6 times a day (e.g. every diaper change).

20. CONT… Passive ROM Cervical Rotation The following stretch is useful to encourage cervical rotation:   1. Rotate to the infant's non-preferred side 2. Place your hand on their cheek 3. Block their opposite shoulder and rotate them   4. The goal is to get their chin over the top of their shoulder   5. Can be performed supine or while being held. Kinesio Taping Kinesio taping is an alternative intervention for CMT. It has been suggested that kinesio taping might decrease treatment duration for CMT and that it can have an immediate effect on muscular imbalance in children with CMT. To apply kinesio tape to the SCM: on the affected side, place tape from insertion to origin of SCM with 5-10% tension; on the unaffected side place tape from origin to insertion with 10-15% tension .  

21. CONT… Home Programme There are certain measures that caregivers can take at home to help their child with CMT: 1. Place toys/decorations to encourage infant to turn to other side. 2. Position the crib or changing table, so the infant must turn to the other side to see / interact with caregivers. 3. Tubular Orthosis for Torticollis (T.O.T) collar.

22. CONT… Vision therapy for focus and tracking The physical therapist will work with exercises to help improve visual focus and tracking/following objects. Balance system therapy The physical therapist may work with the child on inner ear and balance training. This can help improve the child's tolerance for movement and encourage them to explore their environment on all sides. What Kind of Physical Therapist Do I Need? All physical therapists are trained through education and experience to evaluate, manage, and treat a variety of conditions, including torticollis. You may want to consider seeing: - A pediatric physical therapist experienced in treating infants and children with torticollis. - A physical therapist who is a board-certified clinical specialist in pediatric physical therapy, or who has completed a residency or fellowship in pediatric physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your baby’s condition.

23. REFERENCES https://www.physio-pedia.com/Congenital_torticollis https ://www.ncbi.nlm.nih.gov/books/NBK549778/ https :// emedicine.medscape.com/article/939858-treatment#d9 National Institute of Health :   https://www.ncbi.nlm.nih.gov/books/NBK549778 /   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7995649/ Cheng JC, Tang SP, Chen TM, Wong MW, Wong EM. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants--a study of 1,086 cases. J Pediatr Surg. 2000;35(7):1091-1096. doi:10.1053/jpsu.2000.7461 Kuo AA, Tritasavit S, Graham JM Jr , Whitaker LA, Argenta LC, David LR. Congenital muscular torticollis and the associated craniofacial changes. Plast Reconstr Surg. 2006;117(3):909-918. doi:10.1097/01.prs.0000201476.93153.84