Torticollis +

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Mindy -> Torticollis + (February 13, 2000 11:07:00 AM)
Two questions. Firstly, I am embarrassed to say I have no idea about what CPG stim or WBSTTS involves. Can you please let me know where I can find out more about these techniques? Secondly, I am currently treating an 18 month old boy with infantile torticollis. He has no neurodevelopmental problems. He was seeing another therapist up until a few months ago. Treatment includes myofascial stretching techniques to the muscles, passive stretchs for left lateral flexion and right rotation, NDT techniques to stimulate active left lateral flexion and right rotation and advice on positioning and handling to the parents. I have not seen any marked improvements in range and am concerened that we may need to resort to more invasive techniques. Has anyone had any experience with bracing / night splinting? Please keep in mind the compliance and realistic application of these. Any suggestions would be greatly appreciated.

gerry -> Re: Torticollis + (February 18, 2000 3:18:00 AM)
Mindy, I know that there are splints/braces manufactured for patients with torticollis, but I have never used them, sorry. I recently had a friend whose child had botox injections into the SCM to treat torticolis, after not responding to more traditional methods as you describe. I'll ask them what happened.

Dana D -> Re: Torticollis + (March 4, 2000 9:04:00 PM)
I am also treating a 7 month old child with torticollis, and actually am evaluating another one in two weeks.... and I came across a very comprehensive book on torticollis, called "Torticollis: Differential Diagnosis, Assessment and Treatment, Surgical Management and Bracing" by Karen Karmel-Ross/Editor. I purchased it online/amazon. I think it is very useful. [This message has been edited by Dana D (edited March 05, 2000).]

gerry -> Re: Torticollis + (March 22, 2000 6:42:00 AM)
A friend of mine just went to Atlanta, GA, to have a "splint" made for her son who has torticollis. It sounds as though it is not intended to stretch out the muscles, but to reshape the cranium. Evidently, due to the assymetries involved with his positioning, etc., his head has also become assymetrical, and they are addressing that aspect. I'll post again when I find out more.

Dana D -> Re: Torticollis + (March 22, 2000 1:06:00 PM)
How old is the child? How old do you think is "too late" to try to reshape?

Mindy -> Re: Torticollis + (March 24, 2000 7:10:00 AM)
The child is now 20 months. Although he has been receiving physio from 4 months, it was not intensive and by the time I started treating him he was a year and still had a marked lateral tilt, restricted rotation and facial asymmetry. This clinical picture has not improved much since I have been treating him. The sternomastoid muscle is extremely taught and fibrous on palpation. He has about 80% ROM in his neck when asleep, but this is reduced to about 50% when awake. According to “Congeital muscular torticollis and sternomastoit tumor” by Demirbilek S, Atayurt HF in J Pediatr Surg 1999 Apr;34(4):49-51, the older the child when he starts therapy, the more likely he will need surgery :- “25% of the 3 – 6 month old infants, 70% of the 6-18 month old children, and 100% of all the older children required surgery” Since he started therapy quite young, he should have a better prognosis, but the fact that he is nearly two and has still not corrected is quite a concern. We have had a brace made which he has started wearing for an hour or two a day and he will be seeing a doctor regarding BoTox next week. Hopefully these will make a difference. In the meantime, I am having a lot of trouble treating him when he is awake. He is now becoming very resistant to having his neck stretched and I do not believe in treating through crying. Any ideas on this or do you think I need to be cruel to be kind and just restrict him and stretch like mad?

Andrew M. Ball, MS, PT -> Re: Torticollis + (March 24, 2000 9:57:00 AM)
Mindy, I'm glad to see that you have turned to the research for an answer to your question. You may have overlooked a few older studies that may help reshape your treatment approach for this child. Excellent question. Excellent comments too. __________________________________________ In the examination of the soleus muscle, Tardieu et al (1988) found that there was no progressive contracture when the soleus was stretched for at least six hours a day. On the other hand, there was progressive contracture when the stretching time was as short as two hours. Assuming that the same is true of the sternocleidomastoid, "forcing" a child through the crying is not only likely to be a waste of your time and discomforting to the child in the absence of any therapeutic outcome, but you’re likely to be causing severe damage to the therapist-family-child relationship. If the Tardieu study is not enough for ya'll, the Moller study (1985) suggests that even if you do get a lengthening effect after a mere 15 minutes of stretching, that the increase remains for only about 90 minutes. Is the screaming worth it? That’s your call. Personally, that's not a significant enough effect for me to do it. Given this research, would it be possible to brace the child at night, for say 6 to 8 hours, in a comfortable manner that places the SCM at endrange? Could this brace be adjusted as the SCM lengthens from one night to the next? Earlier research, though the methods seem a bit crude, suggests that we can . .. and achieve favorable (and functional) outcomes (Clarren SK, 1979). Andrew M. Ball, MS, PT MBA/PhD Candidate REFERENCES Tardieu C. et al. For how long must the soleus muscle be stretched each day to prevent contracture? Dev Med Child Neurol, 30(1):3-10 1988 Feb Moller M, et al. Duration of stretching effect on range of motion in lower extremities. Arch Phys Med Rehabil, 66(3):171-3 1985 Mar Clarren SK. et al. Helmet treatment for plagiocephaly and congenital muscular torticollis. J Pediatr, 94(1):43-6 1979 Jan ------------------ Andrew M. Ball, MS, PT MBA/PhD Candidate [This message has been edited by Andrew M. Ball, MS, PT (edited March 24, 2000).]

Dana D -> Re: Torticollis + (March 25, 2000 6:52:00 AM)
I agree with what you are saying... regarding stretching through tears... When the child is that upset, they tense up and it is almost pointless to try to stretch. But I did want to share with you a way that I learned to stretch my child with torticollis. Initially, I would try to stretch his neck by moving his head on his body... as we would do with an adult. He did not tolerate that very well. So, now I do the reverse, and stretch by moving his body on his head. I place him in sidelying, on his affected side, and lift his trunk and legs to stretch his head into lateral flexion. I pat his back and count with him and he actually enjoys it.. (most of the time). I also have him prone and have him turn his head to the opposite side, gently hold his head and pat his back to count. His mom crouches down and puts her face near his, and again, he seems to tolerate it well. Again, I know our cases are different, yours seems to be a more severe case, but I just wanted to offer some variations to stretching that I found to work well. Good Luck! Oh and thanks for the reference to the article! I have to try and find it, sounds very interesting! [This message has been edited by Dana D (edited March 25, 2000).]

Mindy -> Re: Torticollis + (April 6, 2000 11:29:00 AM)
Drew, at first I was quite pleased with your response. I liked the fact that you reinforced my feeling that it was not worth it to treat through crying. But with further consideration, you have given me some troubling thoughts. Firstly, if stretching for two hours a day is not sufficient to prevent contractures, why are we stretching at all? We should just be bracing, and if it is not effective, then why are we getting such good results with children that receive early physio for torticollis (see above reference)? Secondly, the study by Tardieu C. on Soleus stretches was performed on children with cerebral palsy. Can we compare a spastic muscle to a sternomastoid tumor? I don't think so. The study by Moller M. on the duration of stretching effect had the muscle stretched for 15 minutes following which they maintained the increased length for 90 minutes. You say ONLY 90 minutes, but I think that is quite a long time to facilitate some active work in the antagonists in order to get cary over which may maintain the length of the shortened side for much longer. I agree with Dana, that when the child is upset, they just tense up and resist the stretch which is counter-productive, so prehaps that is the best reason not to stretch through crying. Thanks though for the article references, it made me think quite carefully about what I am trying to achieve.

Andrew M. Ball, MS, PT -> Re: Torticollis + (April 6, 2000 7:01:00 PM)
Mindy, I suppose I'm busted, you win. I don't think that it's appropriate to translate stretching an ankle in a child with CP to a child with torticollis . . . but it did make you carefully think about what you were doing and why didn't it? Nevertheless, based on what I've read to date, I'd likely still go the night stretching route. If it's more effective in ankle stretching, it's likely more effective in SCM stretching too (though you're quite correct in pointing out that there is no research to support this and I can't back up that clinical assumption). Also, I agree that 90 minutes is pleanty of time for which to be working the opposing muscle groups. The point is that stretching should not be an means in and of itself. Though I'm sure, based upon your comments to date, that stretching is not considered as such in your treatments . . . novice therapists and those new to pediatrics however, frequently make this mistake. Drewfus ------------------ Andrew M. Ball, MS, PT MBA/PhD Candidate

Dana D -> Re: Torticollis + (April 6, 2000 7:34:00 PM)
I agree, that stretching in itself is not the answer...Stretching helps provide range for the opposite SCM and associated musculature to work... I work a lot on head righting (while sitting and suspended/both laterally and anteriorly)...and have seen a lot of improvement.

CJ -> Re: Torticollis + (April 24, 2000 3:22:00 PM)
My baby has has a mild torticollis since six weeks old. I gave up treating him due to screaming and resisting the stretches and concentrated only on avoiding malformation of the skull. At 8 months I finally was able to assess C1/2 ROM when he was asleep and discovered no Left rotation, one mobilisation and he was able to passive rotate fully to the left for the first time. There has been a marked improvement in active neck movements since this although muscle tightness still remains especialy left side flexion.

gerry -> Re: Torticollis + (May 11, 2000 6:08:00 AM)
My friend whose child had torticollis, had a "helmet" made in Atlanta to reshape his head. I just saw them yesterday and they were very pleased. They did not have the helmet with them, but promised to bring it by sometime. It is more of an orthotic, supposedly. They report positive changes in his active movement, also, but this particular helmet is mainly for the shape of his cranium. Also, they ended up not having the Botox.

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