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Andrew M. Ball MS MBA PT -> Re: Torticollis++ (May 14, 2002 7:22:00 PM)
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For those of you who don't know, The prune-belly syndrome (PBS) usually is described as a deficiency of the anterior abdominal muscle involving bilateral cryptorchidism and urinary tract malformations, heart abnormalities, and orthopaedic deformations. The oligohydramnios is believed to produce limited intrauterine space, which in turn leads to fetal compression and resultant deformities. The ortho deformities typically observed include developmental dislocation of the hip (DDH), clubfeet, metatarsus adductus, vertical talus, and congenital muscular torticollis. These deformations should be treated aggressively because children with prune belly syndrome may be expected to have a relatively normal life if their renal function is good. The one exception is that as infants these children are very susceptible to pulmonary infections because of their inability to cough. Therefore, with the exception of the Ger procedure perhaps (this should be the call of the ortho MD), surgical treatment of the hip and other deformations should be delayed until the children are old enough to be able to clear pulmonary secretions easily. You are right, therefore, to be concerned with his respiratory function --- but I'd suggest that should, at this point, be your primary concern --- not the torticollis.
To my knowledge, there is no article in the MEDLINE database on the subject of PBS and an abdominal brace. The theory, however, sounds reasonable, but if you're using one, and it's "working well" you have a responsiblity to write up a case report and contribute to the literature base on the subject. Otherwise, you have an ethical responsiblity to consider the appropriateness of billing for an as yet unproven therapy. As you write your case report, be sure to review the Ger procedure and why you believe years of habiliative physical therapy to be preferable to a surgical procedure and short-term post-operative physical therapy.
The Ewig, et al. and Green, et al. suggest that concern and focus upon abdominal bracing (or any other ortho abnormality such as torticollis) at the detriment of pushing for a Ger, or dealing with the cardiopulmonary status of the child may be misplaced and irresponsive to the patient's primary needs. An abdominal brace, furthermore may compromise the cardiopulmonary status of the child, which as I've said above, should be of primary concern to the physical therapist.
Getting back to the Ger procedure, given the results of the 18 year follow up, published in 2000, one has to wonder why this surgical procedure hasn't even been considered over a brace, which unlike the surgery, isn't likely to ever yield a full recovery for the patient. One may get "results" as a physical therapist, but according to the research, physical therapy as described in your post may be, in terms of efficiency, sub-optimal.
As for your torticollis and plageocehpahly treatment issues, Emrey suggests that with a conservative stretching treatment, full range of motion should be achieved for 50% of children within 4.7 months (SD = 5.06, range = 1-36). That requries strict adherence the the HEP on the part of the parents.
You have excellent clinical reasoning to be concerned that, "bracing/immobilization will cause weakness and possibly encourage him to fight it and increase his lateral flexion to his right side." Clarren, et al. would agree, and therefore suggest that, "rubber straps can be fixed to the outside of the helmet and attached to the side rails of the crib. While the infant sleeps, the straps can be tightened to stretch the shortened sternocleidomastoid muscle." Night stretching is always, in my mind, a more effective way to stretch a muscle, but be carefull with this. I am aware of more than one child treated this way who were nearly chocked by the rubber strap.
On the other hand, Sakamoto describes a brace that, did not, "fix the infant's head in one position for correction. And as a result of this virtue, the sternomastoid muscle of the affected side was relaxed and the vanishing periods of asymmetrical tonic neck reflex are hastened. Use of this brace improved the cure rate [over conventional torticollis braces] and was especially effective in decreasing cranial and facial asymmetry.
As for my 2 cents, I'm a little gunshy about helmets nowadays. The past two children I've worked with who had cranial helmets made for them ended up having severe and significant seizures of, "unknown etiology." I've noticed that the neurologist who was so gung-ho about the helmets 2 short years ago hasn't, to my knowledge, sent a child out of town for a fitting since. Given the positive results of exercise/stretching, the lack of any evidence showing helmets to be any more efficient, and clinically speaking --- the negative experiences of more than one of my helmet wearing patients . . . I personally question their use for torticollis correction.
Andrew M. Ball, PT, MS, MBA
REFERENCES
Clarren SK, Smith DW, Hanson JW. Helmet treatment for plagiocephaly and congenital muscular torticollis. J Pediatr 1979 Jan;94(1):43-6
Emery C. The determinants of treatment duration for congenital muscular torticollis. Phys Ther 1994 Oct;74(10):921-9
Ewig JM, Griscom NT, Wohl ME. The effect of the absence of abdominal muscles on pulmonary function and exercise. Am J Respir Crit Care Med 1996 Apr;153(4 Pt 1):1314-21
Ger R, Coryllos EV. Management of the abdominal wall defect in the prune belly syndrome by muscle transposition: an 18-year follow-up. Clin Anat 2000;13(5):341-6
Green NE, Lowery ER, Thomas R. Orthopaedic aspects of prune belly syndrome. J Pediatr Orthop 1993 Jul-Aug;13(4):496-501
Sakamoto H. [Cap brace: a new treatment for newborn and infant congenital muscular torticollis.] Nippon Seikeigeka Gakkai Zasshi 1992 Nov;66(11):1123-36
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