Congenital muscular torticollis (CMT) is an idiopathic postural deformity evident shortly after birth, typically characterized by lateral flexion of the head to one side and cervical rotation to the opposite side due to unilateral shortening of the sternocleidomastoid muscle. CMT may be accompanied by other neurological or musculoskeletal conditions. Key Points: Infants with CMT are frequently referred to physical therapists (PTs) to treat their asymmetries.
This evidence-based clinical practice guideline (CPG) provides guidance on which infants should be monitored, treated, and/or referred, and when and what PTs should treat. Based upon critical appraisal of literature and expert opinion, 16 action statements for screening, examination, intervention, and follow-up are linked with explicit levels of evidence.
The CPG addresses referral, screening, examination and evaluation, prognosis, first-choice, and supplemental interventions, consultation, discharge, follow-up, suggestions for implementation and compliance audits, flow sheets for referral paths and classification of CMT severity, and research recommendations. All surgical procedures carry the risk of producing excessive weakness or paralysis, causing infection or internal bleeding, complications of anesthesia, or simply not being effective.
In light of these considerations, how are candidates for surgery selected from among ST patients? Simply put, all nonsurgical treatments are attempted first. Surgery is never considered as a first-line or early treatment, even in fairly severe cases of dystonia, because some cases may resolve spontaneously, given time. Additionally, the specific muscles involved at the beginning may change over time. Some muscles may stop contracting and new ones may become involved.
The proper muscles to target may not become obvious until the disorder stabilizes. Chemodenervation with botulinum toxin remains the mainstay of treatment for ST, supplemented by oral medications and pain management. As discussed previously, some patients may develop resistance to botulinum toxin after years of repeated injections. Those patients for whom chemodenervation is no longer effective may be considered for surgery.
Among those patients, surgery works best for those with rotational torticollis, and less well for those who predominantly have retrocollis or anterocollis. Other factors may influence a patient’s suitability for surgery. The coexistence of medical conditions such as heart disease, diabetes, lung or breathing problems, or blood clotting abnormalities will add to the risk of adverse outcomes from surgery.
Selective peripheral denervation is becoming the procedure of choice for those patients who are appropriate candidates for surgery. Note that, as opposed to surgical denervation, the injection of phenol or botulinum toxin achieves chemical denervation. Chemodenervation is not permanent, but destructive surgery is. Also, surgery of any kind rarely completely cures ST.
Peripheral surgeries on the nerves and muscles do not alter the abnormality in the extrapyramidal system of the brain. The brain may recruit adjacent muscles, usually smaller and often not previously involved in the ST, into activity in order to bring the head back to its abnormal set point. Patients who undergo surgery do not usually become free from the need for continued treatment. Many of them must continue receiving botulinum toxin injections and/or medications. All of the factors discussed above must be considered together in selecting any one patient for surgery.
If available, physical therapy by an experienced therapist may improve pain symptoms. The goals of physical therapy include bringing the head position back toward normal, increasing the range of motion, and decreasing pain, thereby increasing functional ability. The physical therapist may employ a variety of techniques to achieve these goals.
Primarily, he will gently move the neck through its range of motion, stretching the spasming agonist muscles. He may take advantage of the effect of geste antagoniste, stimulating the skin by gentle stroking or by applying ice to decrease the contraction of agonists during neck maneuvers. For some patients, gentle neck traction using a mechanical device may alleviate pain. Physical therapy techniques such as ultrasound or diathermy also may help with the pain.
While it is used extensively by some of our patients and is a fairly effective treatment for tension cervicalgia, local massage tends to have mixed results in ST. While it almost always feels good while being performed, pain control is very short-lived. In some patients, massage, especially deep massage, aggravates the spasms and contractions of agonist muscles. As a result, pain may actually increase the following a massage.
However, we have found that an acupressure type treatment, in which the point of an elbow is applied to a spasming trapezius muscle, or to muscles in the back of the neck, is often beneficial. Pressure should not be applied to the sternocleidomastoid muscle, which runs along the front and side of the neck, since doing so is ineffective and may even cause injury. Overall, we have found that properly applied acupressure is a most economical and effective pain relief measure with very low risk or side effects, and it may be performed at home by a spouse or family member.
