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Saturday, April 23, 2016

Torticollis by Trisha Roberts

    Torticollis Definition:  What is it?  

Shortened Neck Muscle in Torticollis
Right Torticollis

Torticollis is a condition that occurs in the muscles of  the neck. Torticollis refers to a shortened or tight Sternocleidomastoid (SCM) muscle that causes, in laymen's terms, a twisted or, ‘wry’ neck.  The Sternocleidomastoid is a major muscle on both sides of  the neck, that is responsible for turning the head (cervical rotation) to the opposite side and tilting the head (lateral flexion) to the side of the muscle.  The Sternocleidomastoid muscle is a complex muscle that has attachments to several different bones and joints. Because of the compacted position in utero that  children maintain in the latter weeks of gestation, all children are born with a tendency to turn their head to one side or the other.  After birth this usually evens out and children are able to keep their heads in mid-line.  Young infants typically revert to their preferred position of comfort when sleeping, which can sometimes lead to an acquired torticollis if care is not taken to encourage even head turning to both sides.  There are children whose Sternocleidomastoid muscle (SCM muscle) is actually shortened at birth or may have a cyst or nodule in the muscle or surrounding tissue; this is referred to as congenital Torticollis.

Torticollis Signs and Symptoms:  How Does it Manifest?

When the Sternocleidomastoid Muscle (SCM Muscle) is tight on one side, it produces a head tilt to that side with head rotation to the other side.  For instance, if the right Sternocleidomastoid muscle is tight, the child’s resting position will be one of head tilt to their right and head rotation to their left, or Right Torticollis (Torticollis to the Right).
Infant Torticollis to the left
Left Torticollis
Right Torticollis
Right Torticollis
This makes looking over their right shoulder difficult and keeping their head in mid-line nearly impossible.  If the left Sternocleidomastoid (SCM) muscle is tight, children have a Left Torticollis (Torticollis to the left) and have difficulty tilting their heads to their right and turning their heads to the left to look over their left shoulder. Sometimes a child will be able to get their head to a mid-line position, but the shoulder on the affected side will be elevated.  It is important that a Physical Therapist perform a Torticollis Evaluation on every child with Torticollis and design a treatment plan specific to that child. 

Implications of Torticollis:  Why is this a Big Deal?

We need to use our bodies evenly and keep our head in mid-line in order to orient ourselves to the world.  It is not normal to keep our head tilted to one side when looking at another person or object.  The uneven musculature in a child diagnosed with Torticollis can lead to permanent changes in that child's body. If Torticollis is left untreated, it can lead to the development of a Totorticollis Facial Asymmetry, which is a shifting of the facial features.
Untreated Torticollis
Torticollis Left Untreated
The body, in an attempt to even itself out will sometimes develop a scoliosis (curvature of the spine) to compensate for the asymmetry at the head and neck.  This leads to a distorted thoracic cavity and encroaches on the space used by the lungs and heart.  Children with scoliosis are more prone to respiratory and cardiac issues.  Wolffe’s law states that the stress placed on a bone will cause the bone to re-shape itself. Cranio-Facial Structures can be affected by Torticollis which can have lifelong implications for that person.  If a baby’s head is always tilted to one side, and they are frequently on their back (supine position), they may develop a flattening of the head (skull)
Baby with Torticollis and Plagiocephaly
Torticollis and Skull Deformity
on the area where they are weight bearing the most; this flattening is called Plagiocephaly (on one side) or Brachiocephaly (flattening along the entire back of the head). If a child develops a severe Plagiocephaly they may need a Cranio-Helmet to correct this skull deformity. Talk to your doctor and physical therapist about the use of a Helmet for Plagiocephaly.

Torticollis can cause asymmetrical sitting
Asymmetrical Sitting due to Torticollis
PT intervention for Torticollis
Physical Therapy For Torticollis
 Torticollis can also delay a baby's Gross Motor Skill Acquistion, keeping a baby from rolling, crawling and walking within the normal time parameters.

Torticollis Treatment:  What can be done about it?


Physicians agree that babies should be placed on their backs to sleep, as there is a reduced risk of Sudden Infant Death Syndrome (SIDs). But babies need to be on their tummies when they are awake so that they will begin to develop strength in their neck and trunk extensor muscles which leads to the development of crawling skills and good core control (See previous blogs) Making sure that children get Tummy Time is extremely important.  Paying attention to a child’s position in their crib, bassinet, car seat, etc. is also important.  Children will naturally turn toward stimulation.  If they always see their parent coming into a room from the right, they will want to turn their head in that direction.  If they hear mother’s voice, the TV or radio from the left, they will want to turn their head to that direction.  We can use this to help improve the mobility or active range of motion of a child’s neck. For instance, if a child has difficulty turning their head to the right (right Torticollis), placing a child in their crib on their back with the door to the room to their right will encourage looking to that direction, as they will  naturally turn to that direction, anticipating the arrival of their parent, food and comfort. Presenting Stimulating Infant Toys to the affected side can encourage a baby to turn to that side.

Toys for Babies with Torticollis
Toys can Stimulate Baby to Turn Head
 Using feeding time as a therapy intervention is also beneficial.  Again, as in our previous example, if a child has difficulty turning to the right, breastfeeding on the mother’s left side first will facilitate head turning to the child’s right.  Or offering the bottle with the child positioned in your left arm will also encourage the child to turn their head to the right.  When placed in sitting, offering toys to the right side of the child will promote more head turning to that side. A skilled Physical Therapist will talk with you about how to position your baby in their car seat and other situations so as to minimize or correct the effects of the Torticollis.


Physical Therapy Intervention for Torticollis

 An Early Intervention Physical Therapist (one who specializes in Physical Therapy with children birth to 3 years old) will be able to analyze the problem, take initial range of motion measurements, provide direct, skilled intervention and instruct parents and care providers in exercises

Physical Therapy for Torticollis
Physical Therapy for Torticollis
 and activities to promote improved head mobility and control as well as facilitate the progression of gross motor milestones of early childhood.

Torticollis Exercises and Treatment might include passive range of motion (stretching exercises), active range of motion, Home Exercise Program, Myofascial Release techniques, Skull Molding Techniques, Kinesio-Taping for Torticollis, Cranio-Helmet (for severe Plagiocephaly), Infant Massage, and Neuro-Developmental Techniques.

Plagiocephaly Treatment with Helmet
Cranio Helmet for Plagiocephaly

Torticollis Treatment using Kinesio Tape
Kinesio Taping for Torticollis


In Summary

The earlier Torticollis is detected, the easier it will be to correct. Therefore the sooner the child is able to get intervention in the form of Physical Therapy, the better.  Take a critical look at your child, your grandchild, your neighbor's child; do they always have their head tilted to one direction?  When you look at pictures of them are they always looking in the same direction? Look at them from the front, back, and a "Bird's Eye View" (Top of the head looking downward)--is there any deformity seen?  Any irregular shape?  Any redness in the creases of the neck?  These may be indicators of Torticollis.

Talk with your doctor and get professional help immediately!

Author:  Trisha Roberts

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  1. At what age is it too late to correct this problem?

  2. The sooner children start receiving treatment, the better! The most effective time is within the first 6-12 months, although children can be seen at any age to address Torticollis and mitigate any lasting effects it might have.

  3. Such a valuable tool and resource. Critical to catch and begin a multi-focus treatment as soon as possible.

  4. we found out 2 months ago my son has this we were given exercises to do at home with him hes now 11 months but im noticing that his left eye is drewpy n one ear is smaller any suggestions?????

  5. Ask your primary care provider for a referral to a Pediatric Physical
    Therapist who has experience with Torticollis. They will be best able to evaluate your child and advise.