Standard conservative treatment of infants with congenital
muscular torticollis (CMT) consisting of stretching, positioning, and
strengthening has been practiced widely throughout North America for
the past twenty years. Published results of treatment have been
inconsistent in use of assessments and descriptors, making outcomes
difficult to analyze. In our clinical experience we have found that
full neck range motion (ROM) was generally achieved within a few months
of beginning treatment for infants under one year of age. Some infants,
however, continued to show persistent head tilt toward the side of the
torticollis. This led us to develop two types of collar, the Tubular
Orthosis for Torticollis (TOT) and a foam collar, to be used as
adjuncts in the management of this group of children.
Description
The
Tubular Orthosis for Torticollis or TOT is assembled from premade
plastic parts; the foam collar is adapted from a small adult-sized
cervical collar. Both devices employ a lateral obstruction to limit
head tilt toward the side of the torticollis but permit freedom of
movement in other directions. We believe that the TOT is somewhat more
dynamic than the foam collar; it produces mild discomfort on lateral
head tilt, thereby stimulating active lifting of the head away from the
noxious input and toward vertical alignment.
Indications
Collar
use is added to the conservative treatment of infants with CMT if they
are 4 months of age or older and show a consistent head tilt of 5
degrees or more. The infant must have adequate ROM and lateral head
righting reaction (head control and strength) to lift his or her head
away from the side of the collar.
Fabrication and Fit
Tubular Orthosis for Torticollis
A
length of PVC tubing twice the circumference of the neck plus 4-6
inches is cut and joined into a circle using an end connector. Two
struts to provide lateral stimulus on the affected side are selected,
allowing .5 inch for T-junctions at the top and bottom: strut A spans
from posterior to the crest of the trapezius to the occiput and strut B
from anterior to the crest of the trapezius to the tip of the mastoid
process. A T-junction is fitted over the PVC tubing approximately 1
inch from the end connector and inserted into the other end of strut A.
A second T-Junction is similarly positioned on the other side of the
end connector and inserted into the other end of strut A. Strut B is
joined to the PVC tubing about 1 inch from strut A at one end and about
3 inches away at the other end, using two more T-Junctions. The ends of
the collar are fastened together with a C-Clip. Occasionally, the end
connector can cause skin irritation and pressure when placed centrally.
An alternative in this case is to place the end connector along the
base of the neck and join the PVC tuning by tying it at the side of the
neck with twill tape.
The collar is placed on the infant and any necessary adjustments are
made to length and position of struts and length of PVC tubing. For
correct fit, the infant should be holding his or her head in midline,
slightly away from the struts, and there should be room for 1 or 2
adult sized fingers to fit between the C-Clip and the back of the neck,
or between the PVC tuning and the anterior neck.
To increase comfort and decrease the likelihood of pinching the skin,
moleskin can be wrapped around the two layers of PVC tubing in the area
under the chin. The struts and T-Junctions can also be covered with
moleskin although this makes it more difficult to adjust the fit of the
collar. Alternatively, the collar can be placed inside the sleeve of
stockinet.
Foam Collar
Choose an adult-sized small, firm foam cervical collar with adequate
length to fit around the infant’s neck. Remove the stockinet and Velcro
to expose the foam. Cut the foam to be narrow under the chin and on the
uninvolved side. A concave section may be cut out under the ear on the
involved side to avoid pressure to the ear lobe. The collar will attach
at the middle of the back of the neck. The collar on the involved side
should support the head as close to midline as possible. Decreasing the
height and thinning the foam on the uninvolved side and under the chin
will allow the child to laterally flex toward that side. The collar
should be as vertical as possible. There should be room for 1 or 2
adult sized fingers to fit between the neck and the collar. A good
place to check this is in the front of the neck during swallowing. The
collar is covered with cotton fabric and Velcro closures are sewn on
Application and Use
Application of the collar is generally easiest with the young infant in
prone. The center of the TOT is placed under the chin, the struts
positioned spanning the shoulder on the affected side, with the top of
the anterior strut on the mastoid process (just behind the earlobe).
The C-Clip is fastened. The foam collar is positioned similarly, with
the highest aspect under the ear on the affected side. As both infant
and caregiver become more accustomed to the process, the collar can be
put on with the infant sitting or standing.
Because the TOT is easily adjusted, it can initially be made to fit
looser than is optimal in order to facilitate the build-up of wearing
tolerance and the learning of application by caregivers. The goal is
full-time wear during the waking hours and most infants achieve this
within the first week (toddlers may require a bit longer). The TOT fit
is then adjusted by changing the length of struts or tubing to
stimulate active correction of head position to achieve midline
orientation. Further adjustments are made as required for growth. The
collar is removed for stretches. Active strengthening exercises may be
done while wearing the collar. We find that collar wear is generally
required for a minimum of 2 to 3 months and may be needed for 8 months
or more in some instances.
The infant’s head position without the collar is reassessed at each
clinical visit. When head tilt is less than 5 degrees consistently,
collar use is gradually decreased. The collar is removed for 1 to 2
hours at a time of day when the infant is most rested and likely to
maintain a good head position (often on rising in the morning or
following naps). Head position is monitored by the parent at theses
times. If a midline position is maintained consistently, time without
wearing the collar is gradually extended. The collar is reapplied if
head tilt recurs. This may be seen near nap times, at the end of the
day or following exercise sessions when the muscles are fatigued. Head
tilt may also increase with teething or when the child is ill.
Precautions
Collar
use is intended to stimulate muscle activation for correction of head
position to midline orientation. If the infant is unable to achieve
this position, he may use the collar as a passive support or may adjust
his body position to avoid correction. The therapist must watch for
depression of the shoulder on the affected side, trunk curvature or
lateral shifting of the cervical spine. All infants should have visual
screening to eliminate the possibility of visual torticollis before
applying a collar.
Some children are reluctant to turn their head toward the affected side
while wearing the collar because it does provide some resistance to
this movement. Extra emphasis should be placed on gaining neck rotation
toward the affected side both in the clinic and at home.
Caution must be taken when applying the collar to avoid pinching or
folding the skin under the tubing or edge of the foam. Infants often
show considerable redness under the TOT tubing and struts after a
period of wear. Parents must be instructed in checking the skin
periodically after removal of the collar. Redness should fade within a
half-hour.
During hot weather some children may develop a heat rash while wearing
a collar. Use of talcum powder or corn starch helps to keep the skin
dry. The TOT can be enclosed in a sleeve of stockinet or other soft
fabric to improve comfort.
Outcome
Our clinical observation of infants with CMT demonstrated that,
although conservative treatment of CMT improved muscle length and
strength, some infants and children did not adopt an upright head
position. We believe that the addition to the treatment program of the
custom made collar which stimulates active use of the contralateral
sternocleidomastoid (SCM) muscle throughout the day results in improved
strength of that muscle and a more consistently upright position of the
head. Infants who also have plagiocephaly may have improved symmetry if
collar use is initiated early.
A small pilot study on the use of the TOT was conducted at British
Columbia’s Children’s Hospital (BCCH) in 1984-85. The group of infants
fitted with a TOT had an average head position of 89.5 degrees (90
degrees = Vertical) at the end of the treatment; the control group had
an average head position of 84.8 degrees.
The use of the collar as an adjunct to conservative treatment of CMT
has been readily accepted by parents, children and infants, and we have
noted no deleterious effects. Its use with infants with CMT over 4
months of age who consistently have a head tilt of more than 5 degrees
has become a routine part of our management program for these infants.
Post-Surgical Splinting for CMT
At
BCCH, orthopaedic surgeons see several new patients each year with
untreated or unresolved CMT. Following surgical lengthening or release
of the SCM, the surgeons prefer to have the child’s head maintained in
a position that prevents re-shortening of the muscle during healing. To
achieve the desired positioning, occupational therapists enter the
operating room immediately following the surgical procedure to
fabricate a low temperature thermoplastic “collar” while the child
remains under anaesthetic. Over the years this collar has taken
numerous forms; the present version is a hybrid of a design developed
at BCCH, with one from Sick Children’s Hospital in Toronto, Ontario,
Canada.
The child’s head is positioned such that the previously shortened
muscle is placed on stretch-that is, tilted laterally away from the
released muscle and rotated toward it. Jobst custom made thermoplastic
material is used with contour foam placed for comfort over the jawline,
the shoulder on the opposite side the surgery, and any bony
prominences, such as the clavicles. Contour foam is also placed over
the ear on the surgical side. The premeasured and pre-cut thermoplastic
material is moulded over the surgical side of the face and skull, the
entire neck and both shoulders.
A rolled reinforcement bar of thermoplastic is added to the surgical
side to strengthen the splint. The foam is replaced in the jaw and
shoulder areas and covered with moleskin. The impression from the foam
over the ear is perforated to facilitate hearing. Straps are added to
hold the splint down onto the chest and shoulders and to keep it firmly
in contact with the skull. The splint is worn 23 hours a day (off for
skin care, stretching and exercises) for the first 1 to 2 post-surgical
months and at night for several more months. We believe that use of
this splint has been effective in maintaining length of the SCM muscle
following surgery.
Conclusion
Two custom-fabricated collars for use as adjuncts to conservative
treatment of CMT and an orthoses for post-surgical maintenance of the
SCM muscle were described. Orthotic aids are believed to be useful for
improving vertical alignment of the head on the trunk in management of
congenital muscular torticollis.
Carol
Jacques, Bsr, Reg OT (BC), is Clinical Coordinator, Occupational
Therapy Department, British Columbia’s Children’s Hospital, Vancouver,
BC, Canada. Karen Karmel-Ross, PT, PCS, LMT, is
Paediatric Clinical Specialist, Department of Rehabilitation Services,
University Hospitals of Cleveland, Cleveland, OH.
References
1. Fabian K, Marshall M. Conservative and surgical treatment of congenital muscular torticollis: a literature review. Physiother Canada. 1984; 36:146-151.
2. Binder
H, ENG G, Gaiser JF et al. Congenital muscular torticollis: results of
conservative management with longterm follow-up in 85 cases. ARCH Phys
Med Rehabil. 1987; 68:222-225.
3. Cottrill-Mosterman
S, Jacques C Bartlett D et al. Orthotic treatment of head tilt in
children with congenital muscular torticollis. J Assoc Children’s
Prosthetic-Orthotic Clinics. 1987; 22(1-3).
