Physical Therapy Management ofCongenital Muscular Torticollis

Publication Date: October 1, 2018
Last Updated: March 14, 2022

ACTION STATEMENTS

I. EDUCATION, IDENTIFICATION AND REFERRAL OF INFANTS WITH CONGENITAL MUSCULAR TORTICOLLIS (CMT)

1: EDUCATE EXPECTANT PARENTS AND PARENTS OF NEWBORNS TO PREVENT ASYMMETRIES/CMT

Physicians, nurse midwives, prenatal educators, obstetrical nurses, lactation specialists, nurse practitioners or physical therapists should educate and document instruction to all expectant parents and parents of newborns, within the first 2 days of birth, on the importance supervised prone/tummy play when awake 3 or more times daily, full active movement throughout the body, prevention of postural preferences, and the role of pediatric physical therapists in the comprehensive management of postural preference and optimizing motor development. (V, P)
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2: ASSESS NEWBORN INFANTS FOR ASYMMETRIES/CMT

Physicians, nurse midwives, obstetrical nurses, nurse practitioners, lactation specialists, physical therapists or any clinician or family member must assess and document the presence of neck and/or facial or cranial asymmetry within the first 2 days of birth, using passive cervical rotation and/or visual observation as their respective training supports, when in the newborn nursery or at site of delivery. (I, A)
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3: REFER INFANTS WITH ASYMMETRIES/CMT TO PHYSICIAN AND PHYSICAL THERAPIST

Physicians, nurse midwives, obstetrical nurses, nurse practitioners, lactation specialists, physical therapists or any clinician or family member should refer infants identified as having postural preference, reduced cervical range of motion, sternocleidomastoid masses, and/or craniofacial asymmetry to their primary physician and a physical therapist with expertise in infants as soon as the asymmetry is noted. (II, B)
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II. PHYSICAL THERAPY EXAMINATION AND EVALUATION OF INFANTS WITH ASYMMETRIES/CMT

4: DOCUMENT INFANT HISTORY

Physical therapists should obtain and document a general medical and developmental history of the infant, including 9 specific health history factors, prior to an initial screening. (II, B)
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5: SCREEN INFANTS FOR NON-MUSCULAR CAUSES OF ASYMMETRY AND CONDITIONS ASSOCIATED WITH CMT

When infants present with or without physician referral, and a professional, or the parent or caregiver indicates concern about head or neck posture and/or developmental progression, physical therapists with infant experience should perform and document screens of the neurological, musculoskeletal, integumentary and cardiopulmonary systems, including screens of vision, gastrointestinal history, postural preference and the structural and movement symmetry of the neck, face and head, trunk, hips, upper and lower extremities, consistent with state practice acts. (, B)
(II-IV)
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6: REFER INFANTS FROM PHYSICAL THERAPISTS TO PHYSICIANS IF INDICATED BY SCREEN

Physical therapists should document referral of infants to their physicians for additional diagnostic testing when a screen identifies: non-muscular causes of asymmetry (e.g. poor visual tracking, abnormal muscle tone, extra-muscular masses); associated conditions (e.g. cranial deformation); asymmetries inconsistent with CMT; or if the infant is older than 12 months and either facial asymmetry and/or 10-15 degrees of difference exists in passive or active cervical rotation or lateral flexion; or the infant is 7 months or older with an sternocleidomastoid mass; or if the side of torticollis changes, or the size or location of an SCM mass increases. (II, B)
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7: REQUEST IMAGES AND REPORTS

Physical therapists should request, review, and include in the medical record all images and interpretive reports, completed for the diagnostic workup of an infant with suspected or diagnosed CMT, to inform prognosis. (II, B)
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8: EXAMINE BODY STRUCTURES

Physical therapists should perform and document the initial examination and evaluation of infants with suspected or diagnosed CMT for the following 7 body structures:
  • Infant posture and tolerance to positioning in supine, prone, sitting and standing for body symmetry, with or without support, as appropriate for age.
(II, B)
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  • Bilateral passive range of motion (PROM) into cervical rotation and lateral flexion.
(II, B)
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  • Bilateral active range of motion (AROM) into cervical rotation and lateral flexion.
(II, B)
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  • PROM and AROM of the trunk and upper and lower extremities, inclusive of screening for possible developmental dysplasia of the hip (DDH).
(II, B)
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  • Pain or discomfort at rest, and during passive and active movement.
(IV, C)
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  • Skin integrity, symmetry of neck and hip skin folds, presence and location of a SCM mass, and size, shape & elasticity of the SCM muscle and secondary muscles.
(II, B)
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  • Craniofacial asymmetries and head/skull shape.
(II, B)
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9: CLASSIFY THE LEVEL OF SEVERITY

Physical therapists and other health care providers should classify and document the level of CMT severity, choosing one of eight proposed grades based on infant's age at examination, the presence of a SCM mass, and the difference in cervical rotation PROM between the left and right sides. (II, B)
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10: EXAMINE ACTIVITY AND DEVELOPMENTAL STATUS

During the initial and subsequent examinations of infants with suspected or diagnosed CMT, physical therapists should examine and document the types of and tolerance to position changes, and motor development for movement symmetry and milestones, using an age appropriate, valid and reliable standardized test. (II, B)
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11: EXAMINE PARTICIPATION STATUS

The physical therapist should obtain and document the parent/caregiver responses regarding:
  • Positioning when awake and asleep.
(II, B)
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  • Infant time spent in the prone position.
(II, B)
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  • Whether the parent is alternating sides when breast or bottle feeding the infant.
(II, B)
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  • Infant time spent in equipment/positioning devices, such as strollers, car seats or swings.
(II, B)
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12: DETERMINE PROGNOSIS

Physical therapists should determine and document the prognosis for resolution of CMT and the episode of care after completion of the evaluation, and communicate it to the parents/caregivers. Prognoses for the extent of symptom resolution, the episode of care, and/or the need to refer for more invasive interventions are related to: the age of initiation of treatment, classification of severity, intensity of intervention, presence of comorbidities, rate of change and adherence with home programming. (See above figure.) (II, B)
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III. PHYSICAL THERAPY INTERVENTION FOR INFANTS WITH CMT

13: PROVIDE THESE FIVE COMPONENTS AS THE FIRST CHOICE INTERVENTION

Physical therapists should provide and document these five components as the first choice intervention for infants with CMT:
  • Neck PROM.
(II, B)
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  • Neck and trunk AROM.
(II, B)
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  • Development of symmetrical movement.
(II, B)
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  • Parent/caregiver education.
(II, B)
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  • Environmental adaptations.
(II, B)
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14: PROVIDE SUPPLEMENTAL INTERVENTION(S), AFTER APPRAISING APPROPRIATENESS FOR THE INFANT, TO AUGMENT THE FIRST-CHOICE INTERVENTION

Physical therapists may provide and document supplemental interventions, after evaluating their appropriateness for treating CMT or postural asymmetries, as adjuncts to the first choice intervention when the first choice intervention has not adequately improved range or postural alignment, and/or when access to services is limited, and/or when the infant is unable to tolerate the intensity of the first choice intervention, and if the physical therapist has the appropriate training to administer the intervention. (, C)
(I-IV)
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15: INITIATE CONSULTATION WHEN THE INFANT IS NOT PROGRESSING AS ANTICIPATED

Physical therapists who are treating infants with CMT or postural asymmetries should initiate consultation with the infant's physician and/or specialists about other interventions when the infant is not progressing as anticipated. These conditions might include when asymmetries of the head, neck and trunk are not starting to resolve after 4-6 weeks of comprehensive intervention, or after 6 months of intervention with a plateau in resolution. (II, B)
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IV. PHYSICAL THERAPY DISCONTINUATION, REASSESSMENT, AND DISCHARGE OF INFANTS WITH CMT

16: DISCONTINUE DIRECT SERVICES WHEN THESE 5 CRITERIA ARE ACHIEVED

Physical therapists should discontinue direct physical therapy services and document outcomes when these 5 criteria are met: PROM within 5 degrees of the non-affected side; symmetrical active movement patterns; age appropriate motor development; no visible head tilt; and the parents/caregivers understand what to monitor as the child grows. (, B)
(II-III)
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17: REASSESS INFANTS 3-12 MONTHS AFTER DISCONTINUATION OF DIRECT SERVICES AND THEN DISCHARGE IF APPROPRIATE

3-12 months following discontinuation from direct physical therapy intervention OR when the child initiates walking, physical therapists who treat infants with CMT should examine postural preference, the structural and movement symmetry of the neck, face and head, trunk, hips, upper and lower extremities, and developmental milestones to assess for reoccurrence of CMT and evidence of atypical development. (II, B)
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Recommendation Grading

Overview

Title

Physical Therapy Management of Congenital Muscular Torticollis

Authoring Organization

Publication Month/Year

October 1, 2018

Last Updated Month/Year

July 18, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Informs clinicians and families as to whom to monitor, treat, and/or refer and when and what to treat.

Inclusion Criteria

Adolescent, Child, Infant

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Intended Users

Physical therapist, occupational therapist, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Rehabilitation, Management, Treatment

Diseases/Conditions (MeSH)

D014103 - Torticollis

Keywords

Congenital Muscular Torticollis, Pediatric Torticollis

Source Citation

Kaplan, Sandra L. PT, DPT, PhD; Coulter, Colleen PT, DPT, PhD, PCS; Sargent, Barbara PT, PhD, PCS Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy, Pediatric Physical Therapy: October 2018 - Volume 30 - Issue 4 - p 240-290 doi: 10.1097/PEP.0000000000000544
 

Methodology

Number of Source Documents
211
Literature Search Start Date
January 1, 2012
Literature Search End Date
September 1, 2017