Congenital muscular torticollis (CMT) is a condition characterized by unilateral sternocleidomastoid (SCM) muscle tightness and shortening1 caused by fibrosis in the muscle.2 Patients with CMT usually demonstrate a lateral head tilt to the involved side with rotation to the opposite side, and craniofacial asymmetry.1–3 An SCM muscle tumor may be also present.1,2,4 The proposed etiology of CMT includes fetal malposition,1,2,5 SCM injury during birth, SCM compartment syndrome, ischemic injury to the muscle, and infection.1,2 Unfortunately, the exact etiology of this condition remains unknown.1,2
CMT is usually managed conservatively, with only 8% to 16% of patients younger than one year of age requiring surgical intervention.1,4 Common physical therapy intervention strategies for CMT include passive stretching of the shortened SCM muscle,2–8 strengthening of the contralateral SCM muscle,1,3,6 active range of motion exercises, and handling and positioning to improve the infant’s postural alignment.1,3,6
Many authors report that passive stretching is a very effective intervention for CMT,2–8 and this has been my experience as well. However, I have also observed that infants frequently resist this activity and cry during passive stretching, especially if they are older than three or four months of age. Karmel-Ross and Lepp6 explain irritability in patients with torticollis as a response to pain resulting from a perinatal or intrauterine compartment syndrome. While there may be numerous explanations for the infant’s crying and resistance to handling, Cheng et al.8 also report that “snapping” of the SCM muscle during manual stretching “is not uncommon” and may signify partial or complete rupture of this muscle as confirmed by clinical evidence and ultrasonography. Therefore, application of this technique may cause considerable pain or discomfort for the patient. In my clinical experience, infants’ resistance and crying frequently appear to make parents feel uncomfortable about using passive stretching, but they usually continue to this procedure as a part of the home exercise program, when its benefits and possible strategies to reduce the baby’s discomfort are explained to them. Some of these strategies include having the mother or father talk or sing to the infant and use their own face as a stimulus for visual tracking during stretching. Unfortunately, these techniques do not always work, and, in spite of my overall success with the use of passive stretching for CMT, I have been interested in finding a method of intervention that would allow the patient to achieve the same results but stay calm and content throughout the physical therapy session. In my experience, Tscharnuter Akademie for Motor Organization (TAMO) therapy9 may be such a method. This therapeutic approach was developed by Tscharnuter based on dynamic theories of motor control that she applied to her clinical practice.9
REVIEW OF DYNAMIC THEORY AS APPLIED IN TAMO THERAPY
According to dynamic theories, motor behavior is not solely controlled by the central nervous system, but is the product of interaction between the organism and the environment.9–11 The organism is capable of quickly creating new movements to adapt to a new situation offered by the environment.11 This adaptation is the result of self-organization of the system, such as the human movement apparatus,11 based on the interaction of multiple subsystems, including the level of arousal, the neuromuscular system, and gravity and other external forces acting on the human body.9,10 Since the human body is a very complex biological system, the exact behavior of each subsystem cannot be predicted because even in two very similar situations, the exact conditions of the organism and the environment are different between the two points in time when these situations occur.9,11 For example, at the end of a basketball game, a basketball player receiving the same type of a pass from his or her team mate as at the beginning of the game may have difficulty catching the ball because of fatigue (change in the organism) and because of slipping on a wet spot on the floor that was not there before (change in the environment). Through perception, the organism extracts dynamic, or constantly changing, task-specific information to execute an action in a given environment.9,11 To succeed in catching the ball, our hypothetical basketball player would need to notice and avoid the wet spot on the floor and make an extra effort to move faster to overcome fatigue.
Liebovich12 views the biological system of the human body as a chaotic system, with variability being one of its characteristics. He suggests that in the process of learning a new skill, chaotic processes in a human brain work by exploring multiple new neural connections to “record” the new information, and later searching multiple “memories” to select the one needed in a particular situation. Therefore, the variability of movement necessary to adapt to changing external and internal forces acting on the system increases. When there is a lack of variability, only a limited number of movement patterns or postures would be available to the system.12 To illustrate, if the basketball player described above is not capable of catching the ball in a variety of ways, he or she will not be able to adapt to the changing game situation and therefore will not succeed.
TAMO therapy principles based on dynamic theory concepts address the goals of developing the child’s abilities to spontaneously adapt motor behaviors to a variety of natural situations, actively select task-specific information, and synchronize his or her actions with the perceived information.9 This is accomplished by emphasizing adaptation to gravity and to the supporting surface.9 For example, a girl with cerebral palsy sitting on a bench may pull her legs up into flexion in an attempt to maintain balance, but as a result, she would end up having very limited contact with the surface of the bench and no contact with the floor surface. This would cause her to attempt balancing on her sacrum in a posterior pelvic tilt position. To address this problem, the therapist may place her hands on the child’s back and apply a gentle, loading vector of force directed longitudinally through the trunk, toward the ischial tuberosities and toward the surface of the bench, without passively moving the patient. Through this handling input, the therapist will merely suggest to the girl that her contact with the supporting surface could be distributed differently, and then wait for her to reorganize and explore this possibility. The child may actively shift her weight anteriorly and place her feet on the floor, which would provide her with sufficient support to assume a more stable sitting position with improved spinal extension.
Liebovich12 states that besides variability, another important characteristic of a chaotic system is its sensitivity to control parameters. A control parameter is a variable that can produce a qualitative change in the behavior of the system.13 For example, with an increase in speed of walking as a control parameter, walking will at a certain point change into running, signifying a qualitative change in the movement pattern. Similarly, in the above example of changing the sitting behavior in the girl with cerebral palsy, the support surface contact may have served as a control parameter for this qualitative change in her sitting posture.
Although the motor control and motor learning theories on which TAMO is based have been in existence for a long time,9–13 TAMO therapy is a relatively new therapeutic approach,9 and the research evidence of its efficacy is very limited.14 Case reports may be used as a valuable way to initiate the process of investigating the benefits of this method. The purpose of this case report is to describe the use of TAMO therapy as a major component of the physical therapy intervention for an infant with CMT.
Patient Description and History
Patient M. was a 6.5-month-old baby boy (4.5 months corrected age) who was referred to physical therapy for evaluation and treatment of CMT. This infant was selected for a case report, because he demonstrated favorable outcomes of intervention that included TAMO therapy as an approach to treatment of his condition.
M. was one of twin brothers born prematurely at 32 weeks gestation via a vaginal delivery. He remained in the neonatal intensive care unit for 5.5 weeks and then was discharged home. Before 2.5 months chronological age, M. was hospitalized several times for different reasons, including inguinal hernia repair, orchiopexy, and respiratory problems. After the last of these hospitalizations, the patient’s mother became concerned with his tendency to look to the right and side bend the head to the left most of the time. She began encouraging him to rotate his head to the left and side bend it to the right through active movement while tracking toys. She frequently changed the infant’s position in the crib and encouraged prone lying when awake. Her son’s pediatrician provided her with some guidance regarding this problem and checked his passive range of motion at the cervical spine at well-child appointments. At 6.5 months chronological, 4.5 months corrected age, the pediatrician found left SCM muscle tightness upon passive examination and referred the infant to physical therapy. Plain film radiographs of the cervical spine were ordered and bony pathology ruled out.
During the physical therapy examination, a thorough history was taken. The baby’s mother hypothesized that his torticollis might have been the result of his position in utero with his twin brother who for some time also had exhibited a tendency to maintain an asymmetrical head position that was opposite to that of M. She also reported that during his hospitalizations, the infant was frequently positioned with his head rotated to the right, which might have contributed to the development of torticollis. The mother expressed a strong interest in performing a home exercise program with M. to help him alleviate this problem.
During this examination, the patient displayed an asymmetrical head alignment, with rotation to the right and lateral flexion to the left in all positions. In addition, he exhibited mild craniofacial asymmetry, with a slight flattening of the left hemiocciput and of the contour of the left cheek. When observed in the supine position, the patient demonstrated a diaphragmatic breathing pattern that was appropriate for his age. However, he was also observed to use accessory muscles of respiration while prone. No cyanosis, reverse breathing, or subcostal retractions were noted during respiration. There was no fibrotic mass found upon palpation of his left SCM muscle. M. was happy, smiling, and cooperative throughout the examination.
Tests and Measures
I used the following examination methods for this patient: developmental testing, movement analysis, reflexes and postural reactions, and still photography.
Because of the patient’s history of prematurity, which might lead to developmental delays, a standardized developmental assessment was conducted using the Alberta Infant Motor Scale (the AIMS).15 M.’s score on the AIMS fell within the 50th percentile for his corrected age of 4.5 months, indicating that his gross motor skills were appropriate for his age.
Movement Analysis, Reflexes, and Postural Reactions
During the AIMS testing, further movement analysis was performed to document the head positions that M. was able to assume spontaneously. These observations allowed me to assess his active range of motion in the cervical spine and make assumptions regarding his SCM muscle strength.
M. displayed lateral head tilt to the left and rotation to the right most of the time while supine, prone, prop-sitting, and in supported standing. In the supine position, he was observed to visually track a toy horizontally to 180 degrees and actively but very briefly move his head into the position of some right lateral flexion and left rotation. In the prone position, he demonstrated head elevation to 90 degrees and active chin tuck, with weight-bearing through his forearms. The infant was able to push up on extended arms and was attempting to reach for toys against gravity with one upper extremity while shifting weight onto the contralateral forearm. M. was able to maintain prop-sitting without external support for a few seconds, prior to loss of balance. When placed in supported standing, he displayed nonobligatory asymmetrical tonic neck reflex (ATNR) to the right, evident in both the upper and lower extremities on the right. Further testing of reflexes and postural reactions is summarized in Table 1. Because infants with torticollis may occasionally present with developmental dysplasia of the hip,2 Galeazzi’s test16 for hip subluxation/dislocation was administered, and results were negative.
Based on the observation of the infant’s spontaneous movement and postural reactions, I concluded that he presented with right SCM muscle weakness as compared to the left. Because M. was able to actively move his head into full rotation to the left and slightly side bend it to the right, his right SCM muscle contraction was assessed as present but weak.
Because M. was able to actively rotate his head in the supine position to 180 degrees to both sides, the passive range of motion measurement of cervical rotation was not taken. The amount of the patient’s habitual lateral flexion of the head to the left was measured in supine using a method of still photography. This method involves positioning the infant supine and providing him or her with a visual stimulus at midline, without taking any additional measures to place the head in a midline position. Then a still picture is taken. Prior to initiating this procedure, the therapist explains it to the patient’s parents and asks them to sign a consent form for still photography. After the picture is taken, it is helpful to make a copy of it, so that a larger sheet of paper is available for measurement. The therapist draws one line through the infant’s eyes and another line through the acromion processes, then measures the acute angle between the two lines. This angle represents the amount of lateral tilt from midline spontaneously exhibited by the infant. I followed this procedure for M. and measured the initial amount of lateral head tilt to the left at 10 degrees (Fig. 1). I learned this method of assessment for children with torticollis through my clinical practice at a large teaching hospital. I have not been able to obtain any written information on this measurement technique, but it appears to be clinically relevant.
Karmel-Ross and Lepp6 recommend using goniometry to measure head rotation and lateral flexion in a variety of positions. I did not use this examination procedure with M. for several reasons. First, based on my clinical experience, infants with torticollis usually resist passive movement in the cervical spine and frequently cry, making their parents very uncomfortable. They may also perceive the therapist as someone negative from the start and may continue to resist therapy in the future. Second, if the range of motion measurements are taken while sitting or prone, as suggested by Karmel-Ross and Lepp,6 and the child resists handling in these positions and pulls the head away from the therapist, a question about the reliability and validity of this method may arise. Third, it appears that further research is needed in this area of pediatric practice. My search for published evidence regarding the reliability of measurement of the cervical spine range of motion in infants with torticollis did not yield any positive results, and only one study, by Youdas et al.,17 examined the reliability of goniometry of the cervical spine in adult patients with orthopedic disorders. Fourth, while goniometry is a measure of impairment, still photography may be considered a measure of function. The ultimate, functional goal of intervention for torticollis may be stated as the ability of the infant to actively assume and maintain a midline, symmetrical, head position through spontaneous, unrestricted movement during transitions and while maintaining static postures. Therefore, an assessment of a spontaneous head position appears to be useful for the initial evaluation and for tracking the patient’s progress over time.
EVALUATION, DIAGNOSIS, AND PROGNOSIS
Physical therapy examination demonstrated that the patient’s strengths included gross motor skills appropriate for his age corrected for prematurity, full active head rotation to the left, good antigravity head elevation in the prone position, ability to exhibit an active chin tuck while supine, good lateral head righting to the left, and emerging lateral protective response to the right. In addition, the patient’s craniofacial asymmetry appeared to be very mild. I hypothesized that this was because M.’s mother had him spend significant amount of time in the prone position every day.
The patient’s problems revealed by the physical therapy examination included left SCM muscle tightness, a 10-degree head tilt to the left measured by still photography; asymmetrical head posture with lateral flexion to the left and rotation to the right in all positions, and right sternocleidomastoid muscle weakness, as evident from a decreased head righting reaction to the right and absent lateral protective response to the left. I hypothesized that M. had difficulty using the support surface contact in the supine position to produce an adequate force for sustained head rotation to the left with lateral flexion to the right. This problem appeared to have caused limitations in the cervical spine active range of motion and consequently in the right SCM muscle strength leading to left torticollis. The patient’s ability to very briefly move his head into the position of right lateral tilt and left rotation supine while (in a “gravity eliminated” position) but not in prone, supported sitting, or supported standing also pointed to his difficulty using the support surface contact to achieve adequate shoulder girdle and trunk control to free the head for active antigravity movement.
Emery3 reports that typical conservative treatment duration for CMT in infants younger than one year of age may vary from three to 12 months. According to an earlier report by the same author,18 the duration of treatment for this condition has been found to correlate with the severity of restriction in range of motion and with the presence of a palpable intramuscular fibrotic mass. Since M. demonstrated full active head rotation to the left, and there was no mass present at the time of his initial evaluation, I concluded that his prognosis for recovery was good and that he would achieve the anticipated goals and expected outcomes of intervention19 in three to eight months. The short-term, three-month, goals set at the initial evaluation are summarized in Table 2.
The time frame for a complete recovery was set at eight months based on the following considerations. First, at the time of the initial physical therapy evaluation, the patient was 6.5 months old and displayed gross motor skills appropriate for his adjusted age of 4.5 months. If he were to continue progressing with his gross motor development according to his age corrected for prematurity, he would be expected to attain independent walking by approximately 14 months of age, eight months from the time of the first visit. The milestone of walking was selected because, based on my clinical experience, I hypothesized that M. might continue to demonstrate some residual right SCM muscle weakness affecting his antigravity head position when his balance and stability skills were challenged. If this were not the case, the long-term outcome of maintaining a midline head position during all functional activities would be met earlier, and the intervention would be discontinued at an earlier time. I recommended to set the frequency of therapy at once per week for four to five weeks,6 then to decrease the number of visits to once every other week, and finally to once every three to four weeks, as M. demonstrated consistent progress toward his therapy goals and his parents became independent with his home program.
Based on the patient’s evaluation, diagnosis, and prognosis, my clinical experience, and the published literature,6,7,9,18,20 I selected the following physical therapy intervention techiniques: (1) TAMO therapy,9 (2) active range of motion exercise16,18 consistent with TAMO principles,9,20 (3) soft tissue mobilization for the cervical musculature,6 and (4) parent instruction in a home program.5–7,18,20,21
TAMO therapy9,20,21 was used as a major component of physical therapy intervention for this infant. In the supine position, M. initially presented with left lateral tilt and right rotation of the head, with support surface contact distributed at the left hemiocciput most of the time. He did not use the support surface contact at posterior cervical spine or right hemiocciput that would have allowed him to generate sufficient force in his right SCM muscle to assume and maintain a midline or left rotation/right lateral flexion position of the head. First, for a few seconds, I applied gentle loading to the patient’s left hemiocciput directed toward the supporting surface, to “confirm” for him where his support surface contact was located at the moment. Second, I introduced the desirable next phase of movement by very slightly changing the vectors (but not the amount) of force applied to the occiput to direct them toward the supporting surface “through” the left transverse and spinous processes of the cervical spine. I did not passively move M.’s head but rather waited for him to reorganize and to respond to the suggestion of a new support surface contact by actively moving his head toward midline. I introduced the next phase of movement by changing the force vectors in small increments (toward the spinous processes and lower mid-occiput, then toward right hemiocciput), and waited for the patient to reorganize to the proposed distribution of the support surface contact. If instead M. moved his head in the direction of his initial position, I did not resist that movement and initiated the same process again from the point at which he had stopped. Third, to let the patient actively explore the newly found distribution of the support surface contact, I took my hands off of his head for a few seconds or minutes. The infant’s mother was sitting on the floor to the left of him the entire time, thus encouraging him to look to the left.
I followed similar handling procedures to redistribute forces acting on the patient’s body in prone and supported sitting. My hand placement differed depending on the current distribution of the support surface contact in each position. For example, in the prone position, with hand placement at M.’s left upper arm and the left side of the back, the direction of force vectors was modified in small increments to induce changes in the support surface contact from the left forearm and the left side of the ribcage to mid ribcage, and then to the right forearm and the right side of the ribcage. The patient’s mother and toys were positioned to the left of him to encourage reaching forward and to the left with his left upper extremity, combined with right lateral flexion and left rotation of the head and with an active chin tuck. Again, I did not move the infant but waited for him to actively initiate pivoting prone or reaching for a toy while exploring the possibilities offered by the new distribution of the support surface contact.
As M.’s head alignment in supine and prone improved from session to session, less attention was given to activities in those two positions, and sitting and quadruped posture and balance were emphasized using the same approach. I carefully graded the amount of support provided to the infant, so that he could actively explore new possibilities for postural control introduced through dynamic loading. For example, using a pillow in front of M. in supported sitting while changing the force distribution at his ischial tuberosities through gentle loading from the upper back allowed him to explore his toys in a secure environment and remain happy and calm. The external support from the pillow reduced the number of degrees of freedom that M. had to control to “free” his head for active, goal-oriented movement. As his trunk control improved, I gradually reduced the amount of external support to let him exercise the newly found sitting stability. The same principles were followed for quadruped activities, belly crawling, movement transitions, and standing.
Active Range of Motion Exercise
Karmel-Ross and Lepp6 describe using active-assistive and active movement to strengthen weak cervical musculature in patients with CMT. This is accomplished by placing toys on the side of torticollis, and by feeding and talking to the infant from the involved side to encourage active head rotation. The authors suggest that concentric, eccentric, and isometric exercise may be used, depending on the patient’s age, ability to cooperate with these activities, and the interest of the caregiver.6 Because TAMO therapy principles of handling do not emphasize “artificial” exercises taken out of context of functional tasks performed in the child’s natural environment,9,20,21 I focused on setting up situations, in which the patient would be interested in looking to the left and upward or downward, thus promoting strengthening of the right SCM muscle and elongating the posterior fibers of the left SCM muscle, respectively. M.’s mother participated in the treatment sessions and was instructed to use this approach for active range of motion exercises for her son as a part of the home program. No resistive exercise was used for this infant.
Soft Tissue Mobilization
Several authors recommend using massage6,22 and other soft tissue mobilization techniques6 for CMT. According to Karmel-Ross and Lepp,6 this type of intervention is helpful in relieving pain and discomfort that may result from a possible compartment syndrome, and in reducing irritable behaviors during therapy in infants with this condition. Tappan and Benjamin23 list muscle relaxation as one of the potential general effects of massage. Based on my clinical experience in treatment of torticollis, soft tissue mobilization techniques appear to promote relaxation of the tight cervical musculature leading to a more effortless use of the weakened SCM muscle on the opposite side.
Soft tissue mobilization to the left SCM, scalene and suboccipital muscles6 was used for M. when he reverted to habitual asymmetrical head position. This possibly occurred because of fatigue after practicing head rotation to the left with lateral flexion to the right in play situations set up for him. This intervention was usually provided in the supine position, unless the infant actively rolled into prone and preferred staying in that position. I applied the following techniques to the cervical musculature to achieve the relaxation effect: superficial and deep effleurage, petrissage, and deep vibration,23 alternating and finishing with superficial effleurage.
Home instruction for a caregiver is a widely excepted intervention for children withCMT2–8; however, most authors2–7 emphasize passive stretching protocols as the main part of the home program. Although Tscharnuter9,20,21 does not specifically address the intervention for torticollis, she recommends using “simple” activities of daily living to modify the child’s movement since they “offer challenging learning opportunities.”21 This suggestion was used to instruct M.’s mother in handling techniques and active range of motion exercise at the time of the initial physical therapy evaluation, to be included into the home program. In addition, I recommended a positioning program for the patient.
M.’s mother actively participated in his physical therapy sessions and practiced creating appropriate situations for her son to exercise his ability to rotate the head to the left and tilt it to the right. I discussed with her specific handling strategies to incorporate active head movement into the daily routine. They included placing toys to the left of the infant while in the supine and prone positions and moving his toys to the left and toward his left thigh while prone to encourage active head rotation to the left, spontaneous chin tuck, weight shifting to the right, reaching with the left upper extremity, and pivoting to the left. Other activities included supporting M. in a vertical suspension position, with his trunk against his mother’s chest and tilted to the left (Fig. 2) while carrying him around the house (when needed), so that he could freely rotate his head to the left and exercise head righting to the right without struggling to maintain his trunk control.
As the patient progressed in his ability to assume midline head alignment in supine and prone and tilt the head to the uninvolved side, the recommended activities were modified to incorporate more challenging transitions and positions against gravity while providing appropriate support to his body. These activities included setting up play situations for M. for reaching forward and upward in supported ring sitting, with subsequent gradual reduction in support; reaching for toys at the shoulder level and higher, progressing to reaching with trunk rotation and out of the base of support; maintaining quadruped with a soft pillow used for support under the abdomen during play and lateral weight shifting in this position; placing toys in front of the infant to encourage belly crawling (when ready); transitioning from supported side lying over a pillow to sitting; and supported standing during play.
According to Tscharnuter,20 to allow children to explore new movement opportunities, more than minimum postural support needs to be provided to them, especially when muscle tightness is involved, so that they can orient to a broad supporting surface and relax, to allow muscle lengthening to occur without discomfort. Following these principles,20 I instructed M.’s mother in a sidelying positioning program for prolonged lengthening of his left SCM muscle without the stress of passive manual stretching as suggested by and modified from Stamos Norton.24 When positioning the infant on the left side, a folded blanket was placed under his head,24 while the rest of his body, from the shoulder down, rested on the carpet (Fig. 3). In right side lying, his mother placed a folded blanket under his body, from the feet to the shoulder (Fig. 4). For both positions, the patient’s back was supported by the couch and blanket rolls, and the blanket thickness was selected, so that he rested comfortably, without attempting to roll out of this position, and played with a toy or his hands in midline. M.’s mother was instructed not to provide any resistance if he rolled into a prone position, but to let him play and reposition him on the other side later in the day.
I documented M.’s progress in physical therapy throughout the intervention using the method of still photography in the supine position. In addition, with the mother’s consent, photographs of the infant were taken in antigravity positions, so that the observed changes in his ability to assume midline head position and actively tilt his head to the right could be documented.
M. was initially seen once per week. At his second intervention session, he actively assumed a midline head position in supine and even displayed a slight head tilt to the right that indicated a possible overcorrection problem. When home program activities were discussed with his mother, she revealed that she had possibly been using too many blanket layers under his head for positioning in left sidelying. I recommended, in spite of M. remaining content and happy during positioning, to use a thinner layer of blankets and less frequently and emphasize strengthening of his right SCM and scalene muscles through active movement in antigravity positions. At his third therapy session, the infant maintained midline head in supine most of the time, with an occasional lateral tilt of approximately 3 degrees to the right.
During the second and third intervention sessions, M. started displaying active head righting to the right in vertical suspension with posterior trunk support, in prone on elbows and in left sidelying. In addition, he demonstrated a lateral protective response to the left in supported sitting, with head righting to the right. After the fourth visit, the frequency of therapy was reduced to once every other week, because the infant demonstrated consistent progress toward his therapy goals, and his parents became independent with his home program.
By his sixth therapy session, M. had met all his short-term goals that were stated at the time of his initial evaluation (Table 2). He displayed a midline head position (0-degree lateral tilt) in supine, as measured by still photography (Fig. 5), and was able to assume and maintain a midline head alignment in prone and sitting while performing the skills that he had already mastered. In addition, he demonstrated active head righting to the right in prone when reaching for a toy against gravity with the left upper extremity. When provided with posterior trunk support, M. was able to assume and maintain midline head position in standing as well. However, when increased effort was required to maintain balance, such as during standing with bilateral upper extremity support only, he displayed some lateral flexion of the head to the left (Fig. 6), possibly due to residual weakness in the right SCM muscle. The same problem was observed when the infant was placed in the quadruped position and when he was reaching for a toy in independent ring sitting, with trunk rotation. In collaboration with his mother, I developed new short-term goals for the patient (Table 2). At that time, the physical therapy frequency was further decreased to once every three to four weeks.
By the eighth intervention session, M. met all his short- and long-term goals. He was able to maintain a midline head alignment during all functional activities and in all static positions, including supported standing (Fig. 7). He displayed symmetrical passive head rotation and lateral flexion to both sides and symmetrical head righting to either side during weight shifting and during transitions between positions. No residual weakness of his right SCM muscle was observed at that time, and, as a result, M. was discharged from physical therapy.
This case report is the first attempt to describe a successful application of TAMO therapy as a major component of physical therapy intervention for an infant with CMT. Other techniques, such as active range of motion exercise and parent instruction, were structured to follow the TAMO therapy principles.9,20,21 In addition, I applied soft tissue mobilization to help relax the patient’s cervical musculature on the involved side after observing the signs of fatigue when he practiced using the uninvolved SCM muscle in play situations created for him.
Although passive stretching for the involved SCM muscle had been widely accepted as an effective method of intervention for CMT,2–8 this technique was not included into the infant’s treatment plan. I selected TAMO therapy as the main method of intervention for two reasons. First, I wanted to avoid causing patient discomfort, resistance to handling, and crying. Because during TAMO therapy the therapist does not restrict or resist the patient’s movement but instead supports active exploration of the environment,9,20,21 this objective was achieved. M. remained content throughout most of his physical therapy sessions, with the exception of the sixth visit, when he became increasingly irritable due to possibly being hungry, as suggested by his mother. The second reason for selecting TAMO therapy over passive stretching was the hypothesis derived from my clinical experience. I hypothesized that the application of this motor organization approach would allow the patient to achieve the short-term goals and long-term outcomes of intervention within the amount of time specified in the Guide to Physical Therapist Practice19 and reported in other literature.3,18 As mentioned above, the duration of physical therapy intervention for CMT in infants younger than one year of age may vary from three to 12 months.3 According to the Guide,19 80% of patients classified in pattern 4B that includes the diagnosis of torticollis are expected to “achieve the anticipated goals and expected outcomes within 6 to 20 visits during a single continuous episode of care”, over a three- to six-month period. M. was seen for a total of nine visits (including the initial evaluation) over a period of four months, and discharged when all his goals were successfully met. Therefore, my hypothesis was confirmed.
The issue of selecting the still photography to track the patient’s progress needs to be discussed. As stated in the examination section of this case report, I have successfully used this method of measurement in my clinical practice; however, no reliability data on its use for children with torticollis are currently available. This warrants a reliability study of the method of still photography for measurement of head tilt in infants with CMT.
It is important to note that when the intervention was initiated, the patient demonstrated rapid progress after the first two or three therapy sessions, first, in active range of motion in a reduced gravity position, and then in antigravity positions. Besides the benefits of TAMO therapy that are discussed below, this may be attributed to the fact that M. demonstrated full active head rotation to the left and did not have an SCM muscle mass that would have required a longer course of treatment.18 Further research is needed to investigate the efficacy of TAMO therapy as a physical therapy method of intervention for CMT for infants with varying severity of restriction in range of motion and with the presence or absence of a palpable intramuscular fibrotic mass.
To examine a possible mechanism of action of TAMO therapy on motor behavior, as described in this case report, it may be helpful to equate the patient to a chaotic system,12 as suggested in the introduction. Liebovich12 compares the amount of change in the input required to control the output of linear and chaotic systems. He states that for linear systems, the bigger the target change in the output, the bigger input is required. On the contrary, for chaotic systems, “a delicate adjustment in the input can make a dramatic change in the output.”12 This notion may be illustrated by comparing passive stretching of the involved SCM muscle and TAMO therapy as interventions for a patient with CMT. If the human body is considered to be a linear system, then a tight SCM muscle can be looked at as a force preventing the child from rotating the head to the side of torticollis and side bending it to the opposite side. A relatively significant amount of force is required to passively overcome this problem through passive stretching. In comparison, looking at a human body as a biological system sensitive to small changes in control parameters would explain how a very gentle input in the amount of force applied to the head of an infant with CMT during TAMO loading could lead to a rapid change in the patient’s ability to assume and maintain the midline head position. Responding to the gradual change in a control parameter, such as the direction of the gentle loading force applied to the occiput, an active, dynamic change in the support surface contact occurs. The area and location of the support surface contact, in turn, serves as a control parameter9 to change the amount of force in the uninvolved SCM muscle the infant is able to generate working from the supporting surface.Further spontaneous exploration of the acquired ability to produce new antigravity movement patterns increases movement variability and leads to generalization of this ability to a variety of similar situations.9 Thus, a “big input”12 in the form of a passive stretching force may not be required to produce a qualitative change in the motor behavior of a child with torticollis.
To summarize, this case demonstrates that infants with CMT who present with unrestricted head rotation to the involved side in the absence of a palpable intramuscular fibrotic mass may benefit from TAMO therapy to achieve a favorable outcome of intervention while avoiding discomfort, resistance to handling, and crying. In addition, this case indicates the need for research to accomplish the following goals: (1) establish the reliability of the method of still photography as a measurement of lateral head tilt in infants with CMT; (2) investigate the efficacy of TAMO therapy as a physical therapy method of intervention for CMT in infants with varying severity of restriction in range of motion, in the presence or absence of an SCM muscle tumor; (3) compare functional outcomes of passive stretching and TAMO therapy in patients with CMT in a randomized clinical trial; and (4) evaluate behavior during therapy sessions in infants with CMT who receive physical therapy intervention emphasizing TAMO therapy as compared to passive stretching.
The author thanks the child who was described in this case report and his family who enthusiastically supported the submission of this manuscript for publication.