INTRODUCTION AND PURPOSE
Congenital muscular torticollis (CMT) and postural torticollis (PoT) are the most common causes of torticollis in infancy.1 Congenital muscular torticollis is characterized by a unilateral shortening of the sternocleidomastoid muscle with or without a fibrous mass2 and occurs in 0.3% to 2.0% of live births.3 It is associated with higher rates of birth trauma and constrained intrauterine environment, but its exact etiology is still unclear. Postural torticollis is a limitation in neck range of motion (ROM) leading to the typical head tilt of torticollis but is also highly associated with plagiocephaly (an oblique deformation of the head without fusion of the cranial sutures). Muscular imbalance or constrained intrauterine environment is hypothesized to cause PoT. The reported incidence of PoT is inconsistent because of variations in its exact definition; however, combined incidence reports for CMT and PoT range from 4% to 16%.4 , 5
For both CMT and PoT, the limitation in neck ROM is the most striking clinical feature. However, torticollis can have a broader effect, ranging from associated craniofacial deformities to higher risk of other orthopedic deformities.5 Little is known about the natural history of CMT and PoT. Even though there are some case reports of recovery without intervention,6 intervention studies show that later age at presentation is associated with poorer outcome.7 Available case reports of untreated torticollis report facial scoliosis, mandibular joint problems, and cosmetic issues.8 Although literature is scarce, authors seem to agree that infants with torticollis should receive conservative intervention to avoid potential deleterious effects.
Strategies frequently used in the conservative management of infants with torticollis include manual stretching of affected muscle groups, specific handling and positioning strategies, active and passive neck ROM exercises, as well as a neurodevelopmental approach to encourage overall symmetry of postures and transitional movements. Physical therapy (PT) is currently the standard conservative care recommended for infants with CMT or PoT and is usually associated with high rates of resolution.2 Van Vlimmeren et al2 suggested that all infants with CMT and infants with PoT presenting before the age of 2 months be referred directly to PT. Even though parents may have direct access to PT services, a certain proportion of infants will be referred to PT by pediatricians or receive conservative care from the physician. Because the role of pediatricians in the care of infants with torticollis is not reflected in the literature, an absence of information exists regarding the current and optimal care provided by these professionals.
A substantial number of studies on conservative intervention for this population have been published; however, the optimal treatment parameters remain unclear. For example, the treatment frequency proposed in different studies ranges from therapy once every 3 weeks9 to stretching every 3 hours.10 No one combination of modalities or intensities has been proven to be more effective than another to resolve torticollis in a timely manner.
In the context of most intervention studies, a standardized intervention is provided to all participants, whereas, in clinical practice, an important number of factors may influence the decision to opt for a particular treatment content and intensity. Yet, little is known about the factors that currently affect the choice of intervention parameters made by pediatricians and physical therapists for the treatment of infants with PoT and CMT. Luxford et al11 reported, in a survey of pediatric physical therapists involved in the treatment of infants with torticollis, that perceived parental competency, the family's daily routine, and the physiotherapist's preference for techniques influenced the selection of stretching exercises parameters for those infants. Literature also reports that severity of neck ROM limitation is a factor to consider, as demonstrated by Cheng et al,7 who obtained successful outcomes with different frequency of intervention based on neck ROM.
Clinical decision making is a complex process guiding the choice of the type and frequency of intervention. Research in this domain shows that health care professionals should rely on a careful assessment of probabilities and risks of given outcomes, taking into account patient preferences, environmental context, family factors, and scientific evidence.12 The available literature on torticollis proposes a breadth of treatment parameters and modalities and little sound evidence to guide therapists in their decision making regarding the intervention needs of infants presenting with torticollis.
A better understanding of the intervention needs of infants with torticollis, gained through an analysis of the clinical decision making of pediatricians and physical therapists, could allow the design of comprehensive assessment tools that adequately represent the burden of the condition. A more accurate vision of the needs gained through an adequate assessment could then lead to the creation of more appropriate intervention strategies, which could help resolve torticollis in a more effective manner. Timely resolution of torticollis is of interest considering the relatively high incidence of CMT and PoT, limited health care resources, and the potential deleterious effects of torticollis.
The objective of this study was to identify the factors currently influencing the determination of intervention needs for infants with PoT and CMT through a qualitative inquiry of pediatric physical therapists' and pediatricians' clinical decision making. The identified factors were mapped using the International Classification of Functioning, Disability and Health—Children and Youth (ICF-CY) published by the World Health Organization in 2007.13 The comprehensive categorization provided by the ICF-CY describes an individual's functioning across 3 domains (body structures and body functions, activities, and participation). It also includes the influence of a health condition and of contextual factors (personal and environmental) on an individual's level of functioning. Considering the highly variable clinical presentation of torticollis, the complexity of clinical decision making, and the important effect of environment on the development of infants, this framework was thought to appropriately cover the different factors that could influence the decision making of physical therapists and pediatricians. It also provides a common language for health care professionals and could, therefore, be used to describe both professionals' perspective.
The present study included 2 phases to reflect different professionals' perspectives on the question. First, the pediatricians' perspective was surveyed to determine what factors influenced their decisions regarding the management of infants with torticollis. In the second phase, a qualitative inquiry of clinical decision making of expert pediatric physical therapists was conducted through focus groups and a national validation survey. The choice of this methodology was guided by the absence of literature on this topic as well as the complexity of clinical decision making.14 Also, focus groups allow participants to interact among themselves, which can generate a greater number of ideas on a theme. Validation of the factors identified during focus groups was then conducted through a larger national survey of pediatric physical therapists. The validation survey also allowed the addition of new factors as well as the report of the current practices for assessment of these factors. Ethical approval for this research project was obtained from the Institutional Review Board. All participants agreed to participate on a voluntary basis, after providing informed consent.
Pediatricians registered with the Association des Pédiatres du Québec and working in the Montreal, Quebec, Canada, area were contacted by mail (n = 271), regardless of their potential eligibility. They were eligible to participate if they (a) were routinely assessing new infants for global development as part of well-baby care and (b) had referred infants to PT for torticollis at least 10 times in the last year. In addition, approximately 40 pediatricians (included in the first mailing) belonging to a pediatric community practice group and known to meet the inclusion criteria were contacted once by e-mail or phone about 1 month after the initial mailing. They were contacted to avoid overrepresentation of hospital-based versus community-based pediatricians.
The package sent to pediatricians included a description of the study, the consent form, and the study questionnaire. They were asked to complete and return it by mail or fax. The questionnaire consisted of sociodemographic information and 6 open-ended questions. The questions addressed the intensity and content of the management provided by pediatricians to infants with torticollis and their families as well as factors influencing the pediatrician's decision to provide different types of management.
Eighteen (6.6%) pediatricians returned the completed questionnaire and their answers led to saturation of themes. Their questionnaires were analyzed qualitatively using a content analysis method. Codes were developed by the principal investigator (J.F.) and were used to generate a list of factors thought to be related to the intervention needs.14 As an example, the code “plagiocephaly” was developed for the following quote from a pediatrician questionnaire: “Or when you have a severe plagiocephaly even without a clear diagnosis of torticollis.” The list of factors was reviewed by the research team. Since the aim of this phase of the study was not to come to a consensus but rather to identify the full range of relevant factors, conflicting ideas for a given topic were not excluded.
To facilitate the organization of the results, the principal investigator mapped the factors identified by the pediatricians with categories of the ICF-CY.13 Each developed code was first classified into 1 of the domains of body structures and body functions, activities and participation, personal factors, or environmental factors. Then, the most specific and accurate first-, second-, or third-level ICF-CY category was identified using the descriptions provided in the ICF-CY manual. As an example, the identified factor “plagiocephaly” was first classified as a body structure, then related to the first-level category structures related to movement, then to the second-level category structures of the head and neck region, and finally to both categories “Bones of Cranium” and “Bones of Face.” The exact methodology has been described in the training video of the ICF Research Branch.15 The mapping results were then reviewed for accuracy by the research team.
Descriptive statistics were used to characterize the sample of participants (Table 1). A lack of information about the total number of pediatricians from the Montreal area meeting eligibility criteria limited the accuracy of the estimated response rate (6.6%) as well as the comparisons between the respondents and the nonrespondents.
Physical Therapists' Perspective: Focus Groups of Expert Physical Therapists
Purposeful sampling was used to select participants. Physical therapists were included if they were (a) involved in the assessment and treatment of infants with torticollis for at least 2 years, (b) seeing at least 3 cases of torticollis per week on average in the past year, and (c) practicing in 1 of the 2 tertiary pediatric university teaching hospitals in Montreal, Canada. These criteria were chosen to ensure that the clinicians involved were aware of the current best practice and had seen many different cases of torticollis. Considering the limited number of potential participants as well as the relative focus of the questions, it was estimated that 3 groups of 4 to 10 participants would be sufficient to address the study question.14 One group of 8 participants and another group of 4 participants were involved in the 2 focus groups, which led to the saturation of themes. This represented 100% of eligible participants in the 2 institutions. The physical therapists who participated had all completed a BSc in physiotherapy in a Canadian university leading to practice, 2 had an MSc degree in rehabilitation, 2 had completed a BSc in another domain, and 6 had completed continuing education training (neurodevelopmental therapy, global postural reeducation). Sociodemographic data describing the participants are presented in Table 1.
An invitation to participate in the focus groups was distributed to the therapists by the chairs of the Department of Physical Therapy of the 2 selected pediatric hospitals. The focus groups, which lasted approximately 90 minutes each, were held in the therapists' own work environment to facilitate open discussion. The discussion was led by the principal investigator, who was assisted by a comoderator (I.G.) who took notes on the discussion and recorded comments on the process. The content of the discussion was audiotaped to allow for transcription and analysis of the content. Questions and probes were developed on the basis of the available literature on torticollis intervention and clinical decision making. Questions referred mainly to factors considered as part of clinical reasoning that underlie the assignment of a given treatment intensity. As an example, the therapists were asked to discuss the aspects that they would like to share with students regarding the choice of treatment frequency for infants with torticollis.
The focus group discussions were transcribed verbatim. A content analysis was performed using the same codes as for pediatricians' questionnaires. When necessary, new codes were developed using the same methodology. The codes were then mapped to the ICF-CY categories using the same procedure as for pediatricians' questionnaires. Descriptive statistics were also used to characterize the sample of participants.
Validation of Factors Through a National Survey of Pediatric Physical Therapists
After the analysis of focus group results, a cross-sectional online survey of pediatric physical therapists was conducted. This was done to validate the factors identified as influencing the clinical determination of intervention needs of infants with torticollis.
Different recruitment strategies were used to ensure broad participation and representation of pediatric physical therapists. First, all members of the Paediatric Division of the Canadian Physiotherapy Association (n = 408) were invited to participate through the online newsletter of the division. A reminder in the following newsletter, published 6 weeks later, was used as a strategy to increase the response rate. Second, the members of the Ordre des Physiothérapeutes du Québec who had advertised treating infants with torticollis and plagiocephaly (n = 410) were contacted by phone or e-mail and invited to participate. Finally, the chairs of the Department of Physical Therapy of 10 pediatric hospitals across Canada were contacted to solicit their physical therapists' participation. Through this broad sampling strategy, physical therapists could have been contacted more than once because of the possible overlap between the sampling sources.
The participants were included if they had done at least 10 assessments of infants with torticollis in the last year. They were excluded if they were working in the hospitals where the participants of focus groups were recruited. Of the 70 physical therapists who were interested in participating, 25 (36%) did not meet the inclusion criteria. The exact proportion of physical therapists surveyed who met the inclusion criteria is unknown; the proportion of eligible therapists from the total population may be lower than the 64% found for our sample, since those demonstrating an interest in participating in the survey may be more likely to work frequently with infants with torticollis. The uncertainty regarding the proportion of eligible therapists and the possible overlap between the members of the sampling sources may have underestimated the response rate (5.5%).
Forty-five physical therapists completed the survey and provided answers for 92.4% of the questions. Ninety-five percent of the participants graduated from a Canadian university, from which 62% received their professional training in the province of Québec. Participants practiced in a variety of settings: private clinics (32%), acute general hospitals (22%), pediatric rehabilitation centers (18%), pediatric hospitals (13%), community-based services (10%), and general rehabilitation centers (4%). Additional details on their practice characteristics are presented in Table 1.
The Web-based survey, using the Survey Monkey platform, was accessible for a period of 2½ months. Questions for the survey were developed from the results of the focus groups. First, before being presented with the results of the focus group, therapists were asked to list the 5 most influential factors affecting their clinical decision making when treating infants with torticollis. Then, for each factor identified through the focus groups, the therapists were asked to state to what extent the given factor influenced their determination of intervention needs of infants on a 5-point scale ranging from 0 (to no extent at all) to 4 (to a very great extent). To explore the assessment practices of therapists for each factor, participants had to indicate (a) whether they assessed this aspect in their practice or not and (b) if they did, which technique, scale, or measure was used to perform the assessment. Although the format of the survey allowed participants to go back to previous questions and change their answers, they were not encouraged to do so.
Each participant first reported the 5 most influential factors in the determination of intervention needs. Their answers were related to the codes previously identified in the focus groups when possible and new codes were developed when necessary. We reported the percentage of participants who identified a given factor as 1 of the 5 most influential ones in their decision making. The percentage of therapists who identified a factor from among the 5 most influential factors was calculated. Then, for each factor identified from the focus groups, the percentage of survey participants who rated the importance of the factor as 3 (great extent) or 4 (very great extent) on the 5-point scale was calculated. Factors not identified during the focus groups but mentioned during the survey were coded using the same method as described earlier. The assessment strategy of participants for each factor was described in terms of percentage using a given assessment method. Descriptive statistics were used to describe the clinical practice characteristics of participants.
Pediatricians' Perspective on Intervention Needs
Pediatricians reported high rates of referrals to PT (based on self-report, median: 100%, range: 15%–100%). Even if some reported lower rates of referral, there was unanimous agreement that intervention, whether provided by pediatricians or physical therapists, was required for all infants presenting with torticollis.
Forty-eight percent of the pediatricians in our sample decided to initiate intervention themselves. The pediatricians generally provided advice on positioning as well as passive stretching of neck muscles and monitored the condition from once every 2 weeks to once every 2 months. Failure to improve under such a regimen was consistently reported as an indication to refer to PT. One pediatrician noted
After many years showing the parents how to do the exercises themselves at home and following them up regularly but finally ending up with residual malformations, I now refer them from the get-go to physiotherapy; they are more motivated.
Table 2 summarizes the factors influencing pediatricians when determining the intervention needs of infants with torticollis. The table is structured using the ICF-CY framework and presents factors for each of the model's domains. Physical characteristics of the infant, such as neck ROM limitation, and family factors, such as parental concerns, were identified by pediatricians as important factors prompting referral to PT. Resources available also appeared to play a role in the decision making regarding the intervention to provide, as highlighted by the following quote:
I work in a nursery, so I can't follow up the infants. I usually ask that their doctor reassess them around three weeks of age, but medical resources are lacking to do so.
Referrals to other health care professions were also reported by pediatricians. When prompted by parental demand, pediatricians stated that they would refer to chiropractic or osteopathy (n = 2) and when the case was complicated, they may refer to physiatry, neurosurgery, or general surgery (n = 3).
Pediatric Physical Therapists' Perspective on Intervention Needs—How Often Should I See This Family?
The focus groups first helped to define the content of the physical therapists' intervention. Physical therapy sessions included the assessment and monitoring of the condition, teaching and parental education, and procedural interventions (hands-on therapy). The core of the intervention was the home program of exercises to be performed by parents themselves. Therapists reported that the combination of PT sessions with a well-implemented home program often effectively led to the resolution of torticollis.
Physical therapists initiated their clinical decision making by analyzing assessment data to confirm, through differential diagnosis, the presence of CMT or PoT. One physical therapist mentioned:
Since there are many underlying factors to a clinical presentation of torticollis, there are all the aspects of differential diagnosis that must be eliminated before stating it is a congenital or postural torticollis.
The next step was to determine the relative proportion of home exercise program and PT intervention (procedural intervention, parent education, and monitoring) required by the family. This proportion depended on various factors that spanned across all domains of the ICF-CY. Personal and environmental factors played an important role in the decision process. The list of factors identified through the focus groups, along with quotes supporting their importance and the corresponding ICF-CY categories, is presented in the Appendix (Supplemental Digital Content 1, available online at http://links.lww.com/PPT/A22). According to physical therapists, and as highlighted by the following quote, either a single factor or a combination of the aforementioned factors may justify increased treatment intensity:
As soon as one element is severe, we follow up regularly and when the combination of everything makes the case severe, then we follow up frequently as well. It is not just the torticollis, it is the scope of the problem that is important.
The validation survey of pediatric physical therapists allowed estimating the perceived importance of each factor in the decision process. When asked to list the 5 most important factors affecting their decision making regarding intervention needs in the first question of the survey, participants highlighted items covering all domains of the ICF-CY and were comparable to the factors identified during focus groups. Range of motion and severity of torticollis were reported by 77% of therapists, followed by age at presentation (52%), parental ability to perform the exercises (48%), plagiocephaly (39%), and gross motor function (36%).
The percentage of therapists who reported a given factor as influencing the determination of intervention needs to “a great or very great extent” is presented in the Figure. All but 7 factors were identified as having an important effect on the clinical decision making of a majority of therapists. The 7 factors identified during the focus groups and deemed as less important by the survey participants either were aspects that are not primary impairments of torticollis or were a specification of a more general category identified as important (eg, Apgar, reported as important by 7% of participants, is more specific than birth complications, reported as important by 51% of participants).
Factors added by the survey participants clarified potential factors in the choice of intervention format and included current follow-up by other health care professionals, geographical distance between the family and the center where services are provided, financial resources of parents receiving services in private practice, and the complexity of the exercises required by the condition of the infant.
The exploratory analysis of assessment practices of the survey participants revealed that even though a large number of factors influencing the determination of intervention needs were identified, only 5 (ie, gross motor function, craniofacial morphology, ROM of the limbs, reflexes, and tone) were routinely assessed using a standardized and validated method by more than 10% of therapists. Mobility of peripheral joints was assessed using goniometry, as needed, by 24% of therapists. Tools used in the assessment of reflexes and tone included the Ashworth scale (original and modified), the Amiel-Tison evaluation of the newborn, and the Movement Assessment of Infants. Craniofacial morphology was assessed using calipers, cephalic index, thermoplastic bands, or the Cranial Technologies Severity Scale. Different measures of gross motor function were reported: the Alberta Infant Motor Scale (n = 25), the Talbot battery (n = 5), Movement Assessment of Infants (n = 1), Peabody Developmental Motor Scale (n = 1), and the Amiel-Tison evaluation of newborn (n = 1).
None of the environmental factors were formally assessed using psychometrically tested tools. There was disagreement as to what approach should be used to assess environmental factors relating to the family. Some therapists reported that they would observe the behavior of parents to judge a familial characteristic (eg, level of compliance), whereas others preferred to ask the parents directly about their concerns and level of confidence in doing the exercises. These results are illustrated in the Figure.
Surveyed therapists identified elements that encouraged their use of assessment tools. These included tools that were easy and quick to administer, required little specialized equipment, and used diagrams to facilitate interpretation. Although practicality was reported as a major issue, physical therapists indicated that the reliability and validity of the measure also influenced their decision to implement a particular tool in clinical practice.
The present study described the clinical decision-making process of pediatricians and pediatric physical therapists in determining intervention needs of infants with torticollis. Both categories of professionals (pediatricians and physical therapists) reported that all infants presenting with torticollis would benefit from formal intervention. The uncertainty regarding natural history and potential deleterious effects of untreated torticollis may justify the interventionist attitude of health care professionals. This is concordant with previous literature recommending conservative intervention for infants with torticollis.2
The factors identified as influencing the decision-making process relative to the intervention needs of infants were similar across both disciplines' perspectives. For each phase of the study, the factors encompassed all domains of the ICF-CY. However, the perspective of the pediatricians was restricted to fewer factors. This could be due to the difference in the survey methodologies used for the 2 groups but also to the nature of pediatricians' practice. Pediatricians often have a limited amount of time to diagnose and evaluate the patient's global health condition and to determine the best interventions to provide. The average consultation duration in the United Kingdom and Spain ranges from 8 to 23 minutes, the latter in the case of new patients.16 , 17 Therefore, they likely restrict their assessment to their perceived most pertinent factors. When asked to identify the most important factors influencing their decision making, the physical therapists noted factors closely related to those identified by the pediatricians, which supports the idea that pediatricians limit their assessment to the most influential factors due to a restricted amount of time. This limited amount of time on the part of pediatricians to provide direct intervention could also explain or contribute to the reported high referral rates to PT observed in this study.
When examining the distribution of factors among ICF-CY domains, we noted that all of the activities and participation factors, and many of the body structures and body functions factors identified, were reported in the literature as clinical features of infants presenting with torticollis. The body structures and body functions factors that were not previously reported in the literature (sensory integration, alertness, primitive reflexes, tone, and weak suck) are all related to the maturation and integrity of the central nervous system. Fowler et al18 performed a study with infants with plagiocephaly, a condition highly associated with torticollis. They discussed the potential relationship between neurologic findings and the development of plagiocephaly. The persistence of primitive reflexes, hypotonia, and diminished alertness could compromise the ability and intrinsic motivation to move, leading to flattening of the occiput, and potentially to torticollis. The presence of these features in a subset of infants with torticollis could modify their intervention needs.
Twenty-one environmental factors were identified as determinants of the decision making of physical therapists. This is the ICF-CY domain where there is the biggest gap between available literature (evidence) and current management (practice). Literature to date primarily focused on the physical components of infants with torticollis, while it appears that a broader perspective is needed to reflect the global needs of this population. Ohman et al19 studied the developmental effect of caregiver positioning practices and found that parents of infants with CMT were less likely than parents of a group of infants who served as controls to place their infant in the prone position while awake, even though they received specific recommendations from physical therapists. The lower rate of implementing recommendations in the CMT group highlights the role that environmental factors, such as caregiver attitudes and practices, should play in the choice of appropriate intervention strategies in the management of torticollis.
This important focus on environment, and more specifically on family, is consistent with the family-centered care model. Family-centered care is composed of a set of values, attitudes, and approaches to health services that recognizes that each family is unique, that the family is the constant in the child's life, and that parents are the experts in their child's abilities and needs.20 Within this model of care, the family and the service providers collaborate to determine the family's strengths and needs. From this assessment, the services and supports needed by the child and family are identified. Supporting evidence of family-centered care illustrates that families who are involved in clinical decision making are more likely to adhere to treatment regimens, which is crucial in the management of torticollis. Those families, therefore, experience better health outcomes for their child. Within the perspective of family-centered care, the assessment of priorities, concerns, and resources is used to identify strategies that empower the family in meeting the needs of their infants. Therefore, the information about the environmental factors playing a role in the determination of intervention needs of infants with PoT should be based on information gathered through discussions with the parents about their needs and concerns rather than on a judgment based solely on observation of parental behavior. Assessment practices in this area may, therefore, need to be reoriented toward a more collaborative method.
Within the environmental factors identified, a subset of factors was related to the health care professionals and to the available services. The personal attitudes and preferences of health care professionals potentially acting as factors affecting decision making reiterate the importance of using scientific evidence when deciding about optimal interventions. Literature regarding the intervention with infants with torticollis is scarce; research regarding the effectiveness of current management strategies could enhance evidence-based practice in this area.
This research presented the clinical decision making of pediatricians from Montreal, Canada, and pediatric physical therapists from Canada, through qualitative inquiry. This geographical limitation may affect the generalizability of results even though efforts to ensure trustworthiness of data and representativeness of the participants were made.
The research team opted for broad and inclusive recruitment strategies to gain richness, breadth, and depth of the data. However, this was done to the detriment of knowledge regarding the sampling sources. This resulted in an inability to compare respondents with nonrespondents. Also, this may have led to an inaccurate estimation of the response rate (which was low for the pediatricians and the physical therapist survey).
Further research in this area should focus on the perspective of parents on intervention needs of their infants with torticollis. This would complement the understanding gained through this study and facilitate the application of family-centered care principles to intervention strategies for this population. Considering that an important proportion of identified factors relates to the environment of the child, questionnaires assessing the family concerns and resources could be identified in the literature to complement health care professionals' assessment and ensure an adequate determination of needs.
An accurate assessment using psychometrically tested outcome measures is critical in the determination of intervention needs. However, as revealed by the exploratory results on current assessment practices, the use of psychometrically robust tools is not widespread. This finding is consistent with the findings obtained by Luxford et al11 in a survey of management of torticollis by physical therapists in New Zealand, reporting that 86% of therapists estimated ROM visually. Researchers in the area of knowledge translation are currently identifying strategies to facilitate the implementation of psychometrically tested outcome measures in clinical practice. These strategies should be taken into account to increase their use in the clinical assessment of infants with PoT and CMT.
Torticollis is often viewed as a simple impairment of the sternocleidomastoid muscle; nonetheless, the intervention needs of infants presenting with this condition are complex and dependent on a spectrum of factors relating to the infant and its environment. This broader perspective of modifiers of intervention needs in infants with torticollis likely applies to other pediatric populations. The application of the holistic approach described in this article, framed by the ICF-CY, would likely enhance the comprehensiveness and quality of care provided by pediatricians and physical therapists.
The authors thank all the pediatricians and physical therapists who generously gave their time to participate in this study.