Congenital muscular torticollis (CMT), a postural deformity of infancy resulting from unilateral shortening of the sternocleidomastoid (SCM) muscle, is typified by lateral flexion of the head to the ipsilateral side and cervical rotation to the contralateral side.1 , 2 With a reported incidence of up to 16% of newborns,3 CMT may be present at birth or develop during the first few months of life and has been correlated with intrauterine and prenatal factors such as increased birth size, intrauterine malposition, breech presentation, or the use of forceps during delivery.1 , 4 There are 3 types of CMT: postural CMT is the mildest form in which the infant has a postural preference but does not have passive range-of-motion (PROM) restrictions5 , 6; muscular CMT, which involves SCM tightness and limited PROM1; and SCM mass CMT, which is the most severe form of CMT characterized by fibrotic thickening of the SCM and limited PROM.7
Clinical practice guidelines are collections of action statements developed to optimize infant care, minimize harm, and reduce the variability of clinical practices.8 , 9 Clinical practice guidelines go beyond a systematic review of the literature and employ a transparent process of weighted appraisal wherein recommendations are graded based upon the strength of the supporting literature, the expertise of the guideline development group, and input from stakeholders including families.8 The Physical Therapy Management of Congenital Muscular Torticollis: An Evidence-Based Clinical Practice Guideline (CPG),1 endorsed by the Academy of Pediatric Physical Therapy) of the APTA, outlines 17 succinct action statements (ASs) related to management of infants with CMT. The CPG includes education, identification and referral (AS11-AS31), examination and evaluation (AS41-AS121), intervention (AS131-AS151), and discontinuation, reassessment, and discharge (AS161-AS171). Statements related to examination include documenting the history, screening, referring the infant to a physician if the physical therapist (PT) identifies red flags inconsistent with a diagnosis of CMT, and requesting images and reports from physicians and other specialists.1 A detailed framework is also provided for examining body structures, activity and gross motor development, participation in daily tasks, classifying the severity of CMT, and determining the prognosis.1 Statements concerning interventions promote use of first-choice interventions supported by higher levels of evidence.1 Additional intervention statements relate to supplemental interventions with lower levels of supporting evidence (such as the use of kinesio-tape or a soft collar) used only to augment first-choice interventions and the need to initiate consultation with the infant's physician when an infant is not responding to interventions as anticipated.1 Statements concerning discontinuation, reassessment, and discharge detail evidence-based discharge criteria and recommended follow-up.1
Although PTs have reported positive attitudes toward practice guidelines,10 Bernhardsson et al10 found that only 47% of PTs frequently use practice guidelines. The main barrier to using practice guidelines was reportedly a perceived lack of time; however, knowing how to integrate infant preferences into guideline use was associated with more frequent use of guidelines.10 Given these factors, the purposes of this case report were to (1) illustrate application of the CPG1 in an outpatient facility by using the CPG1 to guide the PT management of an infant with CMT and (2) identify beneficial changes in facility-wide clinical procedures to reduce the variability of care as outlined in the CPG.1 Informed consent for physical therapy services and permission to publish this case report were obtained from the infant's legal guardian.
DESCRIPTION OF THE CASE
Action Statements 2 to 3: Identification and Referral1
The infant was a 2-month, 10-day old baby who was referred by his pediatrician to an outpatient pediatric physical therapy program at a rehabilitation hospital with a diagnosis of CMT.
Action Statements 4 to 12: Examination and Evaluation1
The general and developmental history, obtained through maternal interview as outlined in AS4,1 revealed that the infant had been born at full term following an uncomplicated pregnancy. The vaginal delivery was accomplished without instrument assistance. The infant was reportedly blue and limp upon delivery, but his appearance, pulse, grimace, activity, and respiration (APGAR)11 score was within the normal range (≥7) at 5 minutes postbirth. Additional testing at birth revealed mild right ventricular hypertrophy that had been resolved without intervention at the onset of the case. The mother reported that, at approximately 2 weeks of age, she noticed her infant's preference for turning his head to the left during waking and sleeping hours. The mother stated that none of her other children had a history of torticollis.
A screen of the neurological, musculoskeletal, integumentary, and cardiopulmonary systems was performed, as detailed in AS5.1 Upon palpation, the infant did not present with any nodules in either SCM muscle. A preference was observed for left active cervical rotation. Active movement was observed at all extremities and age-appropriate muscle tone was noted throughout the extremities and the trunk. Visual tracking in all directions was also age appropriate. Minor redness was noted in the right cervical skin folds. A cardiovascular screen did not reveal anomalies. When asked about the infant's gastrointestinal history, the mother did not report any reflux or constipation. Consistent with his preferred positioning, the mother reported minor difficulties with breastfeeding from the left breast. The infant had not undergone any imaging or other testing related to CMT. All findings were consistent with a diagnosis of CMT and no red flags were identified. Therefore, a referral to the primary pediatrician or requests for imagining were not warranted (AS61 and AS71).
Physical examination included estimation of cervical PROM and active range of motion (AROM) via visual assessment. Findings are listed in Table 1. In the supine position, a resting head tilt of 5.86° to the right was noted as measured via a photograph using ScreenScales software (Softpedia, Bucharest, Romania). Age-appropriate PROM12 of the upper and lower extremities was noted through a visual assessment. A mild flattening of the left occiput was noted, indicating a potential need for a head scan referral. Due to his age, the 10° difference in passive cervical rotation, and the lack of an SCM mass, the severity of the infant's CMT was classified (AS91) as a grade I: Early Mild on the CMT Classification Scale.1 Infant observation did not reveal concerns about pain.
As detailed in AS101 and AS11,1 the infant's activity, developmental, and participation status were examined. In the supine position, the infant was able to occasionally maintain a midline head position, bring his upper extremities to midline, and had bilateral lower extremity movements. In the prone position, with and without chest support, he required moderate assistance to maintain prone-on-elbows and maximal assistance to weight shift. He was able to lift his head in the prone position, with less than 45° of neck extension and tolerate prone for 0 to 30 seconds at a time. He required maximal assistance to roll to and from the supine and prone position. These findings were consistent with typical motor development of a 2-month-old and therefore, per the procedures of the outpatient facility, administration of a standardized developmental test was not indicated. If motor delays had been suspected, per clinic procedure, the Peabody Developmental Motor Scales—2nd edition13 would have been used to formally assess the infant's gross motor skills. Participation status was determined through maternal interview and included the infant spending approximately 20 minutes each day in the prone position, breastfeeding alternating sides with minor difficulties feeding from the left breast, sleeping in the supine position with the head turned primarily to the left, and positioning in equipment occasionally throughout the day. The mother further reported regularly encouraging the infant to actively turn his head to the right.
Consistent with AS12,1 information gathered in the examination related to age, severity, comorbidities, and perceived adherence to home activities was used to determine the infant's prognosis. The infant in this case was 2 months old at the start of intervention, was classified at a grade I: Early Mild on the CMT Classification scale,1 did not have any significant comorbidities, and had parents who appeared to be committed to attending scheduled intervention sessions and carrying out home programming. Therefore, his prognosis in regard to full resolution of symptoms was felt to be excellent.
DESCRIPTION OF THE INTERVENTION (ACTION STATEMENTS 13 to 15)1
Intervention was initiated within the examination session immediately following completion of examination procedures.1 As outlined in AS13,1 the 5 first-choice interventions were used: neck PROM, neck and trunk AROM, development of symmetrical movement, environmental adaptations, and parent education. As outlined in Table 2, neck PROM was targeted through a variety of low-intensity, sustained, pain-free stretches14 to help improve right cervical rotation and left lateral flexion. Caregiver instruction was provided regarding the importance of prone play when the infant was awake, environmental adaptations to promote active head and neck movements (such as alternating the infant's position in the crib), and instruction in a home exercise program (HEP) consisting of the stretches previously described. Individual intervention sessions were initiated 4 weeks following the examination and were scheduled one time per week for 12 weeks to accommodate the family's schedule. The plan of care focused on improving cervical PROM, AROM, development of symmetry, and caregiver instruction regarding the HEP and environmental adaptations. Desired outcomes included symmetrical active and passive cervical rotation and lateral flexion, improved midline head positioning during play, and attainment of developmentally appropriate gross motor skills. At each intervention session, PROM and AROM were visually monitored in all developmentally appropriate positions to ensure that the infant was responding to interventions as anticipated.
Several techniques were used to promote symmetrical active neck and trunk movement. Active rotation via tracking toys or other objects in supine, prone, and supported sitting positions was used to help the infant integrate his increasing available AROM into his activities.15 Facilitated head righting on a therapy ball was used to increase active use of the left cervical lateral flexors, as his body was tilted toward the right. Pull-to-sit activities from the supine into sitting positions and subsequent reverse pull-to-sit with appropriate chin tuck and head in midline were used to promote concentric and eccentric control of the neck flexors. Activities in developmentally appropriate positions such as prone-on-elbows and later prone-on-extended elbows were performed to increase weight bearing through the upper extremities. The infant was also assisted in reaching for his toes in the supine position to promote recruitment of the lower abdominal muscles.
Development of symmetrical movement and participation in perceptual-motor experiences were promoted through facilitation of rolling prone to supine positions and later supine to prone positions over each side, prone-on-elbows (initially with chest support to improve tolerance of prone), and reaching in prone-on-elbows at and below shoulder height. As intervention progressed, unilateral reaching with each upper extremity in both prone-on-extended elbows and prop sitting were added. During each session, the PT monitored equal use of upper and lower extremities during play and facilitated weight shifting and alignment to improve any asymmetries when reaching with either upper extremity. Gross motor skill development and skill quality were monitored at each intervention session to ensure that the infant was responding as anticipated to interventions.
Environmental adaptations (such as reducing the amount of time the infant spent in an infant carrier) and parent education were linked throughout the intervention sessions.1 The infant's mother was instructed to promote active cervical rotation to the right by placing toys or approaching the infant on the right. The mother was observed performing these strategies in session. She also taught her other children to approach the infant from his right side. The infant was placed in different positions (supine, prone, supported sitting, forward propped sitting, lateral propped sitting, and side-lying positions) for play throughout the session,1 and the mother was encouraged to use these same positions at home. The positions not only reduced the time the infant spent in supine,1 but provided a variety of perceptual-motor experiences designed to facilitate overall development and age-appropriate participation within the home environment.15 Caregiver education stressed the importance of achieving the desired outcomes through the HEP.1 The mother was provided with new handouts and recommendations for activities at every session and reminded about the need to be consistent with stretches and other home activities to improve and maintain full cervical PROM.
The infant responded well to the use of first-choice interventions and therefore use of supplemental interventions (as outlined in AS141) was not required. Given the infant's progress and absence of red flags, consultation with the infant's pediatrician and other specialists was not indicated, as defined in AS15.1
DESCRIPTION OF OUTCOMES (ACTION STATEMENTS 16 and 17: DISCONTINUATION, REASSESSMENT, AND DISCHARGE1)
As stated in AS16,1 criteria for discharge from physical therapy include full, symmetrical PROM (within 5° of the nonaffected side), symmetrical active movement throughout the available passive range; age-appropriate motor development, lack of visible head tilt, and parental understanding of what to monitor as the child grows. At the time of discharge, the infant had achieved the desired outcomes and demonstrated a 0.24° right tilt in the supine position, as assessed using the ScreenScales. As noted in Table 1, full and symmetrical cervical rotation and lateral flexion PROM, and full cervical AROM were attained. Due to the slight asymmetry in his active lateral flexion, the mother was encouraged to continue working on this in the HEP. The infant was able to reach at shoulder height in prone-on-elbows and roll supine to and from prone positions over both sides independently. He required minimal assistance to reach while in prone-on-extended elbows and was able to maintain a sitting position with contact guard assistance. Education was provided to the mother regarding the appropriate sequence of gross motor development and the need to monitor symmetrical development of motor skills.1 The infant attended a total of 12 sessions (1 examination session and 11 intervention sessions) and was approximately 6 months old at the time that direct physical therapy services were discontinued. Occasional appointments were missed due to illness and a family vacation; therefore, the 11 intervention sessions occurred over a 16-week period.
Per AS17,1 reassessment of the infant is provided 3 to 12 months after discontinuation of direct physical therapy services. The infant was scheduled and seen for a follow-up 7-weeks postdischarge. He presented with a midline head position and age-appropriate motor skills per informal assessment. Reassessment was again performed when the infant was 20 months old and had been walking for several months. Full cervical PROM and AROM were noted bilaterally with a Muscle Function Scale score of 4 bilaterally. Age-appropriate motor skills were performed without asymmetry. The child was therefore discharged from all physical therapy services.
This case report illustrated application of the CMT CPG1 in an outpatient pediatric facility. The CMT CPG1 provided a framework for infant management starting with the initial examination and ending with discharge recommendations. Desired outcomes were achieved within a total of 11 intervention sessions over a 16-week period. This duration of care and achievement of desired outcomes is consistent with the CMT CPG1 guidelines for duration of care (range from 1.5 months to up to 9-10 months). Per the CMT CPG,1 the duration of care is dependent on the infant's age at the onset of intervention (ie, infants <1 month old at the onset of intervention typically require shorter durations of care than infants who are >6 months old at the onset of intervention).16 When PT interventions are initiated within 1 to 2 months of age, an intensive stretching program has been found to have a 100% success rate in resolving CMT over a 2- to 4-month period.17
Utilization of the CMT CPG1 for this case report, and with other infants with CMT in our clinic, helped to identify beneficial changes in facility-wide procedures related to examination. For example, at the time of this case report, the standard procedure in the clinic was to visually estimate cervical PROM and AROM. Experiences with the CMT CPG lead to clinic-wide use of an arthrodial protractor and the Muscle Function Scale12 to assess PROM and AROM.12 Action statements related to examination of participation status (AS111) and reassessment following discontinuation of direct physical therapy services (AS171) were also identified as areas for improvement. Identification and implementation of improvements in clinical procedures are consistent with the application of the CMT CPG and may positively influence PTs' knowledge and practice when examining and treating specific infant populations.18 , 19
Using the CMT CPG1 facilitated evidence-based practice by summarizing and outlining the evidence necessary to optimize care. A recent survey of 282 pediatric PTs explored the uptake of the 2013 CMT CPG20 by PTs and found that the CMT CPG was implemented by more than 50% of the respondents.21 Survey respondents in this study suggested ways to improve knowledge brokering that included continuing education related to changing practice on individual and system-wide levels and the creation of a CMT CPG1 toolkit containing the tools necessary to perform the examination outlined in the CMT CPG. Respondents further stated a desire for more information on how to use each tool within the CMT CPG.1 Documentation templates22 reflecting the CMT CPG may also assist in uptake of the CMT CPG.1
This case report lacks the control of a research study. There are possible alternative explanations for the achieved outcomes. This case was further limited by the unknown psychometric properties of the ScreenScales, using visual estimation methods of cervical PROM and AROM, and not using logs to track family compliance with the HEP and environmental adaptations.
WHAT THIS CASE ADDS TO EVIDENCE-BASED PRACTICE
Given that perceived lack of time has been identified as the main barrier to PTs' use of clinical guidelines,9 this case illustrates how the recommendations outlined in the CMT CPG1 can be implemented throughout an episode of care without placing an undue time burden upon a therapist. In conclusion, the CMT CPG1 offers a step-by-step, clinically relevant process for implementing each action statement and provides an impetus for clinical facilities to identify and implement best practice procedures that reduce the variability and increase consistency of care for infants with CMT.
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