Assessment and management of torticollis in infancy: A survey of current physiotherapy practice

Abstract

BACKGROUND: Torticollis in infancy is frequently managed by physiotherapists working in paediatrics. However, the assessment and physiotherapy treatment of torticollis in infancy has not been reported adequately in the literature.

OBJECTIVES: To explore the assessment and management of infants with torticollis by physiotherapists in Ireland.

METHODS: An online survey was conducted among members of the Irish Society of Chartered Physiotherapists’ clinical interest/employment groups, specifically: Chartered Physiotherapists in Community Care; Chartered Physiotherapists in Paediatrics; Chartered Physiotherapists in Private Practice; and Chartered Physiotherapists in Women’s Health and Continence.

RESULTS: Sixty-seven physiotherapists completed the survey. There was a high level of agreement amongst physiotherapists regarding what subjective information is sought at initial assessment. However, there was less agreement on the nature of the objective assessment. There was a high level of agreement in the use of assessment techniques for both cervical spine range of motion and posture, with the vast majority of respondents using visual estimation for both. The most common treatment techniques used are positioning, handling and neurodevelopmental facilitation.

CONCLUSIONS: This study explored the physiotherapy assessment and management of torticollis in infancy in Ireland. This survey identified that there was a lack of consensus on the objective examination used with infants. It is recommended that physiotherapists include screening for fine motor and hip asymmetries in their assessments and that a pathway of care is developed including access to further specialists and investigations.

Keywords

Congenital Muscular Torticollis Postural Torticollis physiotherapy assessment management

1 Introduction

Torticollis is a condition of infancy which is frequently referred to physiotherapists working in the area of paediatrics. It is a clinical sign of asymmetric neck function which may be the result from a variety of underlying disorders [1 –3], however, the two main causes are Congenital Muscular Torticollis and Postural Torticollis.

Congenital Muscular Torticollis (CMT) results from an insult to the sternocleidomastoid (SCM) muscle, which may result in a fibrotic lump or ‘pseudo-tumour’. It is thought to be a result of venous occlusion caused by intra-uterine constraint, which leads to fibrosis of the muscle, similar to a compartment syndrome [1, 4]. The ‘pseudo-tumour’ tends to present at 2-3 weeks of life and usually starts to resolve from four months, but may leave non-contractile tissue [5]. CMT is the third highest occurring congenital abnormality in infants, after developmental dysplasia of the hip and talipes-equinovarus. Depending on the diagnostic criteria, the incidence of CMT ranges from 0.3% to 1.9% of newborns [4] but more recently has been reported as high as 16% [6]. CMT involves shortening or excessive contraction of the SCM muscle with reduced cervical spine (CSp) ipsi-lateral rotation and contra-lateral side flexion, and is associated with complex deliveries, breech presentation and hip dysplasia [2, 4].

Postural Torticollis (PT) results from asymmetry of the cervical musculature, without any morphological changes, but secondary to asymmetric positioning and use. One common cause is plagiocephaly, which is flattening of one side of the skull due to external pressure [7, 8]. In both Congenital and Postural Torticollis the asymmetric neck function may be the most obvious clinical feature, but this may have subsequent effects on other aspects of the infant’s development, such as cranio-facial, musculoskeletal and neuro-developmental effects [4 , 9–12].

While muscular dysfunction is the most common reason for torticollis, there are a host of other possible causes ranging from bony, neurological or inflammatory conditions to benign paroxysmal torticollis [1–3 , 13]. Needless to say a detailed and thorough assessment of the infant presenting with torticollis is essential to diagnose appropriately, rule out ‘red flags’ and develop a management plan. An extensive guideline was developed by the American Physical Therapy Association [14]. Recommendations are given for a multi-system assessment of the infant.

Although a variety of tools exists for the assessment of CSp in adults these are often not suitable for use in infants. Active and passive ROM are often mentioned as being used in the assessment of torticollis in infancy, but the details given vary widely. Some articles refer to ROM as being an outcome measure, but give limited detail about the technique used [15 –17]. Others give more details of the assessment but have not tested reliability [8 , 18–21].

A number of measures have been found to be reliable in the assessment of the cervical spine in infants with torticollis. These include measurement of passive cervical ROM using a goniometer and arthrodial protractor [22, 23]; an observational scale for measuring side flexor muscle strength in lateral head righting [24]; and still photography for measuring postural side flexion in supine [25]. Despite these tools being described in the literature, studies have reported that more than 90% of paediatric physiotherapists use visual estimation to assess cervical ROM, with reliable measures such as goniometry only being used by 14–16% [26, 27].

Physiotherapy is an integral part of the conservative management of torticollis in infancy [7]. Earlier studies focussed more on passive stretching [4 , 28–30] whereas more recent studies have included a broader, neuro-developmental approach [10–12 , 31]. van Vlimmerman et al. [7] advise that treatment should be focussed on symmetrical motor development and incremental active ROM of the CSp. These authors do not advise passive manipulations or passive manual stretching to increase ROM, especially when pain is provoked, rather they advise prolonged, low-intensity stretching without pain. In terms of treatment duration, early intervention [15 , 29–32] and being treated by an experienced physiotherapist versus the parents [33] have been found to be more effective. In their evidence-based Clinical Practice Guideline, Kaplan et al. [14] reported five components of first choice intervention: CSp passive ROM; CSp and trunk active ROM; development of symmetrical movement; environmental adaptations; and parent education. Further interventions with weaker evidence were recommended, but only if the therapist was skilled in that specific technique e.g. kinesio-taping. Interventions without evidence were not recommended e.g. soft tissue massage and cranio-sacral therapy.

Given the variability in practice and limited investigation of physiotherapy management of torticollis the aim of this study was to survey Irish physiotherapists working with torticollis of infancy, to determine their assessment and management techniques.

2 Methodology

Permission was granted by Luxford [26] to use the questionnaire they had developed in New Zealand and which had subsequently been used with Swedish physiotherapists by Ohman et al. [27]. This questionnaire contained five sections: general/demographic details of the physiotherapists; information specific to subjective assessment of CMT; information specific to objective assessment of CMT; differential diagnosis; treatment techniques used in the management of CMT. The questionnaire was modified for the Irish health care environment and some slight modifications were made to some questions to gain more qualitative information. The questionnaire was piloted on five paediatric physiotherapists who had experience of torticollis. It was converted to an online, self-administered format, using the online software tool ‘Survey Monkey’^®. The research proposal and questionnaire were approved by the Scientific and Ethics Committees of Temple Street Children’s University Hospital (Ref. 13.032).

Permission was granted by the ISCP to contact members of the employment/clinical interest groups: Chartered Physiotherapists in Community Care; Chartered Physiotherapists in Paediatrics; Chartered Physiotherapists in Private Practice; and Chartered Physiotherapists in Women’s Health and Continence. These were felt to be the main groups of physiotherapists that would treat infants with torticollis.

An invitation to participate was distributed to these physiotherapists via the ISCP group e-mail distribution lists, with instructions and a direct link to the online survey. Definitions for CMT and PT were given. In order to be included in the study the physiotherapist must have seen at least one infant (aged up to 24 months) with a diagnosis of torticollis (as per the provided definitions) within the past 12 months. The link to the survey was available between November 2013 and February 2014.

Quantitative data was analysed using descriptive statistics with the use of Microsoft Office Excel 2010 for Windows. Qualitative data was analysed by content analysis and development of themes [34].

3 Results

The invitation to participate was emailed to members of the ISCP subgroups, of which there were 67 responses. It was not possible to determine the response rate due to the nature of the data collection (i.e. online survey).

3.1 Demographics

Respondents worked in 74 settings (i.e. more than one answer was permitted). Most physiotherapists worked in the community setting (58%), but Fig. 1 demonstrates that infants with torticollis were managed across a range of settings.

In terms of their experience, respondents reported a mean of 14.4 years’ post-graduate experience (range 3–40 years) and 7.2 years’ paediatric experience (range 1–27 years). With respect to their caseload of infants aged≤24 months with torticollis, the majority of respondents had received 1–10 referrals in the past year and currently had 0–5 on their caseload Referrals came from a number of different sources, predominately Public Health Nurses (62.1%) or Paediatricians/Neonatologists (51.5%), but also from General Practitioners (34.8%), other physiotherapists (22.7%), directly from the parents (18.2%), Area Medical Officers (15.2%) and other specialists (6.1%)

3.2 Assessment

Respondents were asked to indicate how frequently they would obtain suggested information in both their initial subjective and objective assessments of an infant with torticollis. The results are summarised in Tables 1 and 2.

Table 1 describes the information collected during the subjective examination. The majority of respondents always used all but one (Apgar Score) of the 19 given options suggested in the online survey. Respondents also reported that they collected information related to: parental concerns; any exercises already being done; thumb-sucking; parental hand dominance; orientation of cot; hearing; and engagement of the infant. Information gathered less frequently was: Apgar scores; birth weight; history of a pseudo-tumour and feeding patterns/difficulties.

Table 2 outlines information collected during the objective examination. Again there was a high level of agreement amongst respondents, with ‘always’ being the most frequent response to all of the 16 given options presented in the online survey. Additional information collected during the objective examination included: parental handling; the infant’s affect/social interaction; eye contact; and the Alberta Infant Motor Scale (AIMS). Respondents also commented that the objective measures used would depend on the age of the infant. Only nine of the 16 options had high use (≥80% often/always): head tilt; head shape; cranio-facial changes; palpation of SCM muscle; passive CSp side flexion; passive CSp rotation; active CSp rotation; lateral head righting; and gross motor function. The information gathered less frequently was: CSp flexion/extension; trunk ROM; thigh crease symmetry; hip ROM; postural asymmetry; postural reactions and fine motor function.

Respondents were asked to indicate how frequently they would use suggested tools in both their assessment of CSp range of motion and CSp posture (e.g. head tilt) in an infant with torticollis.

In terms of assessment tools used, the results were similar for the assessment of the CSp ROM and CSp posture, in that the vast majority of respondents (91%, n = 61) always used visual estimation. Photography was used to a lesser extent (33%, n = 16 sometimes/often), however, some therapists reported that they recommend the parent to take videos/photographs on their own camera. The other four suggested tools (Goniometer, Goniometer with spirit level, Arthrodial protractor and Video recording) were rarely used.

3.3 Management

Respondents were asked to indicate how frequently they would use suggested treatment techniques in an infant with torticollis. The results are presented in Table 3 and are more diverse than the results of the assessment. The most frequently used treatments (≥80% often/always) were: teaching parents handling to achieve a stretch; advice on handling while awake and on positioning while asleep; facilitating active CSp movement; and gross motor stimulation. Information hand-outs were provided often/always by 83.6% of respondents. Passive stretches were performed often/always by 37.3% and taught to parents by 46.3%. Facilitation of postural reactions was performed often/always by 61.2% whereas facilitation of postural symmetry by 70.1%. Gross motor stimulation was performed often/always by 86.6% whereas fine motor stimulation by 52.2%. Comments regarding the use of a pressure device (e.g. pillow) suggested that they should not be used if the infant was sleeping /unsupervised. Further information on passive stretching was provided by 32 respondents, regarding the infant, the parent and the actual technique.

Finally, respondents were asked to describe any other issues they had regarding the assessment and management of infants with torticollis. Fifteen respondents reported a range of issues ranging from access to further referral/investigations; the need for follow-up after discharge and the need for more clinical support.

In summary, of the 67 respondents, there was broad consensus around the information gathered during the subjective examination with slightly more variability on the data collected during objective examination. Visual estimation was virtually universally used during assessment; however, there was more variability in treatment interventions. The most common treatment interventions were positioning, handling and neuro-developmental facilitation. Further information was given on the use of passive stretching.

4 Discussion

This study explored the current assessment and management of infants with torticollis by physiotherapists in Ireland. Respondents worked in a variety of settings but the majority were based in the community, and this was reflected in the highest referral source being Public Health Nurses. Regarding the number of referrals received and the current caseload of infants with torticollis, the results of this study would suggest that for most respondents, torticollis is a relatively small proportion of their clinical workload. In general, respondents were experienced, although less so than the physiotherapists in the similar studies of New Zealand and Swedish physiotherapists [26, 27].

With respect to the assessment, there was a high level of agreement on the subjective information obtained but more variation in the items collected during objective assessment. It is of note that fewer than half of respondents consistently observed thigh crease symmetry and only just over half measured hip ROM routinely, despite the high co-existence of hip dysplasia with torticollis. It is recommended that those assessing an infant with torticollis should also screen for hip asymmetry [14 , 27]. Fine motor skills were assessed less than gross motor skills. Physiotherapists should assess fine motor skills - not only to assess for upper limb asymmetry secondary to a head preference, but also to rule out any primary neurological cause (e.g. hemiplegia, brachial plexus injury) which might have led to the head preference [1 , 27].

As has been previously reported [14 , 27] the vast majority of respondents used visual estimation as their main assessment tool, the only other tool used being photography. Visual estimation has been studied in the adult population and found to have poor reliability [35 –38], however, it has not been tested for reliability in this patient group. Paradoxically, some of the other, less frequently used assessment tools have been demonstrated to have greater reliability [22 –25].

The finding of the current study in terms of assessment and treatment of infant torticollis are broadly similar to previous studies with New Zealand and Swedish physiotherapists [26, 27]. Information gathered in the subjective and objective assessments were broadly similar across all three studies and in terms of the assessment tools used, Irish physiotherapists were similar to their New Zealand and Swedish counterparts, in that the vast majority used visual estimation, although the Swedish physiotherapists used more photography, and they had also included the use of a ‘large protractor’ in their study [27], which was their second most preferred assessment tool.

Treatment techniques focused mostly on positioning, handling and neuro-developmental facilitation. There was also a strong emphasis on advice for, and teaching of, parents. New Zealand [26] and Swedish [27] physiotherapists used more and taught more passive stretches than Irish physiotherapists – however, in the New Zealand and Swedish studies [26, 27] respondents were only asked about CMT, which tends to be more severe than PT. Of the comments made by Irish physiotherapists regarding passive stretching, the emphasis was on the calm state of the infant, the technique being gentle/without resistance, and the infant’s trunk/shoulder being stabilised. A recurrent theme, which arose in the current study regarding passive stretches and in general, was the need for physiotherapists to have access to further specialised assessments and investigations.

4.1 Limitations of the study

The sample size was relatively small and only captured the information from chartered physiotherapists within the four targeted subgroups of the ISCP. The sample was also self-selected so may not be representative of all those who met the criteria to participate. It was also a self-reporting which may have resulted in some bias.

5 Conclusion

This study surveyed 67 physiotherapists in Ireland regarding their assessment and management of infants with torticollis (CMT and PT). There was a high level of agreement amongst respondents in the subjective information sought at initial assessment. There was more variation in the objective assessment and it is recommended that physiotherapists include hip ROM/symmetry and fine motor skills in their objective assessment of these infants. There was also a high level of agreement in the use of assessment tools for CSp ROM and CSp posture, with the vast majority using visual estimation. The use of treatment techniques varied, the most common being positioning, handling and neuro-developmental facilitation. Passive stretches are used, but the comments given regarding technique indicated a level of awareness of the issues to be considered when performing or teaching passive stretches. There is a need for physiotherapists treating infants with torticollis to have a pathway of care and access to further specialists and investigations. A torticollis assessment with guidelines has been developed in Ireland by the Torticollis Working Group of Chartered Physiotherapists in Paediatrics and it is recommended that this be used by physiotherapists in order to provide consistency of assessment.

Conflict of interest

The author has no conflict of interest to report.

Footnotes

Acknowledgments

The author wishes to thank all the physiotherapists who responded to and assisted with the questionnaire, in particular Caitriona Conneely, Eimear Culligan and Judith O’Connell. The expertise of the Torticollis Working Group, Chartered Physiotherapists in Paediatrics, was very much appreciated. Funding was gratefully received from the Physiotherapy Department Research Fund, Temple Street Children’s University Hospital, Dublin.

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