PT 7336 Neuroscience II: Pediatrics

1. PT 7336 Neuroscience II: Pediatrics Case Study III Kristen Gaddis & Jacob Garza

2. Case Study III • Male infant…let’s call him Bob • 19 yr old mother without insurance (low socioeconomic status) • Right cervical rotation • Left cervical flexion • Misshapen head

3. Torticollis • Derived from Latin terms tortus (twisted) and collum (neck). • Preferential posturing of the head and neck to one side. • Asymmetrical cervical movements. • Can be present at birth or develop within the first few months of life due to an imbalance of muscle control or preference of lying on one side.

4. Torticollis Multiple etiologies: • Congenital muscular torticollis (CMT) unilateral fibrosis of the sternocleidomastoid • Underlying neurologic disorder including CNS lesions and brachial plexus damage • Inflammatory illnesses example: pharyngitis • Positional torticollis (PT) persistent positional preference of the head in supine lying

5. Which does Bob have? Since the physician noted the asymmetrical posturing so early in our patient, this finding mostly correlates with congenital muscular torticollis (CMT).

6. Congenital Muscular Torticollis • Possible causes • Breech and forceps delivery, vacuum extraction, and cesarean section • Predisposing factors • Restrictive intrauterine environment, poor muscle tone, or cervical-vertebral abnormalities

7. Congenital Muscular Torticollis Four Types of CMT • Type I (15%) • Fibrotic mass in sternocleidomastoid (SCM) • Type II (77%) • Diffuse fibrosis mixed with normal muscle tissue • Type III (5%) • Fibrotic tissue without normal muscle • Type IV (3%) • Fibrotic cord

8. Again…which does Bob have? After the physician ordered an ultrasound of his left SCM, it revealed that Bob has… Type II Congenital Muscular Torticollis (diffuse fibrosis mixed with normal muscle tissue)

9. What else is troubling Bob? • In 1992, the Back to Sleep campaign was initiated to tell mothers to place their infants on their back while sleeping to prevent SIDS (sudden infant death syndrome). • Since Bob’s head can only face to the right while lying supine during sleep, this caused his head to become misshapen.

10. Plagiocephaly • An asymmetrical condition of the head arising from extrinsic molding. • In many cases, flattening of the occipital skull results in ipsilateral protrusion of the frontal bone and ear and facial asymmetry.

11. Let’s get back to Bob

12. Examination Physical Examination • Alert and active • Asymmetrical posturing of head and neck • Palpation of left SCM reveals no mass • Flattened left aspect of occipital bone and protrusion of left frontal bone(measurement to follow) • Peripheral pulses intact • Cervical ROM limited in L rotation and R lateral flexion, asymmetrical flexion and extension • AIMS- 50th percentile

13. Examination Neurologic Examination • Awake • Normal primitive reflexes present • Rooting, plantar grasp, flexor withdrawal, etc. • Normal muscle tone • Sensory and Motor components of CN intact

14. Measuring Plagiocephaly • Anthropometric measurements • Cranial vault asymmetry (CVA) • Cranial base asymmetry (CBA) • Orbitotragial depth asymmetry (OTDA) • Computed Tomography • 3D photogrammetry

15. Anthropometric Measurements

16. Computed Tomography STARscanner

17. Pathology Plagiocephaly-torticollis deformation sequence • Torticollis is a contracted state of the sternocleidomastoid muscle • 0.6-400 per 100,000 live births • When the deformity is severe it often leads to plagiocephaly

18. Evaluation: Disablement Model Pathophysiology- Plagiocephaly-torticollis deformation sequence Impairment- decreased cervical range of motion Functional Limitation- patient unable to rotate head to left Disability- unable to play with toys, decreased interaction with parents and siblings. Societal Limitations- uninsured mother, social worker applying for medicaid

19. Prognosis • Congenital muscular torticollis usually resolves with conservative treatment. • Complete recovery can take approximately 3 to 12 months with fewer than 16% requiring surgery. • If left untreated, can result in persistent deformity and asymmetry of the head shape

20. APTA Practice Patterns 4B: Impaired Posture 4C: Impaired Muscle Performance 4D: Impaired Joint Mobility, Motor function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction 7A: Primary Prevention/Risk Reduction for Integumentary Disorders

21. Goals • LTG: Pt to achieve full active cervical range of motion in 3 months to be able to have full interaction with environment and prevent further cranial asymmetry. • STG: Pt to achieve passive midline position in 3 weeks • STG: Pt to achieve active midline position in 6 weeks • LTG: Pt to achieve symmetrical cranial shape in 6 months to promote proper growth. • STG: Pt to achieve a decrease in CVA of 2 mm in 3 months.

22. Intervention

23. Intervention • Physical therapy to address the contracted SCM. • Warm compression, massage, slight traction to relax muscle • Passive stretching twice daily • Active and active-assistive exercises for acquisition of skills • Turning head towards involved side • UE reaching on ipsilateral side • Weight-shifting of trunk • Rolling

24. Intervention • Home exercise program • Sustained side-to-side and ear-to-shoulder stretches • Positioning child to look towards affected side to see and play with toys • Implement regular “tummy time” • Family education • Stretching safety- too much strain causes micro-traumata which results in more fibrosis

25. Intervention • Repositioning to address plagiocephaly • NightForm positioning bed • Use rolled towel under babies back to keep head on rounded unaffected side of skull

26. Intervention • Cranial Orthosis to address plagiocephaly • Worn 15-23 hours a day • After improvement following 3-4 months of therapy, pt wears helmet only at night • Tx generally recommended for children 6-18 months of age

27. We haven’t forgotten mom • Support system- Father? Parents? • Income- Paid leave? If working, childcare? • Modify treatment plan to best utilize available resources • Align priorities with mom and be sensitive to her unique circumstances • Be an advocate for Bob’s care • Constant communication with social work • Writing letters to get Bob’s treatment or equipment covered

28. Medicaid Clients • In Texas families and children are eligible for full benefits if… • The household income is below a certain level • Bob’s mother is unemployed and does not have insurance • Social worker is applying for Medicaid for Bob

29. Current Research Topics of research • Therapeutic strategies • Long-term effectiveness of cranial orthotics • Enriching care to patients with low income

30. References • Goodman CC, Boissonnault WG, Fuller KS. Pathology: Implications for the Physical Therapist. Pennsylyvania: Saunders; 2003. • Karmel-Ross K. Torticollis: differential diagnosis, assessment and treatment, surgical management and bracing. New York : Haworth Press; 1997. • Vlimmeren L, Helders P, Van Adrichem L, Engelbert R. Torticollis and plagiocephaly in infancy: Therapeutic strategies. Pedi Rehab. 2006;1:40-46. • Bialocerkowski A, VLadusic S, Choong W. Prevalence, risk factors, and natural history of positional plagiocephaly: a systematic review. Dev Med &Child Neuro. 2008;50:577-586. • Celayir AC. Congenital muscular torticollis: early and intensive treatment is critical. A prospective study. Pediatr Int. 2000;42:504-507. • Lee R, Teichgraeber J, Baumgartner J, et al. Long- term treatment effectiveness of molding helmet therapy in the correction of posterior deformational plagiocephaly: a five-year follow-up. Cleft Palate-Craniofacial J. 2008;45:240-245. • Klackenberg EP, Elfving B, Haglund-a Y, Kerlind, Carlberg EB. Intra-rater reliability in measuring range of motion in infants with congenital muscular torticollis. Advances in Physiotherapy. 2005; 7: 84-91.

31. References 8. Luther BL. Congenital muscular torticollis. Ortho Nursing. 2002;21:21- 28. 9. Parikh S, Craford A, Choudhury S. Magnetic resonance imaging in the evaluation of infantile torticollis. Orthopedics. 2004;27:509-515. 10.McGarry A, Melville T, Greig R, Hamilton D, Sexton S, Smart H. Head shape measurement standards and cranial orthoses in the treatment of infants with deformational plagiocephaly. Dev Med & Child Neuro. 2008;50:568-576. 11.Cheng JC, Wong MW, Tang SP, Chen TM, Shum SL, Wong EM. Clinical determinants of the outcome of a manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases. J Bone Joint Surg Am. 2001;83:679-687. 12.Bhattacharya D, Choudhari K. ‘Idiopathic’ torticollis: have you ruled out a spinal tumor? British J Hospital Med. 2008;69:412-413. 13.Ries E. Enriching Care to Patients with Low Income. PT Magazine. 2007;26-29. 14.Health and Human Services Commision. Texas Medicaid Program Information. 2008. Available at: http://www.hhsc.state.tx.us/medicaid/med_info.html. Accessed March 5, 2009.