Torticollis and Associated Problems

Torticollis is not simply a diagnosis, but a sign of an underlying disorder. Torticollis means �twisted neck� and describes an abnormal neck posture with persistent rotation of the head to one side and lateral flexion to the opposite side. There are over 80 differential diagnoses which may cause a torticollis posture.

The incidence of torticollis has increased dramatically since the AAP �Back to Sleep� campaign was launched. The incidence used to be 1 in 300 and some recent studies report the incidence is now 1 in 60. Also another study reports that 57% of twins have torticollis.

Torticollis can be congenital (occurring during or shortly after birth) or acquired (caused by the environment). Congenital torticollis can be caused by a tearing or stretching of the SCM (sternocleidomastoid ) muscle, a shortening of the muscle, a fibrotic tumor or a cervical spine abnormality. Some associated problems include hip dysplasia, club foot, metatarsus abductus or a brachial plexus injury. Acquired torticollis can be plagiocephaly induced-a flat spot on the head causes the child to rotate to that side when lying on their back. It can be positionally induced for babies that spend time lying on their backs in swings, bouncers, car seats, or due to swing/crib placement within a room. It can be caused by an infection that inflames the lymph nodes in the neck. It can also be induced by vision problems or even reflux.

Some associated problems related to torticollis include:

• Delayed motor development
• Visual disturbances (visual field, astigmatism)
• Orthodontic and jaw problems (TMJ)
• Auditory problems
• Oral motor problems (jaw/tongue alignment, muscle strength)

Children with torticollis may exhibit postural asymmetry. Most children with torticollis show a left head tilt, with a right head turn. Their left shoulder may be elevated, left arm internally rotated and left hand may be fisted. Their trunk may show lateral flexion to the left, like a �C� position. They may sit on the right buttock and prefer to side-sit to the right side. They may also transition only to the right side.

Neck active range of motion may be decreased. They may be unable to equally rotate their head to the left and right sides and may have unequal head righting reactions when tipped sideways. Some children have decreased use of upper extremities, fisting, and problems with reaching overhead or poor fine motor coordination. This can cause difficulty with rolling, crawling, pulling to stand and walking.

Some children with torticollis also have oral motor problems. They may have an open mouth posture. Their tongue may be pulled to one side. They may have trouble with jaw closure/alignment. All these issues will affect feeding.

Children may have facial asymmetry such as the left forehead being more prominent, left ear being pushed back, left eye more prominent, left cheek more rounded and the right side of the chin flattened.

How do physical therapists treat torticollis? They use a variety of stretching & strengthening exercises that incorporate both passive and active range of motion. Tummy time is very important and there are many ways of positioning and carrying children that promote strengthening, stretching and use of the non-preferred side.

The suggested timeline for intervention is as follows:

• 0-2 months: prevention strategies, screening at �well baby� check ups, referral if tightening of neck or flattening of head is noticed
• 1-5 months: stretching, strengthening, repositioning, symmetry of movements
• 4-12 months: continue same as above, but if persistent head flattening is noted begin helmet treatment, or if head tilt continues try a TOT collar
• Over 12-14 months: the window for helmet treatment closes, but other interventions can be continued.

The TOT collar goes around a child's neck to prevent head tilt/turn. One study showed 8.5 degrees of improvement with use and stretching, while only a 3.9 degree improvement with stretching alone.

If you suspect your baby may have torticollis or plagiocephaly (head appears flat on back or sides) see your pediatrician and make a referral to early intervention as soon as possible.

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