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16 estudios científicos, en su idioma original (casi todos en inglés).
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Asymmetry in infancy is a clinical condition with a wide variation in appearances (shape, posture, and movement), etiology, localization, and severity. The prevalence of an asymmetric positional preference is 12% of all newborns during the first six months of life. The asymmetry is either idiopathic or symptomatic. Pediatricians and physiotherapists have to distinguish symptomatic asymmetry (SA) from idiopathic asymmetry (IA) when examining young infants with a positional preference to determine the prognosis and the intervention strategy. The majority of cases will be idiopathic, but the initial presentation of a positional preference might be a symptom of a more serious underlying disorder. The purpose of this review is to synthesize the current information on the incidence of SA, as well as the possible causes and the accompanying signs that differentiate SA from IA. This review presents an overview of the nine most prevalent disorders in infants in their first six months of life leading to SA.We have discovered that the literature does not provide a comprehensive analysis of the incidence, characteristics, signs, and symptoms of SA. Knowledge of the presented clues is important in the clinical decision making with regard to young infants with asymmetry. We recommend to design a valid and useful screening instrument.
Background. Positional plagiocephaly (PP) is a cranial deformation frequent amongst children and consisting in a flattened and asymmetrical head shape. PP is associated with excessive time in supine and with congenital muscular torticollis (CMT). Few studies have evaluated the efficiency of a manual therapy approach in PP. The purpose of this parallel randomized controlled trial is to compare the effectiveness of adding a manual therapy approach to a caregiver education program focusing on active rotation range of motion (AROM) and neuromotor development in a PP pediatric sample.
Methods. Thirty-four children with PP and less than 28 week-old were randomly distributed into two groups. AROM and neuromotor development with Alberta Infant Motor Scale (AIMS) were measured. The evaluation was performed by an examiner, blinded to the randomization of the subjects. A pediatric integrative manual therapy (PIMT) group received 10-sessions involving manual therapy and a caregiver education program. Manual therapy was addressed to the upper cervical spine to mobilize the occiput, atlas and axis. The caregiver educational program consisted in exercises to reduce the positional preference and to stimulate motor development. The control group received the caregiver education program exclusively. To compare intervention effectiveness across the groups, improvement indexes of AROM and AIMS were calculated using the difference of the final measurement values minus the baseline measurement values. If the distribution was normal, the improvement indexes were compared using the Student t-test for independent samples; if not, the Mann-Whitney U test was used. The effect size of the interventions was calculated using Cohen’s d.
Results. All randomized subjects were analysed. After the intervention, the PIMT group showed a significantly higher increase in rotation (29.68 ± 18.41°) than the control group (6.13 ± 17.69°) (p = 0.001). Both groups improved the neuromotor development but no statistically significant differences were found. No harm was reported during the study.
Conclusion. The PIMT intervention program was more effective in increasing AROM than using only a caregiver education program. The study has been retrospectively registered at clinicaltrials.gov, with identification number NCT03659032. Registration date: September 1, 2018.
Aim. To investigate for congenital muscular torticollis (CMT) and positional plagiocephaly (PP) the effectiveness and safety of manual therapy, repositioning and helmet therapy (PP only) using a systematic review of systematic reviews and national guidelines.
Methods. We searched four major relevant databases: PubMed, Embase, Cochrane and MANTIS for research studies published between the period 1999–2019. Inclusion criteria were systematic reviews that analysed results from multiple studies and guidelines that used evidence and expert opinion to recommend treatment and care approaches. Three reviewers independently selected articles by title, abstract and full paper review, and extracted data. Selected studies were described by two authors and assessed for quality. Where possible meta-analysed data for change in
outcomes (range of movement and head shape) were extracted and qualitative conclusions were assessed.
Results. We found 10 systematic reviews for PP and 4 for CMT. One national guideline was found for each PP and CMT. For PP, manual therapy was found to be more effective than repositioning including tummy time (moderate to high evidence) but not better than helmet therapy (low evidence). Helmet therapy was better than usual care or repositioning (low evidence); and repositioning better than usual care (moderate to high evidence). The results for CMT showed that manual therapy in the form of practitioner-led stretching had moderate favourable evidence for increased range of movement. Advice, guidance and parental support was recommended in all the guidance to reassure parents of the favourable trajectory and nature of these conditions over time.
Conclusions. Distinguishing between superiority of treatments was difficult due to the lack of standardised measurement systems, the variety of outcomes and limited high quality studies. More well powered effectiveness and efficacy studies are needed. However overall, advice and guidance on repositioning (including tummy-time) and practitioner-led stretching were low risk, potentially helpful and inexpensive interventions for parents to consider.
Purpose An association between congenital muscular torticollis (CMT) and developmental dysplasia of the hip (DDH) has been established in the literature; however, whether the screening of patients with CMT for DDH requires hip imaging remains controversial. The purpose of this study is to determine (1) the coexistence rate of DDH requiring treatment in individuals with CMT and (2) if physical exam alone is sufficient screening.
Methods A single-center retrospective chart review was performed among 97 consecutive patients between 1/1/ 2003 and 9/1/2012 with CMT who had hip imaging performed.
Results 12 % (12/97) of patients with CMT had DDH, all requiring treatment. 75 % (9/12) of the patients with DDH had an abnormal clinical exam. Of the three patients with DDH and a normal clinical exam, two patients were presenting for a second opinion after being treated for DDH prior to evaluation. 90 % (9/10) of patients with DDH at the time of presentation had an abnormal hip exam. All 12 patients with hip dysplasia were referred for DDH or DDH with CMT. There were no patients who were referred for CMT alone that had DDH.
Conclusions In the care of a patient with CMT, it is important that the clinician remains vigilant about screening for DDH. An ultrasound or radiograph of the hips should be strongly considered as part of the evaluation of a child with CMT.
Level of evidence. IV.
Torticollis in Latin word means twisted neck and was first defined by Tubby in 1912. [1] Torticollis is the postural deformity of head and neck, which may be acquired or congenital. Acquired Torticollis may be due to trauma, inflammatory, psychogenic or neoplastic. Congenital muscular Torticollis is a postural deformity of head and neck detected at birth or shortly after birth, primarily resulting from unilateral fibrosis & shortening of the Sternocleidomastoid muscle. Torticollis is also known as twisted neck. [2,3,4] The most common Physiotherapy treatment were passive stretch, handling advice, facilitation of neck muscle strength and facilitation of active cervical ROM.
Congenital muscular torticollis (CMT) is a common newborn pediatric muscular deformity of the neck. The purpose of this article is to suggest a clinical algorithm for pediatric clinicians to promote prompt identification and intervention for infants with CMT. Early intervention for a child with CMT at less than 1 month of age yields a 98% success rate by 2.5 months of age, with the infant achieving near normal range of motion. Intervention initiated at 6 months of age or later can require 9 to 10 months of therapy with less success in achieving full range of motion
of the cervical musculature. The clinical algorithm proposed here incorporates the American Physical Therapy Association guideline for CMT to optimize outcomes for the child and reduce health care expenditures. Current evidence and guidelines demonstrate that primary care providers are the primary diagnostic clinicians, while physical therapists are the preferred provider for the treatment of CMT.
Background. Many infants with congenital muscular torticollis (CMT) have deformational plagiocephaly (DP), and a small cohort also demonstrate mandibular asymmetry (MA). The aim of this retrospective study was to evaluate mandibular changes in these infants with previous computed tomography (CT) scans who underwent physical therapy (PT) to treat CMT.
Methods. A retrospective study included patients presenting to a pediatric plastic surgery clinic from December 2010 to June 2012 with CMT, DP, and MA. A small subset of these patients initially received a 3D CT scan due to concern for craniosynostosis. An even smaller subset of these patients subsequently received a second 3D CT scan to evaluate for late-onset craniosynostosis.
Patients were treated with PT for at least 4 months for CMT. Initial CT scans were retrospectively compared to subsequent CT scans to determine ramal height asymmetry changes. Clinical documentation was reviewed for evidence of MA changes, CMT improvement, and duration of PT.
Results. Ten patients met inclusion criteria. Ramal height ratio (affected/unaffected) on initial CT was 0.87, which significantly improved on subsequent CT to 0.93 (P < .05). None of the patients were diagnosed with craniosynostosis on initial CT. One patient was diagnosed with late-onset coronal craniosynostosis on subsequent CT.
Conclusions. We identified a small cohort of infants with MA, CMT, and DP. These patients uniformly demonstrated decreased ramal height ipsilateral to the affected sternocleidomastoid muscle. Ramal asymmetry measured by ramal height ratios improved in all infants undergoing PT.
AIM. The purpose of this study was to assess the prevalence of transient functional motor asymmetry in infants with congenital postural torticollis. METHODS: This was a retrospective review of the medical records of infants with postural torticollis. We analyzed epidemiological, obstetric, perinatal data, physical therapy, physician assessments, and clinical follow-up for two years after diagnosis.
RESULTS. Of 173 children, 44 (25.4%, 95% confidence interval ¼ 19.5 to 32.4) demonstrated functional asymmetry. Demographic and obstetrical data did not differ between the asymmetry/nonasymmetry groups. Delayed motor development (P ¼ 0.01) and plagiocephaly (P ¼ 0.032) were more common in infants with motor asymmetry. No difference was observed in the frequency of referral for further neurological diagnosis between the group with functional asymmetry and that without asymmetry. Among the 44 patients with functional asymmetry, 78% depicted no evidence of torticollis by the age of two years, and the motor asymmetry had disappeared in 82%.
CONCLUSION. Benign, transient functional motor asymmetry occurred in a quarter of infants with congenital postural torticollis. Transient motor delay was also significantly more common in the asymmetry group. In most cases, motor asymmetry and motor delay disappeared by the age of two years. Plagiocephaly was more common in the asymmetry group. Clinician awareness
of this transient asymmetry may have avoided unnecessary diagnostic tests in these infants.
Importance. This is the first report, to our knowledge, of a child with torticollis due to saccular dysfunction.
Observation. An 18-month-old infant with torticollis was referred for postural imbalance and observed rotary nystagmus. The infant had undergone physical therapy treatment of left torticollis for nearly 15 months. Cervical vestibular evoked myogenic potentials (cVEMPs) were recorded to assess saccular function and caloric stimulation and positional and rotational testing were performed
to evaluate other vestibular receptors. The child demonstrated abnormal cVEMP findings, with a lowamplitude response on the left, which indicated leftsided saccular dysfunction. The patient’s rotarytorsional nystagmus suggested positional vertigo secondary to abnormal saccular function.
Conclusions and Relevance: This case highlights that saccular dysfunction should be considered when timely resolution of congenital torticollis is not obtained with physical therapy. Early detection of abnormal saccular function in infants and young children with CPT is necessary to ensure appropriate intervention. Further study needs to be done to confirm our findings.
Background. Although the success of conservative management of congenital muscular torticollis has been well documented, relatively little is known about the determinants of this outcome, such as treatment duration and exercise frequency. The aim of the present study was to define factors related to treatment duration, to compare different frequencies and intensities of home treatment programs and their effect on the speed of recovery.
Methods. The present study was a prospective study of 45 infants (26 male, 19 female) with congenital muscular torticollis referred to the pediatric surgical outpatient during a 1 year period. Following a standardized initial assessment, parents were taught our intensive home treatment protocol, consisting of passive stretching exercises repeated every 3 h.
Results. The mean age at initial assessment was 38.6 days (range 15–120 days). Mean treatment duration was found to be 3.2~1.3 months. All patients were treated by use of our intensive protocol of passive stretching exercises (100% success). No surgery was necessary.
Conclusions. In patients with early treated congenital muscular torticollis, there is no place for surgical treatment. This group of patients can be successfully treated using an intensive protocol of passive stretching exercises. In addition, this treatment protocol has a very short treatment duration compared with other standardized protocols. A successful outcome depends primarily on good cooperation with the parents, especially in developing countries.
Our representation of the visual field is not homogenous. There are differences in resolution not only between the fovea and regions eccentric to it, but also between the nasal and temporal hemiretinae, that can be traced to asymmetric distributions of photoreceptors and ganglion cells. We review evidence for differences in visual and attentional processing and oculomotor behaviour that can be traced to asymmetries of the visual system, mainly emphasising nasal-temporal asymmetries. Asymmetries in the visual system manifest in various measures, in basic psychophysical tests of visual performance, attentional processing, choice behaviour, saccadic peak velocity and latencies. Nasal-temporal asymmetries on saccadic latency seem primarily to occur for express saccades. Neural asymmetries between the upper and lower hemifields are strong and cause corresponding differences in performance between the hemifields. There are interesting individual differences in asymmetric processing which seem to be related to the strength of eye dominance. These neurophysiological asymmetries and the corresponding asymmetries in visual performance and oculomotor behaviour can strongly influence experimental results in vision and must be considered during experimental design and the interpretation of results.
Purpose. To investigate the factors influencing and long-term effects of manual myotomy (MM) occurring during physiotherapy for congenital muscular torticollis (CMT).
Methods. We retrospectively collected the clinical data of children with CMT receiving physiotherapy between 2008 and 2018. The children were divided into manual myotomy (MM) and non-manual myotomy (NMM) groups according to whether MM occurred during treatment. We assessed physiotherapy outcomes in children with CMT using craniofacial asymmetry parameters and the Cheng–Tang rating score. By measuring the ear-eye distance, ear-nose distance, eye-mouth distance, ear-mouth distance, half-head circumference, and half-head top at two sides to evaluate
craniofacial asymmetry. Based on the Cheng–Tang assessment criteria, we recorded the range of rotation, range of lateral flexion, the status of the contracted muscle, the hardness of the mass, the extent of head tilting during activities and sleeping, the status of daily activities, face size, type of head shape, cranial changes, and subjective head tilting to assess the effectiveness of treatment. Clinical data and outcome indicators (craniofacial asymmetry parameters and Cheng–Tang rating score) were compared.
Conclusion. MM may occur during physical therapy for infants with CMT, especially for newborns. It is a clinical phenomenon that occurs during physiotherapy, not an adverse event that may lead to a poor outcome. It is more likely to occur in younger children, those with a larger SCM mass, and with DDH. Physiotherapists should consider the definition and tetrad signs of MM, and carefully control the stretch strength to ensure effective treatment and also avoid severe complications. Children with MM generally have a good prognosis. However, we do not recommend MM as a goal of treatment. In clinical practice, physiotherapists should investigate relevant factors in advance to predict the possibility of MM, and take preventive measures to avoid possible complications.
Introduction. The aim of this controlled study was to analyze the degree and localization of 3-dimensional (3D) facial asymmetry in adult patients with cleft lip and palate (CLP) compared with a control group and its impact on the visual perception of faces.
Methods. The degree of 3D asymmetry was analyzed with a novel method without landmarks in 18 adults with complete unilateral CLP and 18 adults without congenital anomalies. Furthermore,
the CLP and control faces were rated for appearance, symmetry, and facial expression by 30 participants.
Results. The results showed that adults with CLP had significantly greater asymmetry in their facial soft tissues compared with the control group. Moreover, the lower face, and particularly the midface, had greater asymmetry in the CLP patients. The perceptual ratings showed that adults with CLP were judged much more negatively than those in the control group.
Conclusions. With sophisticated 3D analysis, the real morphology of a face can be calculated and asymmetric regions precisely identified. The greatest asymmetry in CLP patients is in the midface. These results underline the importance of symmetry in the perception of faces. In general, the greater the facial asymmetry near the midline of the face, the more negative the evaluation
of the face in direct face-to-face interactions. (Am J Orthod Dentofacial Orthop 2010;137:168.e1-168.e8)
Objective. To compare the effects of manual stretching and postural control intervention in infants with
congenital muscular torticollis and to investigate the factors that predict treatment duration.
Design. Randomized, controlled trial.
Setting. An outpatient rehabilitation clinic in a tertiary university hospital.
Subjects. Infants <6 months of age with congenital muscular torticollis.
Intervention. Group 1 included 38 infants who received postural control intervention. Group 2 included
38 infants who received manual stretching.
Main measures. The thickness of the sternocleidomastoid tumor, rear head and facial asymmetry, and
head tilt were variables measured before and after treatment. Additionally, the treatment duration was
measured.
Results. The mean treatment duration was 92.53 ± 34.38 days for group 1 and 88.21 ± 37.23 days for
group 2. The mean change of thickness of the sternocleidomastoid tumor was 6.88 ± 1.90 mm for group
1 and 6.05 ± 2.85 mm for group 2. There were no statistically significant differences in the mean treatment
duration and the mean change of thickness of the sternocleidomastoid tumor between the groups (P >
0.05). The first treatment day after birth was associated with the treatment duration. In addition, facial
asymmetry, the first treatment day, tumor thickness, and head tilt were associated with the treatment
duration (P < 0.05). This regression model had a 57.4% explanatory power.
Conclusions. There was no difference between these treatments regarding the treatment duration and
the change of thickness of the sternocleidomastoid tumor. Infants with congenital muscular torticollis
who were treated earlier had a shorter treatment length.
B ACKROUND. Soft tissue mobilization techniques (STM) are used in clinical practice in treatment of congenital muscular
torticollis(CMT).However, little is known about its effectiveness.
OBJECTIVES. To investigate whether using STM to manage CMT in babies with mild to moderate head tilt was effective or
not.
METHODS. Twenty-nine babies with CMT aged between 0-6 months, who had a head tilt from 5 to 20 degrees were allocated
to two groups. Both groups received a baseline home program (positioning, handling strategies, stretching and strengthening
exercises, environmental adaptations). The study group (SG) also received STM three times a week. Babies were evaluated
initially, at six weeks, at 12 weeks and for follow-up at 18 weeks with muscle function scale, head tilt and range of motion for
neck lateral flexion and rotation.
RESULTS. Both groups showed significant improvements in all measured parameters (p < 0.05). In comparison of groups,
there were differences at six weeks in favor of the SG for neck rotation (0.001) and head tilt (= 0.006); but at 12 weeks and
follow up, there were no longer any differences between the groups in any of the measured parameters.
CONCLUSIONS. STM techniques are effective in getting faster positive results in the treatment of CMT.
Keywords. Congenital muscular torticollis, pediatric physiotherapy, musculoskeleteal manipulations
Este estudo investiga a relação entre a Displasia do Desenvolvimento do Quadril (DDH) e o Torcicolo Congênito Muscular (CMT). Foram revisados retrospectivamente 186 pacientes com DDH e 109 com CMT entre 1995 e 2004. Foi observado que entre pacientes com DDH, 5,9 foram posteriormente diagnosticados com CMT. Entre aqueles com CMT, 3,7 foram diagnosticados com DDH. A coexistência de DDH e CMT foi de 7,9 em pacientes com DDH e 12,5 em pacientes com CMT, independentemente de qual diagnóstico precedeu o outro. Meninos com DDH tinham 4,97 vezes mais chances de ter ambos DDH e CMT, comparados às meninas. O estudo confirma que pacientes com CMT devem ser examinados para DDH e bebês com DDH, especialmente meninos, devem ser acompanhados para o desenvolvimento de CMT.
Observações Este estudo oferece insights valiosos sobre a inter-relação entre DDH e CMT, destacando a importância de uma avaliação cuidadosa e monitoramento em pacientes com qualquer um dos diagnósticos. A descoberta da maior probabilidade de meninos com DDH desenvolverem CMT é particularmente notável, sugerindo que fatores genéticos ou hormonais podem desempenhar um papel. Implicações para a Prática Clínica O estudo ressalta a necessidade de triagem e acompanhamento específicos para DDH e CMT, dependendo do sexo do paciente e do diagnóstico inicial. Isso pode ajudar na detecção precoce e no tratamento mais eficaz dessas condições.