NEPA is fortunate to have many bright, altruistic and dedicated pediatricians. Over the past thirty years, I have had the pleasure and privilege to work with them and their patients. One of the most common problems referred to physical therapy by pediatricians is infant torticollis. Torticollis, also referred to as wryneck, means “twisted neck” in Latin. While adults often wake up in the morning with a stiff neck from sleeping in an awkward position, (acute or acquired torticollis), infants too, suffer from this condition when they are born with a stiff neck, locked in one position called infant or congenital torticollis. In one case, young “Packie” fought with his two brothers for space in his mother’s uterus. As a triplet, it is believed his head was tilted to one side for an extended period of time which caused him to be born with infant torticollis. In another case, little Britany, had a difficult birth and may have suffered some minor trauma to her neck muscles in the birthing process, resulting in infant torticollis. In the case of baby Mason, there was no history of trauma during or after birth and his stiff neck may have been due to uterine positioning.
WHAT IS INFANT OR CONGENITIAL TORTICOLLIS?
Photo 1: Baby Mason Schneider (3 months) with “Infant Torticollis” demonstrates a shortening of the right sternocleidomastoid muscle of the neck which tilts his head to the right and rotates it to the left.
Infant or congenital torticollis occurs when an infant’s head is tilted to one side and rotated toward the other. For example, the infant's head is tilted with the right ear toward the right shoulder and the chin is rotated to the left due to the shortening of the muscle responsible for this position (See Photo 1 for example).
Infant torticollis is most often discovered at birth or shortly thereafter. Often, a parent will notice that the infant has a preference for looking in one direction and avoids the other. It is especially apparent when feeding, nursing, playing, resting, or sleeping.
Photo 1: Baby Mason Schneider (3 months) with “Infant Torticollis” demonstrates a shortening of the right sternocleidomastoid muscle of the neck which tilts his head to the right and rotates it to the left.
CAUSES
The medical literature cites several possible causes of infant torticollis. Most often it is due to poor positioning of the baby in the uterus especially when space is limited as in the case of twins or triplets. Infant torticollis can also occur when a fetus is in a breech position in the uterus. In breech, the baby’s buttocks face the birth canal and can also cause awkward positioning and difficult birthing. A difficult delivery using a forceps or vacuum device may contribute to the problem. In all of these cases, one of the neck muscles called the sternocleidomastoid, is traumatized which leads to shortening and tightening. Over time, the baby assumes the more comfortable shortened position which tilts the head toward the side of the tight muscle. In rare cases, the condition is associated with damage to the nervous system, spine or blood supply.
SIGNS AND SYMPTOMS
The classic sign of infant torticollis is limited range of motion of the neck as it tilts to one side more than the other. The classic head tilt may not be as noticeable immediately after birth and it is often detected by the parents while bathing, feeding, and playing with their infant. Once detected, it is important to bring it to the attention of your pediatrician because early intervention is very important. Remember, not all of the signs and symptoms need to be present to have infant torticollis, as there are various degrees of involvement.
TREATMENT
Photo 2: Baby Mason Schneider is placed in a car seat and rolled towels are used to maintain his head in a mid-line position.
Physical therapy is the treatment of choice for infant torticollis. However, it is important to note that the most important treatment given to an infant with torticollis is given, not by the pediatrician or physical therapist, but by the parents. The physical therapist will evaluate and treat the infant once or twice a week, but the parents will be instructed to continue the treatment several times a day for an optimal outcome.
Physical therapy involves stretching the tight and strengthening the weak muscles of the neck. The muscles can be prepared for stretch by employing a very light massage to the tight cord-like muscles. Care not to irritate the skin is important and skin care techniques may be required if the skin is open or irritated. Then, a mild to moderate passive stretch to the tight tissues is employed by the physical therapist. It should be slow, gradual and sustained for 30 to 60 seconds. It is expected that the infant will cry due to pain during the stretch but as the tissue elongates, the pain will dissipate. A pediatrician or physical therapist will teach the parents how to perform the stretch safely. Following the stretch, the infant will be placed in a position, often a car seat, with a towel roll to maintain a mid-line head position. This is also the position of choice throughout the day to maintain the head in mid-line. (See Photo 2 for example)
Additional instructions for the parents include: holding, feeding and playing with the child in positions that stretch the tight side and encourage movement in the opposite direction. Even when doing something as simple as holding the child face to face, the parents head can be used to maintain a mid-line position. (See Photo 3 for example).
PROGNOSIS – OUTCOMES
Photo 3: Baby Mason’s father is using the right side of his head to stretch the right side of baby Mason’s head toward the left side.
Not surprisingly, the earlier the detection and intervention, the better the outcome. I am pleased to report; in most cases, when treatment is employed within the first 3-4 months after birth, the outcomes are excellent in 3-6 months, depending on the severity of the problem. When parents are committed to participate and implement the program at home, progress is expedited. While rare, in more difficult cases, additional medical tests are often used to rule out other potential problems.
If you suspect that your infant may have torticollis, contact your pediatrician for a consultation.
MODEL: Mason Schneider– 3 months old
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum” in the Scranton Times-Tribune.
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.comPaul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at The Commonwealth Medical College.
