December 7, 2015
The Saga Continues…….
Unfortunately in paediatrics the saga is the continued increase in the number of children referred for torticollis. The numbers are so high that the APTA has a set of clinical guidelines for its management (1).
We have observed that this phenomenon correlates with the “Back to Sleep” campaign, which further correlates with the rise of baby equipment (that is all a variation of the supine/back-lying position). I’ve talked about various aspects of torticollis before here, here and here. As therapists we continue to work hard at promoting tummy time . But we should realize that the world order has changed – today’s babies are not ever going to come close to the 20 hours per day babies used to spend in tummy time prior to the 1994 Back to Sleep campaign (2) – it’s time to advance our practice.
Rather than thinking about torticollis as solely a musculoskeletal problem, I think we should also consider the vestibular system and the role it plays during the development of head/neck/trunk control. When a baby is born, the vestibular system is fully developed and ready to help the baby cope with gravity (3) – it’s like the Jedi force of the sensory systems! On his tummy, baby is stimulated to lift his head for various reasons; to clear the airway, to shift pressure or to see what is happening in the world. And even though his arms are right at his sides, he can push off the surface slightly and assist with the head lifting. As the infant lifts his head, even slightly, there is early activation of the vestibular system, triggering the vestibulocollic reflex. This reflex directly activates the neck muscles bilaterally to help stabilize the head in space.
However, today’s newborn is in supine for the vast majority of a 24-hour period (this includes all baby seats, car seats and strollers). There is no head lifting in this position and so vestibular input is significantly decreased. Being propped in upright before head control develops means that the baby often falls into end-range extension, side flexion and rotation for stability – exactly the pattern we see in our babies with torticollis. This pattern can also be transmitted through the trunk and create a rotational pull through the soft tissue there as well, again perhaps serving a stability function.
There’s also another factor that may play into the development of torticollis – many of the babies I see with this diagnosis have decreased physiological flexion as many have slightly lower muscle tone. Place these babes in supine against gravity, and their heads slightly extend secondary to an altered rib cage position. This puts the sternocleidomastoid muscles in a lengthened position, which makes it harder to activate them. If a baby can’t activate the SCMs bilaterally to keep the head in midline, and her neck is in slight extension, there is that tendency to fall to one side and rotate to seek stability – again the pattern we see in torticollis.
Finally, the more a time a child spends with the head tilted, the more visual and vestibular input is processed in this position – might this lead the baby to a different perception regarding where their midline is located? I don’t know the answer to that but I obsess about it a lot.
Babies with torticollis are referred far more often later in childhood for gross motor, fine motor or speech difficulties (4). Therapists can harness the power of the vestibular system to address multiple systems in our early treatment of this issue. I do not know if this change in my treatment protocol makes a difference in the long term, but it does seem to be making progress easier and smoother in the short term. Please share your experiences with this population so we can all learn from each other. And may the force be with you.
PRACTICAL APP
I am now more standardized regarding the vestibular component of my treatment programming for babies with torticollis. My program is: tucked in sitting in their parents’ arms with their head supported in as neutral a position as possible, they spin clockwise at 1 rotation per 2 seconds (I use a metronome to set the speed), followed by a rest of several seconds. The same movement is repeated counterclockwise. We begin at one rotation and gradually increase to 5. The same protocol is repeated in right sidelying and left sidelying (5). I then proceed to postural treatment of the musculoskeletal components of torticollis (6) combined with visual tracking in all planes (with their head facilitated in neutral alignment).
References
1. Kaplan SL, Coulter C, Fetters L. Physical Therapy Management of Congenital Muscular Torticollis: An Evidence-Based Clinical Practice Guideline. Ped Phys Ther. 2013; 25: 348-94.
2. McKenna Wendy. MovePlayGrow.com. Oct 9, 2015.
3. Haywood K, Getchell N. Life Span Motor Development. Human Kinetics, Windsor, ON, 2005.
4. Oledzka M, Suhr M. (2013). Clinical approach to the evaluation and treatment of congenital torticollis. APTA CSM, San Diego, CA.
5. Kawar M, Frick S, Frick R. Astronaut Training: A sound activated vestibular-visual protocol. Madison, WI, Vital Links, 2005.6.
6. Lee I. The effect of postural control intervention for congenital muscular torticollis: A randomized, control trial. Clin Rehabil. 2015; 29(8): 795-802.
photo credits: happybeinghealthy.com, kovaandt.com