Torticollis comes from the Latin words tortus, which means "twisted" and collum, meaning "neck." Congenital muscular torticollis (CMT) is also sometimes referred to as wry-neck, stiff-neck, crooked-neck and twisted-neck. It was first defined in 1912 as "a deformity, congenital or acquired in origin, characterized by lateral inclination of the head to shoulder, with torsion of the neck and deviation of the face." Between 0.3% and 2% of newborns present with congenital muscular torticollis (CMT) which is thought to be a painless condition caused by the unilateral shortening of the sternocleidomastoid muscle (SCM.) The shortening of SCM gives an ipsilateral head tilt and contralateral rotation of the face and chin on the involved side. If diagnosed early enough it can be managed easily, seldom requiring surgery with the best outcomes seen in children between 1 and 4 years of age.

Origins

The origin of CMT is still up for debate, wile the most popular theories behind the impairment include intrauterine crowding, muscle trauma during a difficult delivery, soft-tissue compression leading to compartment syndrome and congenital abnormalities of soft-tissue differentiation within the SCM muscle. Histologic studies of resected surgical specimens have demonstrated edema, degeneration of SCM muscle fibers and fibrosis.

Presentation

There are different presentations of children with CMT, the most common is an obvious head tilt toward the affected side with the chin pointing to the contralateral side. Plagiocephaly, flattening of an infant's head or face, is reported in up to 90% of cases with CMT. Treatment is required to stop unilateral weight bearing which causes deformity of the skull base and cranium which can continue into adulthood.

Assessment of this condition can begin during the pediatric massage intake process of asking parents if their child often tilts their head in one direction, prefers looking over one shoulder instead of turning the head to follow with eyes, difficulty breastfeeding in one position, and displays frustration when attempting to turn their head in one direction. These are possible signs and symptoms of infants, or young children, with torticollis.

Classification

As discussed in Nilesh's 2013 article, "Congenital Muscular Torticollis", currently there are three classification groups for children with CMT. Group 1 is the sternocleidomastoid tumor group, which consists of torticollis with a palpable pseudotumor or swelling in the body of SCM. This is a hard, movable mass within the substance of the SCM noted at birth. This mass is usually located in the middle to lower third of the sternal portion of SCM. The pseudotumor usually becomes large after its first noted and then slowly resolves over a period of 5-21 months. This is the most common presentation and contributes to 28.2% to 47.2% of diagnosed cases of CMT in infants. Group 2, known as muscular torticollis, consists of torticollis with tightness of the SCM, but no palpable tumor. The last group, Group 3 (also known as POST), is a postural torticollis without a mass or tightness of the SCM. In an alternative system of classification, pseudotumor of infancy and CMT are described as a separate diagnosis.

Treatment

Treatment of torticollis is dependent on the age of infant, the severity of torticollis, the diagnosis of plagiocephaly and the possible presence of associated neuromuscular or orthopedic impairment. About 50% to 70% of SCM tumors resolve spontaneously during the first year of life with little to no lifelong symptoms. Physical therapy and the use of massage is often strongly recommended.

Massage

Before massage treatment begins, it is important to have the child completely diagnosed by a medical professional. The amount of additional conditions that are associated with torticollis demand a full evaluation and treatment involving extra care. As mentioned earlier in this article, the SCM is most often the muscle that is affected with torticollis. It originates on the medial end of the clavicle and attaches behind the ear. The sternocleidomastoid muscle has the function of both turning the head and assists in tilting from side to side.

With the child in safe position, the pediatric massage therapist, or trained parent, may apply gentle stroking techniques to the lateral, posterior and anterior areas of the unaffected side prior to addressing the affected side. This approach is often helpful is reducing spasms.

Unlike with adult clients, we do not recommend an ivolved stretching protocol with children. Rather, it is best to soften the tissue and use a favorite toy or engagement item to help the children track and turn their own head to follow. This gentle motion will help to monitor comfort level of the client and prevent overstretching the soft tissue.

Incorporate child friendly approaches to engage the child to turn their head from side to side, bring their head to chest and orient to midline. When the child is prone, resting comfortably on their abdomen, encourage the child to lift their head to increase orientation and strength.

Per the American Academy of Pediatrics (AAP) recommendations for sleeping, many parents place their baby on their back to sleep for prevention of SIDS. However, it is just as important that parents incorporate supervised "tummy time." Tummy time or prone to play enable normal developmental progression and can help build muscle in the neck and upper back.

With CMT occurring in one of every 300 live births, it is essential to know simple, natural ways of dealing with this condition. Massage provides an excellent way to gently lengthen affected muscles while encouraging growth and development in children. Additionally, if taught to parents at home, it can provide an excellent was for parent and child to bond.

Resources

1. Nilesh K, Mukherji, S. Ann Maxillofac Surg. 2013 Jul-Dec; 3(2): 198–200. Congenital muscular torticollis.
2. Tubby AH. 2nd ed. Vol. 1. London, England: MacMillan; 1912. Deformities and Diseases of Bones and Joints; p. 56.
3. Wei JL, Schwartz KM, Weaver AL, Orvidas LJ. Pseudotumor of infancy and congenital muscular torticollis: 170 cases. Laryngoscope. 2001;111:688–95.
4. Davids JR, Wenger DR, Mubarak SJ. Congenital muscular torticollis: Sequela of intrauterine or perinatal compartment syndrome. J Pediatr Orthop. 1993;13:141–7.
5. Tang S, Liu Z, Quan X, Qin J, Zhang D. Sternocleidomastoid pseudotumor of infants and congenital muscular torticollis: Fine-structure research. J Pediatr Orthop. 1998;18:214–8.
6. Hollier L, Kim J, Grayson BH, McCarthy JG. Congenital muscular torticollis and the associated craniofacial changes. Plast Reconstr Surg. 2000;105:827–35.
7. Ballock RT, Song KM. The prevalence of nonmuscular causes of torticollis in children. J Pediatr Orthop. 1996;16:500–4.
8. Loder RT. Congenital abnormalities of the cervical spine. In: Frymoyer JW, Wiesel SW, editors. The Adult and Pediatric Spine. 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2004. pp. 605–17.