Infants With Congenital Muscular Torticollis Requiring Supplemental Physical Therapy Interventions
Greve K, Goldsbury CM, Simmons EA. Infants with congenital muscular torticollis requiring supplemental physical therapy interventions. Pediatric Physical Therapy. 2022;34(3):335-341. doi:10.1097/pep.0000000000000906Link to Original Article: https://journals.lww.com/pedpt/Fulltext/2022/07000/Infants_With_Congenital_Muscular_Torticollis.13.aspx
Key Points
1. Nine percent of infants with congenital muscular torticollis (CMT) received supplemental interventions (SI) during their physical therapy treatment.
2. The most frequently used SI was kinesiological tape, followed by manual techniques, the TOT collar, and the Benik system.
3. Infants who received SI had larger baseline passive range of motion (ROM) and muscle function differences and required more treatment visits over a longer duration compared to infants who received first-choice interventions (FCI) only.
4. There were statistically significant differences in baseline age, passive cervical ROM, muscle function, and treatment time between the SI group and the FCI-only group.
5. Infants who received SI were more likely to have a CMT classification grade, plagiocephaly type, and external referrals compared to the FCI-only group.
6. There were no statistically significant differences in CMT resolution between the SI group and the FCI-only group, suggesting that both approaches were effective in treating CMT symptoms. However, education is needed when using SI.
Introduction
This section of the research paper discusses the use of supplemental interventions (SIs) in addition to first-choice interventions (FCIs) for the treatment of congenital muscular torticollis (CMT) in infants. The clinical practice guideline (CPG) recommends SIs when the first-choice intervention is not effective, access to services is limited, or the infant cannot tolerate the intensity of the first-choice intervention. The CPG categorizes different SIs based on the level of evidence. Microcurrent, kinesiological tape, soft tissue mobilization, and myokinetic stretching are classified as SIs with high levels of evidence, while the Tscharnuter Akademie for Motor Organization (TAMO) technique, tubular orthosis for torticollis (TOT collar), soft foam collar, and custom fabricated cervical orthoses have low levels of evidence.
Microcurrent, which involves low-frequency alternating current, has been found to improve cervical range of motion (ROM) and reduce treatment duration compared to therapeutic exercise and ultrasound. Kinesiological tape has shown mixed results in terms of muscle activation and cervical ROM. Soft tissue mobilization has been shown to improve passive cervical ROM and head tilt in the short term. Myokinetic stretching has demonstrated improvements in SCM thickness, cervical ROM, and head shape, but the lack of a control group and the young age of the participants raise some limitations.
The TAMO technique, soft foam collars, and custom fabricated cervical orthoses have limited evidence regarding their effectiveness. The TOT collar has been reported in cases of ongoing head tilt, and custom fabricated cervical orthoses have not been studied in infants. There is a lack of data on the frequency of SI use and the characteristics of infants who receive SIs in clinical settings. The objectives of the study discussed in this section were to describe the frequency of SI use and compare the outcomes of infants who received FCIs only versus those who received FCIs and SIs.
Methods
Participants
The Participants section of the research paper describes a retrospective study conducted on infants with congenital muscular torticollis (CMT) at a Midwestern academic research hospital. The study included infants who were evaluated between January 2017 and June 2018 in an outpatient setting. The researchers selected this time frame because documentation started capturing the use of selective infantile positioning (SI) during treatment in 2017.
Infants were included in the study if they had CMT, but were excluded if they had a nonmuscular cause of head tilt, abnormal neurological or visual screening, or had their initial physical therapy visit after 17 months of age.
A total of 933 infants were initially identified from the CMT registry. However, during the researchers' audit, it was discovered that some infants were incorrectly placed in the CMT registry at the initial examination, while others were excluded during the course of treatment. Twenty-six infants were ultimately excluded due to abnormal neurological findings (n = 22), abnormal vision findings (n = 2), and other nonmuscular cause for abnormal posture (n = 2). Overall, 907 infants met the inclusion criteria for the study.
Procedures
The Institutional Review Board approved this investigation, which involved extracting data from a local registry. The data were audited by three researchers and then deidentified. Baseline information for each infant included date of birth, sex, race, ethnicity, insurance type, age at first physical therapy visit, age when torticollis was first noticed, plagiocephaly type, cranial shape, recommended referrals, cervical rotation and lateral flexion ROM differences, Muscle Function Scale (MFS) score differences, CMT classification grade, and CMT presentation. Variables for infants' episode of care included intervention type, status of CMT goals, and number of days and visits to meet CMT goals or terminate physical therapy treatment. The infants were divided into two groups: a first-choice interventions-only group (FCI G ) and a first-choice interventions with supplemental intervention group (SI G ). These variables were previously reported in a study of infants with CMT from this local registry, which explained the reliability and validity of the measures.
Results
This study included 907 infants, the majority of whom were male, non-Hispanic, and White. The average age of the infants at the initial examination was 3.5 months. The symptoms of torticollis were first detected by the caregiver in the majority of infants within the first three months of life. Left CMT presentation was found in 44% of infants, while right CMT presentation was found in 34% of infants. Most infants had an early mild classification grade of CMT. Plagiocephaly types I to V occurred in 76% of infants. The average difference in active cervical rotation range of motion between sides at baseline was 19°, while the difference in passive rotation range of motion was 6°. The difference in passive cervical lateral flexion range of motion between sides at baseline was 10°. The average difference in MFS score between sides at baseline was 1 point. The majority of infants were recommended for the plagiocephaly clinic for treatment, and a small percentage were referred to other specialties. The average duration of treatment was 93 days, with an average of 8 treatment visits completed. 67% of infants achieved the treatment goals, while the remaining 33% discontinued treatment before achieving the goals. Tables and contain individual data for the cohort.
Description of Supplemental Interventions
In this study, 907 infants were observed, with 91% of them being placed in the FCI G group and 9% assigned to the SI G group. In the SI G group, a variety of supplemental interventions were used, including kinesiological tape, manual techniques, the TOT collar, and the Benik Contralateral Torticollis Bracing System. Forty infants received kinesiological tape, with 15 infants having the tape applied to inhibit the involved side and 12 infants having it applied to facilitate the uninvolved side. Five infants received tape on both sides, and eight infants received tape on unspecified areas or other muscle groups. Manual techniques were used for 38 infants, the TOT collar was used for 23 infants, and the Benik system was used for one infant. A total of 16 infants (19%) in the SI G group received more than one type of supplemental intervention.
Comparison of Groups at Baseline
The baseline characteristics of the study groups were compared. The majority of both groups were White, with a slightly higher percentage in the SI group. The initial age at examination was younger in the FCI group compared to the SI group. Torticollis was first detected by caregivers at a similar rate in both groups. The severity of torticollis varied between groups, with the FCI group having a higher proportion of infants classified as early mild and the SI group having a higher proportion of infants classified as early moderate or severe. Plagiocephaly types were similar between groups, with a slightly higher proportion in the FCI group. Differences in range of motion (ROM) were observed between groups, with the SI group having slightly larger mean differences between sides for cervical rotation and lateral flexion ROM. Muscle Function Scale scores were also different between groups, with the SI group showing a larger mean difference between sides. External referrals to the plagiocephaly clinic and other specialty referrals were recommended for a higher percentage of the FCI group. Statistically significant differences were found between groups for age, passive cervical rotation ROM, passive cervical lateral flexion ROM, and Muscle Function Scale scores. Associations were found between groups for CMT presentation, classification grade, plagiocephaly type, and recommended referrals. No significant differences were found between groups for gender, ethnicity, race, insurance type, age CMT was first noticed, cranial shape, or active cervical ROM.
Comparison of Groups' Episode of Care
This section of the research paper compares two groups, the FCI G and the SI G, in terms of their episode of care. The mean treatment duration for the FCI G was found to be 85 days, with a standard deviation (SD) of 61 and a median of 76. In contrast, the SI G had a mean treatment duration of 173 days, with an SD of 85 and a median of 155. The FCI G completed an average of 7 visits, with an SD of 8 and a median of 6, while the SI G completed an average of 14 visits, with an SD of 7 and a median of 12.
At the end of treatment, 67% of the FCI G had met all goals, while 33% had discontinued treatment without meeting goals. In the SI G, 66% had achieved all goals, while 34% had discontinued treatment without achieving goals.
Statistical analysis revealed significant differences between the two groups for both the number of treatment visits (P = .000) and the treatment duration (P = .000). However, no statistically significant difference was found between the groups in terms of achieving goals.
In summary, the FCI G had a shorter treatment duration and fewer visits compared to the SI G. A higher percentage of the FCI G achieved all goals compared to the SI G, but the difference was not statistically significant.
Discussion
Supplemental Intervention Type
The most frequently used supplemental intervention (SI) for infants with congenital muscular torticollis (CMT) is kinesiological tape. However, there are various techniques used for its application, and it is unclear which method is most effective. Manual techniques such as myofascial release and massage are also commonly used, especially early in treatment episodes. SIs with limited evidence in the literature, such as the TOT collar and the Benik system, were used in a small percentage of cases. The TOT collar was used for infants who had previously received other SIs, while the Benik system was used as a last resort after other interventions failed. Both of these interventions require approval from a specialized CMT team and have low levels of evidence supporting their use. SIs such as the TAMO technique and soft foam collars were not used at the author's facility but could be investigated in the future. Some infants received multiple SIs when the first did not fully resolve CMT symptoms. Therapists tended to use SIs with higher levels of evidence before interventions with low or no published evidence. Caregiver challenges and therapist confidence may influence SI decision-making. It is recommended that further research be conducted to investigate the effectiveness of combination SIs for CMT treatment. Additional training is required for the safe and effective use of certain SIs, and therapists without the necessary training refer infants to trained therapists. Standardization and formal training requirements for manual techniques are lacking, which may impact their use and infant outcomes.
Comparison of Infant Groups
This section of the research paper discusses the comparison of infant groups in relation to the initiation and outcomes of physical therapy services. The majority of caregivers in both groups noticed symptoms of torticollis before 3 months of age, but infants in the second group (SI G) presented at an older age for their initial physical therapy visit. The prognosis is better for infants with milder passive range of motion (ROM) discrepancies, specifically cervical rotation. However, infants in the SI G presented with larger passive cervical rotation and lateral flexion ROM deficits, requiring more treatment visits over a longer duration compared to the first group (FCI G). This suggests that children in the SI group are more likely to receive selective inhibition (SI) in their treatment when they present at older ages with greater ROM deficits. Physical therapists can educate caregivers on the potential use of SI if an infant is older with more severe ROM restrictions. Additionally, infants in the SI G are more likely to be referred to external specialists, such as plagiocephaly clinic, occupational therapy, orthopedics, ophthalmology, or neurology. The increased referrals during the episode of care in the SI G may be due to unresolved symptoms and extended physical therapy treatment time, which leads to a recommendation for further examination by an external provider. It is suggested that further investigation may be necessary for some infants who lack progress during physical therapy treatment.
Limitations and Future Research
The limitations of this study include the potential for error in data entry by clinicians, as well as the fact that data was only collected from the authors' facility and may not be generalizable to other institutions. Including data from multiple sites would provide a more comprehensive understanding of how sensory integration is used in different locations. Additionally, the study did not include the use of recently effective supplemental interventions such as microcurrent. Further research should be conducted on other sensory integration techniques used at this facility, including the TOT collar and the Benik system, which have less evidence in the literature.
The results of the study may also be influenced by variations in clinician confidence with different sensory integration techniques. Manual techniques were predominantly used by a small group of clinicians who received specific training, and were typically employed early in the treatment process, in contrast to other sensory integration techniques which were used later in therapy. Future research should consider analyzing manual techniques separately from other techniques, due to their distinct methods and timing of usage by clinicians.
Conclusions
In a study conducted on infants with congenital muscular torticollis (CMT), it was found that 9% of the infants received supplemental intervention (SI) during their physical therapy treatment. The most common types of SI used were kinesiological tape, manual techniques, the TOT collar, and the Benik system. Infants with moderate to severe CMT who had their first physical therapy visit at a later age and had greater deficits in passive range of motion and muscle function were more likely to receive SI. Although infants who received SI had more therapy visits over a longer period, they experienced similar resolution of symptoms as infants who received regular physical therapy treatment (FCI) only. These findings suggest that SI can be a useful tool for physical therapists when CMT symptoms are not improving. However, it is important to provide adequate training to clinicians and educate caregivers about the use of SI. Future research should focus on understanding the effectiveness of each SI technique and determining the optimal order of use for infants with CMT.
Opportunities for Future Research
1. Investigate the effectiveness of kinesiological tape in infants with congenital muscular torticollis (CMT) in terms of muscle function and cervical range of motion.
2. Evaluate the use of manual techniques, such as myofascial release and massage, as supplemental interventions in the treatment of CMT in infants.
3. Examine the effectiveness of the Tubular Orthosis for Torticollis (TOT) collar as a supplemental intervention for infants with CMT who have unresolved head tilt.
4. Assess the outcomes of using the Benik Contralateral Torticollis Bracing System as a supplemental intervention in infants with CMT who have not responded to first-choice interventions.
5. Compare the effectiveness of different combinations of supplemental interventions, such as kinesiological tape and manual techniques, in the resolution of CMT symptoms in infants.
6. Investigate the impact of caregiver education on the use and effectiveness of supplemental interventions in the treatment of CMT in infants.
