Article

Validity and reliability of the muscle function scale, aimed to assess the lateral flexors of the neck in infants

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Physiotherapy Theory and Practice
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Abstract

Infants with congenital muscular torticollis (CMT) often have an imbalance in muscle function in the lateral flexors of the neck, and the need for a valid and reliable assessment tool to determine muscle function in these muscles is essential. The lateral uprighting response is used to examine and to strengthen the sternocleidomastoid muscle. A Muscle Function Scale (MFS) has been refined and used for several years in a clinic for infants with CMT. The MFS describes an infant's muscle function in the lateral flexors of the neck through ordered categorical scores. The aim of this study was to find out if the muscle function scale (MFS) is valid and reliable. A panel of experts examined validity, and the kappa statistic and intraclass correlation coefficient were calculated for interrater and intrarater reliability. The MFS is found to be a valid tool to measure the muscle function of the lateral flexors of the neck in infants with CMT. The interrater and intrarater reliability is high for both novice and experienced physiotherapists (kappa>0.9; ICC>0.9).

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... Assessment techniques need to have robust psychometric properties in order to be of value for both research and clinical practice. A systematic review of psychometric properties of instruments for assessment of CSp function in infants with CMT [49] evaluated five studies [50][51][52][53][54] which had assessed six instruments, of which only two were found to have good psychometric properties from high-quality studies. These included still photography for assessment of habitual head tilt in supine [53] and the Muscle Function Scale for the assessment of side-flexor muscle function in lateral head righting [52]. ...
... A systematic review of psychometric properties of instruments for assessment of CSp function in infants with CMT [49] evaluated five studies [50][51][52][53][54] which had assessed six instruments, of which only two were found to have good psychometric properties from high-quality studies. These included still photography for assessment of habitual head tilt in supine [53] and the Muscle Function Scale for the assessment of side-flexor muscle function in lateral head righting [52]. Subsequent to this review, a CMT severity classification system, based on age of infant, CSp ROM and presence or absence of SCM mass, has also been found to have good reliability [5,55]. ...
... Table 1 Results of intra-rater reliability and inter-rater reliability divided into CSp active rotation and head tilt videos The decision to video the infants was based on achieving a balance between being realistic and practical. Still photography has been used in other reliability studies [52,53] but it is a static technique, whereas postural head tilt and CSp active rot, the two dimensions being assessed in this study, are both dynamic. Some studies have used 3D imaging, but this has been found to be a time-consuming technique, poorly tolerated by the infants [75,76], and it is not readily available in clinical settings. ...
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There is a lack of reliable and valid measurement tools to assess neck function in infants with congenital muscular torticollis, and most physiotherapists use visual estimation, which has not been adequately tested for reliability in this population. We examined the reliability of visual estimation of head tilt and active neck rotation in the upright position, on infants with congenital muscular torticollis by physiotherapists. We recruited 31 infants and 26 physiotherapists. Therapists rated videos of infants’ head position in the frontal plane (tilt) and transverse plane (active rotation) using visual estimation, on two occasions at least one week apart. Overall, inter-rater reliability was good (mean ICC, 0.68 ± 0.20; mean SEM, 5.1° ± 2.1°). Rotation videos had better reliability (mean ICC, 0.79 ± 0.14) than head tilt videos (mean ICC, 0.58 ± 0.20). Intra-rater reliability was excellent (mean ICC, 0.85 ± 0.08). Both head tilt and rotation had excellent reliability (mean ICC, 0.84 ± 0.08 for head tilt and 0.85 ± 0.09 for rotation). There was no correlation between intra-rater reliability and clinical experience. Conclusion Visual estimation had excellent intra-rater reliability in the assessment of neck active rotation and head tilt on infants with congenital muscular torticollis. Visual estimation had acceptable inter-rater reliability in the assessment of neck active rotation but not of head tilt. There was a wide variation in reliability with no correlation between reliability and clinical experience. Assessment tools for head tilt that are more psychometrically robust should be developed.What is Known: • A thorough assessment of infants presenting with torticollis is essential, using assessment tools with robust psychometric properties • Visual estimation is the most commonly used method of assessment of neck function in infants with torticollis What is New: • Visual estimation had excellent intra-rater reliability in the assessment of neck active rotation and head tilt in the upright position in videos of infants and acceptable inter-rater reliability in the assessment of rotation but not of head tilt • Physiotherapists’ clinical experience had minimal relationship with reliability
... Four assessed CSp function as an element of a wider condition [40,49,51,61], and four described methods of assessment of torticollis but not assessment of their measurement properties [1,12,13,19]. Therefore, a final selection of five studies [9,33,46,53,62] was included in this review. These five studies examined measurement properties of six assessment tools for infants with torticollis: electronic pendular goniometer (digital inclinometer) [9], standard goniometer [33], large protractor [33], Muscle Function Scale [53], still photography [33,62] and ROM limitation scale [46]. ...
... Therefore, a final selection of five studies [9,33,46,53,62] was included in this review. These five studies examined measurement properties of six assessment tools for infants with torticollis: electronic pendular goniometer (digital inclinometer) [9], standard goniometer [33], large protractor [33], Muscle Function Scale [53], still photography [33,62] and ROM limitation scale [46]. Details are described in Table 1 and in Figs. 2, 3, 4, 5, 6 and 7. ...
... Of these five studies, all investigated reliability and one also described content validity and hypothesis testing [53]. Therefore, three of the potential 12 COSMIN sections were used to assess methodological quality. ...
Article
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The aim of this study was to systematically review the measurement properties of instruments which assess cervical spine function in infants with torticollis. Electronic searches were performed in MEDLINE, CINAHL, Embase, Web of Science and the Cochrane Library, combining three constructs (‘torticollis’, ‘cervical spine assessment’ and ‘measurement properties’). Two reviewers independently rated the methodological quality and the quality of measurement properties of identified articles, using both the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist and quality criteria for measurement properties. Five studies, using six instruments, met the inclusion criteria and were analysed. Included instruments were the goniometer, electronic pendular goniometer, protractor, still photography, Muscle Function Scale and a range of motion limitation scale. All studies assessed reliability, and one study also assessed content validity and hypothesis testing. The methodological quality of the studies varied from poor to excellent according to the COSMIN checklist. Two instruments were found to have good measurement properties from high-quality studies: still photography for the assessment of habitual head tilt in supine and the Muscle Function Scale for the assessment of side-flexor muscle function in lateral head righting. Conclusion: This systematic review identified two reliable tools for the assessment of cervical spine function in infants with torticollis. Further research is required to assess the measurement properties of tools already described in the literature and to develop further tools for use in this population.What is known? • A thorough assessment of the infant presenting with torticollis is essential, in order to correctly diagnose, rule out ‘red flags’ and manage appropriately • Assessment tools need to have robust measurement properties in order to be of value for clinical practice and research What is new? • This systematic review identified two valid and reliable tools for the assessment of cervical spine function in infants with torticollis • Further research is required to assess the measurement properties of tools already described in the literature and to develop further tools for use in infants with torticollis
... 4 Concomitant conditions may include cranial deformation 1 and cervical spine musculature imbalances. [5][6][7] While one SCM is shortened, evidence suggests that both sides are affected. The shortened SCM has fibrotic tissue and disorganized muscle fibers, 8 but animal models suggest strength changes on the opposite side due to overlengthening. ...
... 29 Active lateral cervical flexion against gravity was measured in degrees to measure weekly progress and with the Muscle Function Scale (MFS). 5 This toddler was not cooperative lying in the supine position; therefore, resting head tilt was measured via photography in sitting, with the parent stabilizing the toddler' s pelvis. 30 The photographs were printed, and head tilt was measured as otherwise described by Rahlin and Sarmiento. ...
Article
Purpose: This case describes the first episode of care, using conservative treatment, massage, and frequency-specific microcurrent (FSM), for a 19-month-old boy with grade 8 left congenital muscular torticollis with fibrotic nodules. Methods: Ten weeks of physical therapy provided stretching, strengthening, massage, and parent education, adding FSM in weeks 3 to 10 for this patient. Results: Full passive cervical rotation and lateral flexion, 4/5 lateral cervical flexion strength, improved head tilt, and inability to palpate fibrotic nodules were achieved by week 8, with partial home program adherence. Conclusions and recommendations for practice: Excellent outcomes were achieved with conservative care in a patient with poor prognosis and likelihood of surgical referral. Combining stretching, strengthening, massage, postural reeducation, and FSM resulted in full range and good strength in an exceptionally short time. The combination of massage and FSM, not previously reported, are tools that may be effective in congenital muscular torticollis treatment.
... Artrodial protraktor kullanılarak boyun lateral fleksiyon ve rotasyonlarının pasif hareket genişliği ölçümleri yapıldı (10). KFÖ, fotografik baş tilti ölçümü ve artrodial protraktor kullanımı önceki araştırmalarda geçerli ve güvenilir bulunmuştur (9,10,22). DP şiddetinin değerlendirilmesinde Plagiosefali Şiddet Değerlendirme (PŞD) Ölçeği kullanıldı. Bu ölçek, boyun tilti, frontal asimetri, oksipital asimetri, kulak şifti, fasyal asimetri alt gruplarından oluşmaktadır. ...
... Öncelikle, sağlıklı tarafın kas kuvvetini değerlendirmek için KFÖ kullanıldı. Altı-sekiz haftadan küçük bebeklerde normal motor gelişimin doğası gereği, düzeltme reaksiyonu ile ilişkili boyun lateral kas kuvveti zaten gelişmemiştir(22). Bu nedenle, kas fonksiyon indeksindeki iyileşme bebeğin motor gelişimine paralel olarak sağlanmış olabilir. ...
Article
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Purpose: This study was aimed to investigate the response of deformational plagiocephaly and congenital muscular torticollis to a home-based physiotherapy program. Methods: Thirty-Two babies with congenital muscular torticollis and deformational plagiocephaly, aged between 0-6 months were the participants of the study. Babies received a home-based physiotherapy program. They were evaluated initially, at the sixth, the 12th and the 18th weeks after the first visit Subjects were assessed using Muscle Function Scale, neck passive range of motion, and head tilt were used to evaluate congenital muscular torticollis, Plagiocephaly Severity Assessment Scale, and ear shift were used to assess deformational plagiocephaly. Results: Significant improvements were recorded for congenital muscular torticollis between initial and sixth week, the sixth and 12th weeks (p<0.05). At the 12th week, a plateau was regarding this improvement (p>0.05). Deformational plagiocephaly improvement continued between the 12th and the 18th weeks (p<0.05) after which of slight degree occipital flattening to slight degree was still not fully recovered. Conclusion: The study showed that even if congenital muscular torticollis was cured in three months, time still required for recovery of deformational plagiocephaly.
... A number of measures have been found to be reliable in the assessment of the cervical spine in infants with torticollis. These include measurement of passive cervical ROM using a goniometer and arthrodial protractor [22,23]; an observational scale for measuring side flexor muscle strength in lateral head righting [24]; and still photography for measuring postural side flexion in supine [25]. Despite these tools being described in the literature, studies have reported that more than 90% of paediatric physiotherapists use visual estimation to assess cervical ROM, with reliable measures such as goniometry only being used by 14-16% [26,27]. ...
... Visual estimation has been studied in the adult population and found to have poor reliability [35][36][37][38], however, it has not been tested for reliability in this patient group. Paradoxically, some of the other, less frequently used assessment tools have been demonstrated to have greater reliability [22][23][24][25]. ...
Article
torticollis by physiotherapists in Ireland. METHODS: An online survey was conducted among members of the Irish Society of Chartered Physiotherapists’ clinical interest/employment groups, specifically: Chartered Physiotherapists in Community Care; Chartered Physiotherapists in Paediatrics; Chartered Physiotherapists in Private Practice; and Chartered Physiotherapists in Women’s Health and Continence. RESULTS: Sixty-seven physiotherapists completed the survey. There was a high level of agreement amongst physiotherapists regarding what subjective information is sought at initial assessment. However, there was less agreement on the nature of the objective assessment. There was a high level of agreement in the use of assessment techniques for both cervical spine range of motion and posture, with the vast majority of respondents using visual estimation for both. The most common treatment techniques used are positioning, handling and neurodevelopmental facilitation. CONCLUSIONS: This study explored the physiotherapy assessment and management of torticollis in infancy in Ireland. This survey identified that there was a lack of consensus on the objective examination used with infants. It is recommended that physiotherapists include screening for fine motor and hip asymmetries in their assessments and that a pathway of care is developed including access to further specialists and investigations.
... Ohman et al 22 described the validity and reliability of the muscle function scale (MFS) for measuring muscle function in the lateral flexors of the neck in infants with CMT. However, this method is not commonly used clinically as demonstrated by the survey conducted by Luxford and colleagues who found that 86% of therapists used VE for assessment of cervical motion in CMT. 14 The MSF assessment technique also relies on VE of the head position relative to a horizontal reference to assess muscle function/ strength and assign a score on an ordinal scale of 0 to 5. 8,22 The intent of the current study was to evaluate the infant's ability to produce an effective neck-righting response to a graded lateral trunk tilt from the vertical orientation. ...
... Ohman et al 22 described the validity and reliability of the muscle function scale (MFS) for measuring muscle function in the lateral flexors of the neck in infants with CMT. However, this method is not commonly used clinically as demonstrated by the survey conducted by Luxford and colleagues who found that 86% of therapists used VE for assessment of cervical motion in CMT. 14 The MSF assessment technique also relies on VE of the head position relative to a horizontal reference to assess muscle function/ strength and assign a score on an ordinal scale of 0 to 5. 8,22 The intent of the current study was to evaluate the infant's ability to produce an effective neck-righting response to a graded lateral trunk tilt from the vertical orientation. Therefore, the MSF was not deemed appropriate for use in this study. ...
Article
Purpose: The purpose of this study was to evaluate the clinical feasibility of using a 2-dimensional (2D) video analysis (VA) system compared with visual estimation (VE) for measurement of active cervical rotation and lateral flexion in infants with congenital muscular torticollis. Methods: Twelve infants participated in this study. Active cervical motion in rotation and lateral flexion was measured by VE and 2D VA. Results: Significant differences between VE and VA were found for left lateral flexion, right lateral flexion, and right rotation. Average total time for VA was 23.96 minutes. Conclusions: This study suggests that the use of VA may improve the measurement of active cervical motion to improve clinical assessment of infants with congenital muscular torticollis. However, VA time is excessive and, therefore, not clinically feasible. Further studies are indicated to explore other software for this application.
... The infants underwent application of KT for the first time during the period of September 2010 to June 2011. Before and after the KT was applied, the infants were assessed with the Muscle Function Scale (MFS) [4,11]; scores for both the right and left side were noted. In the analysis, the terms "affected side" and "unaffected side" are used instead of left and right sides. ...
... The MFS describes an infant's muscle function in the lateral flexors of the neck through ordered categorical scores of 6 levels from 0 to 5. The MFS has high intrarater and inter-rater reliability, Ͼ .9 [4,11]. When the MFS is used, the infant is held in a vertical position and then lowered to a horizontal position in front of a mirror. ...
Article
To investigate the immediate effect of kinesiology taping (KT) on muscular imbalance in the lateral flexors of the neck. A retrospective study. Twenty-eight infants with congenital muscular torticollis and muscular imbalance in the lateral flexors of the neck were chosen consecutively. Data regarding the Muscle Function Scale (MFS) score before and after the first taping session were obtained from the records. A significant decrease in the difference between the MFS scores was found after KT was applied (P < .001). Significantly greater scores were noted on the unaffected side after KT (P = .02) and significantly lower scores were noted on the affected side after KT (P = .003). Multiple regression demonstrated that the MFS score on the unaffected side (P < .001) and use of the muscle-relaxing technique (P = .009) were significantly associated with a decrease in the difference between the MFS scores of the 2 sides. KT has an immediate effect on muscular imbalance in infants with congenital muscular torticollis.
... 11 The righting response, which involves compensatory contraction of the neck muscles to maintain upright head position against gravity, is affected in infants with torticollis. 12 In the righting response, the infant's head fails to straighten to the opposite side when the body is tilted toward the affected side, and there is excessive straightening of the head to the affected side when the body is tilted toward the opposite side, resulting in left-right asymmetry. 9 Infants with postural torticollis and deformational plagiocephaly have been reported to exhibit delayed motor development in previous studies. ...
Article
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The study examined how neck muscle imbalance and plagiocephaly affect the lying and rolling activities in 118 infants aged 4 to 6 months with postural torticollis. Outcome measures included age, sex, cervical movement, and plagiocephaly severity. Neck muscle function was assessed with the Muscle Function Scale (MFS), and infant motor abilities in lying and rolling were evaluated through the corresponding dimensions of the Gross Motor Function Measure (GMFM). Multiple regression analysis showed that a better MFS score of the affected neck was significantly associated with improved lying and rolling activities in the GMFM (p < .01), and importantly, the interaction between the plagiocephaly and the MFS scores of the affected neck muscle in these activities was found to be significant (p < .05). These results highlight the need for early intervention in infants with torticollis to address muscle imbalance and plagiocephaly, crucial for early motor development (KCT0008367).
... 3 A few studies have assessed active ROM and passive lateral flexion in combination. 15,16 Some methods also use radiographs of head tilt, 17 an objective symptom of CMT. These have the disadvantage of being uncooperative and timeconsuming during examinations in infant or young children. ...
... Some studies have compared the passive neck range of motion (ROM) measurement methods in young children [14,15]. In some studies, the active ROM [16] and active or passive side flexion [17] have been evaluated together. In addition, some methods use radiographs [18], photographs [19], or goniometers [20], but there is no gold standard for evaluating head tilt, an objective symptom of patients with torticollis. ...
Article
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The head tilt of patients with torticollis is usually evaluated subjectively in clinical practice and measuring it in young children is very limited due to poor cooperation. No study has yet evaluated the head tilt using a three-dimensional (3D) scan and compared it with other measurement methods. Therefore, this study aimed to objectively demonstrate head tilt through clinical measurements and a 3D scan in children with torticollis. A total of 52 children (30 males, 22 females; age 4.6 ± 3.2 years) diagnosed with torticollis and 52 adults (26 men, 26 women; age 34.42 ± 10.4 years) without torticollis participated in this study. The clinical measurements were performed using a goniometer and still photography methods. Additionally, the head tilt was analyzed using a 3D scanner (3dMD scan, 3dMD Inc., Atlanta, GA, USA). There was a high correlation between the other methods and 3D angles, and the cut-off value of the 3D angles for the diagnosis of torticollis was also presented. The area under the curve of the 3D angle was 0.872, which was confirmed by a moderately accurate test and showed a strong correlation compared with other conventional tests. Therefore, we suggest that measuring the degree of torticollis three-dimensionally is significant.
... ICC>0.9). 4,16 To assess the degree of craniofacial changes Severity Scale for Assessment of Plagiocephaly (PSI) was used. 8 The scale is an ordinal visual scale which contains 5 items: 1) posterior flattening, 2) ear misalignment, 3) forehead asymmetry, 4) neck involvement and 5) facial asymmetry. ...
Article
Introduction/Background The aim of this study is to investigate the effects of kinesiology taping and different application techniques in the treatment of CMT in addition to therapeutic exercises. Material and method Thirty-three infants with congenital muscular torticollis were randomly assigned to three groups. Each was received stretching, strengthening and positioning exercises twice a week for three weeks. Group 1 included 11 infants who only received exercises, Group 2 included 12 infants who received kinesiology taping applied on the affected side by using inhibition technique in addition to exercises. Group 3 included 10 infants who additionally received kinesiology taping applied on the unaffected side by using facilitation technique and on the affected side by using inhibition technique. Range of motion in lateral flexion and rotation of the neck, muscle function and degree of craniofacial changes were assessed at pretreatment, posttreatment and, 1 month and 3 months’ posttreatment. Results Friedman analysis of within-group changes over time revealed significant differences for all of the outcome variables in all groups except cervical rotation in Group 3 (P < 0.05). No significant differences were found between groups at any of the follow-up time points for any of the outcome variables (P > 0.05). Conclusion There is no any additive effect of kinesiology taping to exercises for the treatment of congenital muscular torticollis. Also different techniques of applying kinesiology taping resulted in similar clinical outcomes.
... To assess cervical lateral flexion motion, authors of the CMT CPG (Kaplan, Coulter, and Sargent, 2018) recommend using the Muscle Function Scale (MFS) (Öhman, Nilsson, and Beckung, 2009). The MFS is a visually appraised ordinal scale of active lateral neck righting used as a side-to-side comparison tool for infants with CMT. ...
Article
Introduction Upright infant active cervical motion (ACM) is difficult to measure accurately by a single examiner. Clinically, physical therapists use visual estimation, which has limited reliability and concurrent validity with gold standards. Consistent, reliable, and valid active motion measurements are needed to document infant status and response to intervention. Purpose Two-dimensional (2D) photo digitization measurements were compared to three-dimensional (3D) motion analysis measures of infant active neck rotation and lateral flexion. Methods Typically-developing infants participated (five boys, nine girls; 3–7.5 months). An experienced pediatric physical therapist and six novice raters marked photographs and used two different 2D methods to measure cervical rotation and three different 2D methods to measure cervical lateral flexion in photographs. To determine the intra- and interrater reliability of the 2D measurement methods and their concurrent validity with the 3D measures, a subset of lateral flexion photos was marked and measured by 14 experienced pediatric physical therapists. Results Novice and experienced examiner measurements of 2D ACM exhibited moderate to excellent intra- and inter-rater reliability. The results of the 2D lateral flexion ACM measurements completed by novice and experienced raters consistently differed from those obtained using the 3D measurement methods. Conclusion The 2D rotation ACM measurement methods were reliable and demonstrated concurrent validity with the gold standard 3D measure. Infants’ lateral flexion ACM examined using 2D measures did not correlate with the results of 3D measurements. This indicated that 2D measurements of active infant cervical lateral flexion could not be used as a valid indicators of 3D motion.
... For our purposes, we needed something with a simple setup (so we could not use anything external for tracking) and a light footprint (so that it can be implemented nearly anywhere). Additionally, there is very little surface area on the subjects (typically infants or small children), so larger markers that need high-resolution will not work [7,11]. We opted for a custom-built blob recognition because we can use distinct colors on a variety of surfaces for our markers. ...
Chapter
Pediatric physical therapists (PTs) have long struggled to diagnose and treat congenital muscular torticollis (CMT) at early stages, when such diagnosis and treatment would do the most good. Much of this problem is that very young infants and toddlers have difficulty with poses, are difficult to measure due to their small size, lack of compliancy, and inability to remain stationary. It often takes a team of pediatric PTs to perform these measurements, and usually in a clinical setting. We wish to create a toolset and a methodology that allows for simpler diagnostics, more comprehensive monitoring and treatment, and wider access to such care and treatment by creating TorticollisAR - an Augmented Reality (AR) application that performs critical measurements in a familiar, convenient setting (such as the home). The app uses tracking markers integrated into either bands or clothing to take measurements in real-time and while the subject is in motion.
... In these cases, it comes to the tearing or breakdown of the muscular fibers as a cause of excessive prolongation, which is not immediately noticeable. Consequences are hematomas within the MSCM that it is formed in the third week of the baby's birth that it can be seen when the baby's neck palpitates [17,18]. ...
Article
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Objective: Torticollis is a deformity characterized by the lateral flexion of the head to the arm on the side of the localization of deformity and its rotation on the opposite side. The aim of this paper is to identify the clinical characteristics that have an impact on the progression of the congenital muscular cramping, as well as to show the role of kinesitherapy in the treatment of torticollis.Methods: The research was conducted in the “Therapy” - Physical Therapy Clinic in Pristina, in the 2-year period since February 2014 until 2016. The total number of infants diagnosed with torticollis is 160, ranging from 0 to 9 months. At the beginning of the research, the examinations of all infants were performed, all the necessary tests, measurements, and motor functions. Afterward, they were rehabilitated for 3 consecutive weeks with 5 sessions per week, a total of 15 sessions for each. After the rehabilitation was completed, over again, the same tests were made as it was done in the beginning. Questionnaires were completed on the first and last visit for all infants.Results: In the first visit of the infants’ examination, there was no significant difference between the groups (Chi-test=0.96, p=0.1), whereas in the second examination, after 15 rehabilitation sessions, there was a significant difference in improvement of all the treated groups with kinesiotherapy. Significant result was achieved in mobility where at the beginning of the treatment, there was a very large limitation of neck mobility (different mean = −31.0±10.0.95% CI: 33.7-−28.2, p<0.001). A small limitation of mobility remained only among some third-degree infants in the 6-9 month age group because of the time appearance for physical treatment was delayed (different mean = −27.8±12.6, 95%, CI: 31.2-−24.4, p<0.001).Conclusion: From the results of our research on kinesiotherapy with infant toddlers with torticollis, we conclude that kinesitherapy has a primary and very successful effect on the treatment of babies with muscular torticollis.
... ICC>0.9). 4,16 To assess the degree of craniofacial changes Severity Scale for Assessment of Plagiocephaly (PSI) was used. 8 The scale is an ordinal visual scale which contains 5 items: 1) posterior flattening, 2) ear misalignment, 3) forehead asymmetry, 4) neck involvement and 5) facial asymmetry. ...
Article
Full-text available
Objective: To investigate the effects of kinesiology taping and different types of application techniques of kinesiology taping in addition to therapeutic exercises in the treatment of congenital muscular torticollis. Design: Prospective, single blind, randomized controlled trial. Setting: An outpatient rehabilitation clinic in a tertiary university hospital. Subjects: Infants with congenital muscular torticollis aged 3-12 months. Interventions: Group 1 included 11 infants who only received exercises, Group 2 included 12 infants who received kinesiology taping applied on the affected side by using inhibition technique in addition to exercises. Group 3 included 10 infants who additionally received kinesiology taping applied on the unaffected side by using facilitation technique and on the affected side by using inhibition technique. Main measures: Range of motion in lateral flexion and rotation of the neck, muscle function and degree of craniofacial changes were assessed at pretreatment, post treatment and, 1 month and 3 months' post treatment. Results: Friedman analysis of within-group changes over time revealed significant differences for all of the outcome variables in all groups except cervical rotation in Group 3 (P<0.05). No significant differences were found between groups at any of the follow-up time points for any of the outcome variables (P>0.05). Conclusions: There is no any additive effect of kinesiology taping to exercises for the treatment of congenital muscular torticollis. Also different techniques of applying kinesiology taping resulted in similar clinical outcomes.
... Range of Motion (ROM) of the neck in lateral flexion and rotation was measured, muscle function in the lateral flexors of the neck and head tilt were examined [33] [34]. The parents were asked about the infants sleep position and amount of tummy time when awake. ...
Article
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Developmental plagiocephaly (DP) has been an increasing problem since the successful “back to sleep campaign”. The referrals for DP have increased by more than 400% during the years 2004 to 2008. Many infants spend less time in the prone position nowadays and some of the risk factors for DP are: tummy time less than 3 times per day, torticollis and slow achievement of motor milestones. Improved information for the parents is needed but also other strategies to prevent DP. This study is a continuum of an earlier pilot study; the aim was to investigate the effect of a pillow, designed to reduce pressure on the infant head. Method: Infants aged zero to two months were included in the study. They were randomized to either intervention group or control group. Head shape was investigated on two occasions, on the second occasion motor development, mobility and muscle function of the neck were also investigated. The parents were asked about tummy time and sleep position. All infants were investigated by the same physical therapist, blinded to group belonging. Result: Fishers exact test showed that it was more common with decreased CVAI among infants in the intervention group (P 0.001). Paired t test showed significant decrease in CVAI for the intervention group (P 0.002), but not for the control group (P 0.96). Conclusion: This study shows that a specially designed pillow can decrease DP in young infants.
... SOMP-I assesses motor function and motor performance. Range of Motion (ROM) of the neck in lateral flexion and rotation were measured, and muscle function in the lateral flexors of the neck and head tilt was examined [18,19]. The parents were asked about the infants sleep position and amount of tummy time when awake. ...
Article
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Developmental plagiocephaly has increased since the back to sleep campaign and is nowadays a rather common condition in infants. Prevention is the best way to decrease this problem, therefore, tools for treatment are needed. This case description of two children who dropped out from a study of a specially designed pillow indicates that the Mimos pillow may work as the treatment in young infants with developmental plagiocephaly.
... Muscle function/strength of the lateral flexor muscles of the neck was estimated by using the same technique as when tested with the Muscle Function Scale [10]. Holding the child horizontally around the trunk without support for the head, the child was asked to lift the head as high as possible. ...
Article
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Background: Infants with congenital muscular torticollis are born with an asymmetric range of motion and a muscular imbalance in the cervical spine, as a result of a shortening or excessive contraction of the sternocleidomastoid muscle. Purpose: The study aimed to investigate passive range of motion (PROM) for rotation and lateral flexion, and muscle function of the cervical spine in children that had a history of CMT as infants. Study design: a prospective cohort study. Patient sample: 58 children at the age of 3.5 to 5 years that had been treated for CMT have infants participated in the study. Method: PROM was measured with protractors and muscle function was estimated with a modified Muscle Function Scale. Data from infancy were taken from earlier records. Result: PROM in rotation of the neck was mean 98.7° and PROM in lateral flexion of the neck was mean 69.1°. Symmetric PROM of the neck was found in 74% of the children for rotation and in 88% of the children for lateral flexion. Multiple regression showed that gender and PROM in rotation as infants had a significant impact on asymmetric PROM. Forty-five percent of the children had some degree of muscular imbalance in the lateral flexors of the neck. Conclusion: Possible risk factors for later asymmetric PROM are: gender, birth weight, gestation week and PROM in rotation as infants. These factors ought to be taken into consideration when developing guidelines for long-term follow-up.
... It is also important to be observant on the infant's motor development. Assessments and treatments are described in several studies [1,5,22,23]. The aim of the current study is to obtain knowledge about the existing practice in the physical therapy management of infants with CMT among members of a network for torticollis and also to develop a draft assessment protocol that could be used when examining an infant with CMT. ...
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Background: Infants with congenital muscular torticollis (CMT) are treated with physical therapy, however the knowledge about type of assessment and treatment in current clinical practice is not clear. Aim: This study aimed to investigate the management of infants with CMT within a network of physical therapists. Settings/population: Physical therapists from a network for CMT participated in the study. Method: With permission a questionnaire from New Zealand was used. Subsequently an expert group of physical therapists developed a draft assessment protocol. Result: In general there was a high degree of consensus between the respondents in the current survey. For the assessment visual estimates were most commonly used and an evaluation of cervical muscle strength of the neck was always/often conducted. The most effective form of intervention as perceived by the respondents in the management of CMT was passive stretching, handling advice, facilitation with strengthening exercises of the neck muscle and facilitation of active cervical range of motion. There were big discrepancies in assessment of hand- and hip asymmetry. Conclusion: There seems to be a need to develop international guidelines for CMT to improve the evidence practice of assessment and treatment.
... Hence lack of head control, asymmetry of the head and a favoured side can be discovered. Range of Motion (ROM) of the neck in lateral flexion and rotation was measured, muscle function in the lateral flexors of the neck and head tilt were examined [32,33]. The parents were asked about the infants sleep position and amount of tummy time when awake. ...
Article
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Developmental plagiocephaly (DP) has been an increasing problem since the successful “back to sleep campaign”. The referrals for DP have increased by >400% during the years 2004 to 2008. Many infants spend less time in the prone position nowadays and some of the risk factors for DP are as follows: less than 3 times per day for the tummy time, torticollis and slow achievement of motor milestones. There is a need for better information to the parents but also for other strategies to prevent DP. The aim of this study was to investigate the effect of a special pillow and thus to reduce pressure on the infant head. Method: infants aged zero to two months were included in the study. They were randomized to either intervention group or control group. Head shape was investigated on two occasions, on the second occasion motor development, mobility and muscle function of the neck were also investigated. The parents were asked about tummy time and sleep position. All infants were investigated by the same physical therapist, blinded to group belonging. Result: seven infants had CVAI >3.5 on the last assessment, five of these had not used any method to reduce pressure. Fishers exact test showed a tendency where infants with reduced pressure on the head had less DP (P 0.08). Paired t test showed significant decrease in CVAI for the infants who had had reduced pressure on the head (P 0.01). Among these infants the CVAI was zero for 47% in the last assessment. For the infants who had not had a reduction of pressure on the head, there was no indication of a decrease of CVAI (P 0.45), and only 12% of these infants had a CVAI that was zero in the last assessment. Conclusion: this pilot study shows that a specially designed pillow may prevent DP in young infants. However, a larger sample is needed to confirm or disprove this. The study is planned to go on until there are 200 participants.
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Background Congenital muscular torticollis (CMT) is a postural condition evident shortly after birth. The 2013 CMT Clinical Practice Guideline (2013 CMT CPG) set standards for the identification, referral, and physical therapy management of infants with CMT, and its implementation resulted in improved clinical outcomes. It was updated in 2018 to reflect current evidence and 7 resources were developed to support implementation. Purpose: This 2024 CMT CPG is intended as a reference document to guide physical therapists, families, health care professionals, educators, and researchers to improve clinical outcomes and health services for children with CMT, as well as to inform the need for continued research. Results/Conclusions: The 2024 CMT CPG addresses: education for prevention, screening, examination and evaluation including recommended outcome measures, consultation with and referral to other health care providers, classification and prognosis, first-choice and evidence-informed supplemental interventions, discontinuation from direct intervention, reassessment and discharge, implementation and compliance recommendations, and research recommendations.
Article
Purpose To examine the intrarater and interrater reliability and construct validity of the Functional Symmetry Observation Scale, Version 2 (FSOS-V2) in infants with congenital muscular torticollis (CMT). Methods The FSOS-V2 is a video-based measure of postural and movement symmetry in infants with CMT. Four examiners scored 50 participants’ videos twice. Scores obtained by the same rater and across 4 raters were compared to examine intrarater and interrater reliability, respectively. Participants’ habitual head deviation from midline in supine photographs was measured using a protractor. Relationship between the head tilt angles and FSOS-V2 scores was examined to assess construct validity. Results Fifty infants with CMT, age range 1 to 16 months, participated. Results indicated moderate to good intrarater and poor to moderate interrater reliability. The FSOS-V2 construct validity was supported. Conclusion The FSOS-V2 can be used by the same therapist repeatedly to make clinical decisions. Further research will strengthen its psychometric properties.
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Background Congenital muscular torticollis (CMT) is a well-known diagnosis among physiotherapists specializing in pediatric care, especially when working with infants. However, knowledge of bilateral torticollis is limited. The purpose of this article was to describe how bilateral torticollis may present itself clinically. Case One infant with CMT with sternocleidomastoid tumor (SMT) on the right side, and some limitation in rotation towards the right side and in lateral flexion towards the left side, i.e, the muscle on the right side was shortened. While sitting with support, he tilted the head to the left and was stronger in the lateral flexors on the left side which fit well with a postural left-sided torticollis (PT). The other infant had bilateral muscular torticollis (MT), the sternocleidomastoid muscle thickened bilaterally, and both active and passive rotations were affected. The head was held in flexion, and active rotation was severely limited to both sides. For both cases the therapeutic interventions were to gain a normal range of motion (ROM) and a good posture of the head. Conclusions CMT can appear in different ways and may be bilateral. Both infants gained good ROM and better head position, however case I still needs some training. To gain more knowledge about bilateral CMT, we should follow these cases over a longer period of time. It is important to communicate and discuss our experiences with each other to understand rare cases of CMT.
Article
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Background Congenital muscular torticollis (CMT) is a well-known diagnosis among physiotherapists specializing in pediatric care, especially when working with infants. However, knowledge of bilateral torticollis is limited. The purpose of this article was to describe how bilateral torticollis can appear in infants. Case One infant with CMT with sternocleidomastoid tumor (SMT) on the right side, and some limitation in rotation towards the right side and in lateral flexion towards the left side, that is, the muscle on the right side was shortened. While sitting with support, he tilted the head to the left and was stronger in the lateral flexors on the left side which fit well with a postural left-sided torticollis (PT). The other infant had bilateral muscular torticollis (MT), the sternocleidomastoid muscle thickened bilaterally, and both active and passive rotations were affected. The head was held in flexion, and active rotation was severely limited to both sides. For both cases the therapeutic interventions were to gain a normal range of motion (ROM) and a good posture of the head. Conclusions CMT can appear in different ways and may be bilateral. Both infants gained good ROM and better head position, however case I still needs some training. To gain more knowledge about bilateral CMT, we should follow these cases over a longer period of time. It is important to communicate and discuss our experiences with each other to understand rare cases of CMT.
Article
Objective The purposes of this pilot study were to compare short-term outcomes of the Perception-Action Approach (P-AA) and standard care based on 5 components of first-choice interventions listed in the congenital muscular torticollis (CMT) clinical practice guideline. Changes in postural alignment, symmetrical use of both sides of the body during movement and play, gross motor development, and behavior observed during therapy were considered. Methods Thirty-two participants were enrolled in a 2-group (P-AA and standard care) randomized, single-blind trial with pre-post test measures. Participants were infants with CMT, age range 5 to 35 weeks at enrollment. Outcome measures administered at initial and final evaluations included still photography, arthrodial goniometry, Muscle Function Scale, Alberta Infant Motor Scale, and Functional Symmetry Observation Scale (FSOS). Participants in both groups attended 3 intervention sessions. Their behavior exhibited during therapy was compared using the Therapy Behavior Scale (TBS) Version 2.2. Results Data collection was interrupted by the COVID-19 pandemic lockdown. Twenty-four infants completed the study (10 in P-AA and 14 in the standard care group). There were no significant differences between the groups in performance at initial and final evaluations. Both groups improved on most outcome measures. The P-AA group made greater gains on the FSOS, and the TBS Version 2.2 scores were higher in the P-AA group, but these results did not reach significance. Conclusions Results suggest that similar short-term outcomes may be obtained in infants with CMT undergoing P-AA and standard care interventions. Definitive conclusions regarding the efficacy of the P-AA in infants with CMT cannot be made at this time. Nevertheless, the pilot findings provide valuable preliminary data for a future efficacy trial, which will require funding. Impact This was the first randomized controlled trial to provide evidence for use of P-AA intervention in infants with CMT.
Article
Purpose The purposes of this case report were to (1) highlight the use and efficacy of the Tubular Orthosis for Torticollis (TOT) Collar in a prolonged and complex episode of care for an infant with congenital muscular torticollis (CMT) and (2) describe an infant with CMT receiving a physical therapy episode of care interrupted by the COVID-19 pandemic, leading to use of supplemental interventions. Summary of Key Points The patient presented was an infant with CMT who received physical therapy treatment, including the TOT Collar, to resolve all symptoms. Statement of Conclusions The TOT Collar helped achieve midline head position after all treatment options were exhausted at the end of a lengthy episode of care impacted by the COVID-19 pandemic. Recommendation for Clinical Practice The TOT Collar may be an appropriate supplemental intervention choice for infants with CMT whose symptoms do not resolve with first-choice interventions.
Article
Purpose: To systematically review current evidence on the physical therapy assessment, intervention, and prognosis of congenital muscular torticollis (CMT) to inform the update to the 2018 CMT Clinical Practice Guideline (CPG). Methods: Six databases were searched for studies that informed assessment, intervention, and prognosis for physical therapy management of infants with CMT. Results: Fifteen studies were included. Four studies investigated the psychometric properties of new and established assessments. Six studies informed the feasibility and efficacy of first-choice and supplemental interventions including traditional Chinese medicine and neural and visceral manipulation. One qualitative study found that parents of infants with mild and severe CMT had different concerns. Five studies informed prognosis, including factors associated with treatment duration, clinical outcomes, and use of supplemental interventions. Conclusion: Newer evidence reaffirms 5 of 17 recommendations of the 2018 CMT CPG and could increase the recommendation strength to strong for neck passive range of motion.
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Objective To detect the effect and safety of massage therapy on infants with congenital muscular torticollis. Methods A total of 56 infants with unilateral congenital muscular torticollis were enrolled in this retrospective comparative study. The subjects were divided in two groups, namely, the control group and the massage group. The control group ( n = 28) received the treatment of sternocleidomastoid muscle (SCM) stretching, while the massage group ( n = 28) received massage therapy combined with SCM stretching. The following parameters were compared: the cervical range of motion (ROM) and functional level (muscle function scale and ratio of muscle function scale scores). Complications, if any, were also recorded. Results Of the 56 infants, 7 infants (12.5%) underwent surgery with little functional improvement. The total effective rate of conservative treatment was 87.5%. No significance was found in terms of the surgery rate between both groups (14.29 vs. 10.71%, P = 0.693). After treatment, the ROM (including rotation and lateral flexion) and the ratio of muscle function scale scores improved significantly ( P < 0.05). In the latest follow-up, the massage group showed a greater improvement in rotation and lateral flexion. However, no significant difference in the muscle function scale score ratio was found ( P = 0.126). Importantly, no adverse events related to blood vessels, nerves, and SCM occurred. Conclusions Providing massage therapy in infants with congenital muscular torticollis is a safe and effective method to improve the cervical range of motion and function. However, this study did not find any decrease in the surgical rate between two groups of patients despite adding such therapy.
Article
Purpose: To describe demographic factors, baseline characteristics, and physical therapy episodes in infants with congenital muscular torticollis (CMT), examine groups based on physical therapy completion, and identify implications for clinical practice. Methods: Retrospective data were extracted from a single-site registry of 445 infants with CMT. Results: Most infants were male (57%), Caucasian (63%), and firstborn (50%), with torticollis detected by 3 months old (89%) with a left (51%), mild (72%) CMT presentation. Cervical range of motion (ROM) limitations were greatest in passive lateral flexion and active rotation. Sixty-seven percent of infants completed an episode of physical therapy, 25% completed a partial episode, and 8% did not attend visits following the initial examination. Age at examination, ROM, and muscle function differed significantly between groups. Conclusions: Physical therapists may use clinical registry data to inform practice for timing of referral, frequency of care, and clinician training to manage infants with CMT.
Article
Purpose: To describe the development of the Functional Symmetry Observation Scale (FSOS) Version 2 and its content validation. Methods: The FSOS Version 2 is an observational assessment that quantifies symmetry in spontaneous movement and posture in infants with congenital muscular torticollis, age birth to 18 months. Twenty expert pediatric physical therapists were identified through purposive sampling and invited to participate in a modified Delphi study. Survey data were collected on Qualtrics. Consensus was evaluated using median ratings and percent agreement on Likert Scale items. Thematic analysis was performed for open-ended question responses. Results: Thirteen experts completed Round 1 and 2 surveys. In Round 1, consensus was achieved on all but 1 item. The scale was modified based on received feedback. In Round 2, consensus was achieved on all items (median rating of 4, agreement at 85%-100%). Conclusions: This study established the content validity of the FSOS Version 2.
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Background: Congenital muscular torticollis (CMT) is a postural deformity evident shortly after birth, typically characterized by lateral flexion/side bending of the head to one side and cervical rotation/head turning to the opposite side due to unilateral shortening of the sternocleidomastoid muscle; it may be accompanied by other neurological or musculoskeletal conditions. Infants with CMT should be referred to physical therapists to treat these postural asymmetries as soon as they are identified. Purpose: This update of the 2013 CMT clinical practice guideline (CPG) informs clinicians and families as to whom to monitor, treat, and/or refer and when and what to treat. It links 17 action statements with explicit levels of critically appraised evidence and expert opinion with recommendations on implementation of the CMT CPG into practice. Results/conclusions: The CPG addresses the following: education for prevention; referral; screening; examination and evaluation; prognosis; first-choice and supplemental interventions; consultation; discontinuation from direct intervention; reassessment and discharge; implementation and compliance audits; and research recommendations. Flow sheets for referral paths and classification of CMT severity have been updated.
Article
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To determine the comparative effectiveness of non-surgical and non-pharmacological interventions for the management of congenital muscular torticollis (CMT) in infants and children aged 0 to 5 years. © 2018 The Cochrane Collaboration. The link for the protocol can be found through: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD012987/full. Published by John Wiley & Sons, Ltd.
Article
Backround: 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.
Article
Objective: To compare the short-term efficacy of 2 dosages of stretching treatment on the clinical outcomes in infants with congenital muscular torticollis. Design: This was a prospective randomized controlled study. Fifty infants with congenital muscular torticollis who were randomly assigned to 100-times stretching group and 50-times stretching group received stretching treatment for the affected sternocleidomastoid muscle. The outcomes including the head tilt, the cervical passive range of motion, and the muscle function of cervical lateral flexors determined by the muscle function scale were assessed at baseline and at 4 and 8 weeks after treatment. The sternocleidomastoid muscle growth analyzed by the thickness ratio of sternocleidomastoid muscles was measured using ultrasonography at baseline and 8 weeks after treatment. Results: Except the ratio of muscle function scale scores, the postintervention outcomes were all significantly improved in both groups compared with baseline (P < 0.05). The 100-times stretching group showed greater improvement compared with 50-times stretching group in head tilt and cervical passive range of motion at 4 and 8 weeks after treatment (P < 0.05). Conclusions: Stretching treatment of 2 dosages may effectively improve head tilt, cervical passive range of motion, and sternocleidomastoid muscle growth in infants with congenital muscular torticollis. The stretching treatment of 100 times per day is likely to associate with greater improvement in head tilt and cervical passive range of motion.
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» Voorkeurshouding en schedeldeformatie op de zuigelingenleeftijd komen de laatste twee decennia zeer frequent voor, sinds de veranderde preventieve adviezen ten aanzien van wiegendood om zuigelingen niet meer op de buik of zij te laten slapen. Er is een oorzakelijk verband tussen de hanterings- en positioneringsgewoonten (slapen, voeden, spelen, verzorgen), de motorische ontwikkeling, de voorkeurshouding en schedeldeformatie. Met behulp van een recentelijk ontwikkelde, objectieve meetmethode voor schedeldeformatie, plagiocefalometrie, kan de mate van schedeldeformatie door de fysiotherapeut worden vastgelegd en in de tijd worden gevolgd. Protocollaire kinderfysiotherapie heeft een bewezen reducerend effect op de schedelasymmetrie, in vergelijking met de reguliere zuigelingenzorg. Het is belangrijk om nieuwe, wetenschappelijk bewezen kennis te implementeren in de dagelijkse praktijk van alle kindgerichte professionals in de gezondheidszorg. Een landelijke, multidisciplinaire JGZ-richtlijn Preventie, signalering en aanpak van voorkeurshouding en schedelvervorming komt eind 2011 gereed. In de komende tijd zal er meer bekend worden over zuigelingenasymmetrie, omdat er verschillende wetenschappelijke onderzoeken lopen.
Article
Abstract Objective To investigate the immediate effect of kinesiology taping (KT) on muscular imbalance in the lateral flexors of the neck. Design Randomized controlled trial. Participants Twenty-nine infants with congenital muscular torticollis and muscular imbalance in the lateral flexors of the neck were chosen consecutively. Also five healthy infants with no signs of muscular imbalance in the neck were tested. Method The infants were randomly allocated to either intervention group or control group. The intervention group had kinesiology taping applied on the affected side using the relaxing technique. The healthy infants were tested both with and without kinesiology taping. The evaluator was blinded to whether the infants were taped or not. Results There was a significant difference in the change of MFS scores between the groups (P<.0001). In the intervention group there were significantly lower scores on the affected side that had been taped (P<.0001) and also significantly higher scores on the unaffected side (P=.01). There were no significant differences in the control group. For the healthy infants, with no imbalance in the lateral flexors of the neck, there were no changes to the MFS scores whether the kinesiology tape was applied or not. Conclusions For infants with congenital muscular torticollis, kinesiology taping applied on the affected side has an immediate effect on the MFS scores for the muscular imbalance in the lateral flexors of the neck.
Article
Congenital muscular torticollis (CMT) is an idiopathic postural deformity evident shortly after birth, typically characterized by lateral flexion of the head to one side and cervical rotation to the opposite side due to unilateral shortening of the sternocleidomastoid muscle. CMT may be accompanied by other neurological or musculoskeletal conditions. Infants with CMT are frequently referred to physical therapists (PTs) to treat their asymmetries. This evidence-based clinical practice guideline (CPG) provides guidance on which infants should be monitored, treated, and/or referred, and when and what PTs should treat. Based upon critical appraisal of literature and expert opinion, 16 action statements for screening, examination, intervention, and follow-up are linked with explicit levels of evidence. The CPG addresses referral, screening, examination and evaluation, prognosis, first-choice and supplemental interventions, consultation, discharge, follow-up, suggestions for implementation and compliance audits, flow sheets for referral paths and classification of CMT severity, and research recommendations. Available at the Pediatric PT journal website: https://journals.lww.com/pedpt/Abstract/2013/25040/Physical_Therapy_Management_of_Congenital_Muscular.2.aspx
Article
Purpose: To present an algorithm with accompanying treatment parameters for the management of congenital muscular torticollis (CMT) based on the best available literature. Methods: A systematic search of PubMed, MEDLINE, CINHAL, and Cochrane databases was conducted to identify evidence to guide the conservative management of CMT. Results: An evidence-based algorithm was created based on three prognostic factors that influence treatment duration and outcome, including a sternocleidomastoid fibrotic mass, passive range of motion rotation deficit, and age at initiation of treatment. Preliminary treatment parameter recommendations for clinic and home programming accompany the algorithm. Conclusion: Use of the proposed evidence-based algorithm with accompanying preliminary treatment parameter recommendations may improve consistency of care and outcomes for infants with CMT. While a higher level of evidence supports the three prognostic factors utilized in the algorithm, research gaps continue to exist with regards to treatment parameters.
Article
This study focuses on the treatment of the muscle function imbalance and asymmetric head posture for infants with congenital muscular torticollis (CMT). The aim of this study was to compare treatment time for groups with different strategies for muscle function training. The treatment goal was to achieve a symmetric head posture. Thirty-seven infants were randomised to three groups. Group I was treated only with handling strategies. Group II got the same handling strategies but also received specific strength exercises. Group III received the same treatment as group II but was also provided with weekly training by a physiotherapist. Mean age at the start of treatment was 4.5 months of age, range 1-10.5. The possible effect of covariates was also investigated; age at the start of treatment, range of motion (ROM) in rotation of the neck, ROM in lateral flexion of the neck, the muscle function scale (MFS) score, plagiocephaly, and gender were analysed with ANCOVA. Thirty-one treated infants achieved symmetric head posture before the age of 12 months. Mean treatment time (3.5 month) did not differ significantly between the groups. All infants randomised to group I could stay in that group. The MFS score and age at the start of the treatment influenced treatment time (p < 0.05). The treatment time for all groups was similar. Early referral to physical therapy of infants with CMT and muscle function imbalance in lateral righting could shorten treatment time. Studies about natural course and long-term effects of muscular imbalance must be investigated in future research.
Article
To investigate the time needed to achieve a good result in the range of motion (ROM) in the neck for infants with congenital muscular torticollis (CMT). Comparison of stretching treatments performed by physical therapists and parents. Twenty infants (10 female and 10 male) with CMT. The infants were randomly assigned to 1 of 2 groups. Stretching treatment was continued until a good ROM was obtained in both rotation (≥ 90°) and lateral flexion (no side difference). The main outcome measurement was treatment time. The infants were evaluated for ROM in rotation and lateral flexion, muscle function in the lateral flexor muscles of the neck, plagiocephaly, and head tilt. The time needed to achieve a good result according to the ROM in the neck was significantly shorter (P < .001) in the physical therapist group than in the parent group. Symmetrical head posture was achieved sooner (P = .03) in the physical therapist group. Infants with CMT gained good ROM and symmetric head posture approximately 2 months sooner when treated by an experienced physical therapist; however, interpretation of the results of this small study should be guarded. Further studies are needed to confirm these results.
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Reliability coefficients often take the form of intraclass correlation coefficients. In this article, guidelines are given for choosing among 6 different forms of the intraclass correlation for reliability studies in which n targets are rated by k judges. Relevant to the choice of the coefficient are the appropriate statistical model for the reliability study and the applications to be made of the reliability results. Confidence intervals for each of the forms are reviewed. (23 ref) (PsycINFO Database Record (c) 2006 APA, all rights reserved).
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Isometric muscle force was measured in 217 normal children aged 3.5-15 years. The standard error of a single determination made by the same observer was ca. 9% of the muscle force. When two measurements were made by different observers the standard error of the difference was estimated at ca. 17%. Reference values for isometric force are given for boys and girls separately. With regard to 7 of the 10 muscle groups tested the force was significantly greater in boys than in girls as early as at ca. 10 years of age. Age and weight were the most important predictors of muscle force.
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A new evaluative measure of motor and sensory function was developed for children with epilepsy aged six to 16 years. The bases for the measure were theories of normal motor development and motor control, and the conceptual framework was the World Health Organization's International Classification of Impairments, Disabilities, and Handicaps. The assessment protocol has 59 items, including gross motor function, gait, balance, coordination, strength, range of motion, velocity, fine motor function, sensation, perception, and performance on neurological tests. The quality and level of sensorimotor function were scored. Classification of handicap was included in the test. Intrarater and interrater reliability were evaluated and found to be good (r(s) ≥ 0.9). The test was administered to 274 children, and evidence of good content validity, criterion- based/concurrent validity, construct validity, and responsiveness to change was found. The test was found to be a useful measure of motor and sensory function in this heterogeneous population of children with epilepsy involved in an epilepsy surgery program.
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The purpose of this descriptive study is to report the outcomes of a case series of children treated with physical therapy for developmental muscular torticollis (DMT). The treatment program described emphasizes parental home programs of positioning and strengthening as opposed to hands-on passive range of motion. We studied a sample of convenience of 23 children (mean age = 18 months, SD = 9.7 months) whose parents agreed to a follow-up evaluation. Initial evaluations were reviewed retrospectively and compared with the follow-up, posttest data. Results showed that at an average of 14 months postinitial examination, 83% of the children had no observable head tilt, only slightly decreased (three to six degrees) passive and active cervical range of motion on the involved sides, and full lateral head righting in all but one child, and there was no residual facial asymmetry or plagiocephaly in 66% of the children. Ninety-five percent of the parents categorized the physical therapy from helpful to very helpful. Overall outcome was judged utilizing a point system that incorporated a variety of clinical aspects of torticollis. Good to excellent results were achieved in 96% of the children based on these criteria. (C) Williams & Wilkins 1997. All Rights Reserved.
Article
A new evaluative measure of motor and sensory function was developed for children with epilepsy aged six to 16 years. The bases for the measure were theories of normal motor development and motor control, and the conceptual framework was the World Health Organization's International Classification of Impairments, Disabilities, and Handicaps. The assessment protocol has 59 items, including gross motor function, gait, balance, coordination, strength, range of motion, velocity, fine motor function, sensation, perception, and performance on neurological tests. The quality and level of sensorimotor function were scored. Classification of handicap was included in the test. Intrarater and interrater reliability were evaluated and found to be good (rs >= 0.9). The test was administered to 274 children, and evidence of good content validity, criterion-based/ concurrent validity, construct validity, and responsiveness to change was found. The test was found to be a useful measure of motor and sensory function in this heterogeneous population of children with epilepsy involved in an epilepsy surgery program. (C) 2000 Lippincott Williams & Wilkins, Inc.
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Every year, about 60 infants receive treatment for congenital muscular torticollis (CMT), at the Department of Physiotherapy. The aim of this study was to do a survey of children treated for CMT, and investigate if there was a difference between the affected and not affected side. Children born 1999–2001 treated for CMT at The Queen Silvia Children's Hospital were asked to participate in a survey. The children were evaluated once and a scoring system was used, which included functional and cosmetic results. The neck movement, endurance, elevation of the shoulder and lateral band were compared with the uninvolved side. Head tilt and craniofacial asymmetry were evaluated by the use of clinical observations and photographs. The majority (96%) had excellent/good range of motion and excellent/good posture (94.5%) of the head. The most notable findings were craniofacial asymmetry and asymmetry in endurance of neck muscles. The conclusion was that most children had an overall excellent or good status at time for the survey and functional problems were rare. For 45% of the children craniofacial asymmetry was still present and for 41% there was asymmetry in endurance of neck muscles. Whether asymmetric muscle endurance is an important factor has to be further examined.
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The EK {Egen Klassifikation} scale was developed to assess overall functional ability in the non-ambulatory stage of Duchenne muscular dystrophy (DMD). The purpose of this study was to examine the reliability of the EK scale. Six subjects with DMD, selected as representative of the entire range of functional ability seen in the nonambulatory phase of the disease, were video recorded and assessed using the EK scale. The assessment required both interview and performance of functional activities. The video records were shown to 17 healthcare professionals comprising seven three physiotherapy students, four occupational therapists, two social workers and one physician. They viewed and assessed the video recordings. Seven of the professionals repeated the assessments after 6-8 weeks. Intra-class correlation coefficients determined for both inter- and intra-rater reliability were 0.98. The standard deviation of individual estimates of EK sum was 0.95 when physiotherapists, an assessment was repeated by different evaluators on the same subject and 0.78 when repeated by the same evaluator. Weighted kappa values for individual categories ranged from 0.67 to 0.94. The EK scale was found to be highly reliable when used by healthcare professionals assessing the subjects from videotapes.
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The aim of this study was to assess status after surgery for congenital muscular torticollis. Twenty-eight children were evaluated once and the scoring system used included functional and cosmetic results. Neck movement, muscle strength and endurance were compared with the uninvolved side. Head tilt, elevation of the shoulder, craniofacial asymmetry, and lateral band and operative scar were evaluated by clinical observations and photographs. Limited range of motion was significant in both rotation (p=0.027) and side flexion (p=0.005) on the operated side. Most children achieved an overall excellent or good result after surgery but a tendency for head tilt and some degree of facial asymmetry were common.
Article
This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.
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A retrospective review of 277 patients with congenital muscular torticollis seen between 1970 and 1982 was conducted. In 85 cases this was supplemented by questionnaires and recent photographs, permitting a two- to 13-year follow-up. The first visit for 81.6% of patients was before six months of age. All were enrolled in a specific physical therapy program at the time of the first visit, unless they presented with severe torticollis after 12 months of age. Torticollis was mild to moderately severe in 90.6% of cases. Sternomastoid fibrotic nodules were present in 38.6%, more frequently in the more severe cases. Hip dysplasia increased in direct relation to severity and occurred in 10.5% of cases. At 12 months the torticollis had been conservatively resolved in nearly 70% of patients regardless of severity and presence or absence of focal fibrosis. Tenotomies were indicated in only ten children, eight of whom had first been seen after 12 months of age. Long-term sequelae were mild and consisted of craniofacial asymmetry, intermittent head tilt, and mild scoliosis. Developmental asymmetry or high tone due to limited mobility in the cervical spine were noted in 25.3% of infants initially and tended to subside with appropriate therapy. However, 11.8% of patients with long-term follow-up showed persistent functional asymmetry of the involved body side despite mild or moderate severity, early diagnosis, and complete resolution of the torticollis. Long-term observations indicate that congenital torticollis rarely requires surgical treatment.
Article
Although the success of conservative management of congenital muscular torticollis has been well documented, relatively little is known about the determinants of response to treatment, such as treatment duration. The purpose of this study was to determine how factors such as severity of restriction of range of motion, age at initiation of treatment, and presence of a palpable intramuscular fibrotic sternocleidomastoid muscle mass affect treatment duration. One hundred one children (mean age = 4 months, SD = 2.87, range = 0.5-15.5) who were diagnosed with congenital muscular torticollis and referred to physical therapy at British Columbia's Children's Hospital (Vancouver, British Columbia, Canada) prior to 2 years of age were included in the study. Following a standardized initial assessment, parents were taught the home treatment program, which included passive stretches of the affected sternocleidomastoid muscle and strengthening exercises for the contralateral side, and positioning and handling skills. Evaluation at 2-week intervals included measurement of passive neck rotation and lateral flexion using an adapted standard goniometer. Treatment duration was defined as the time between initiation of treatment and achievement of full passive neck range of motion. Complete recovery (full passive range of motion) was achieved in all but one of the children in this sample. The mean treatment duration was 4.7 months (SD = 5.06, range = 1-36). Correlations were noted between severity of restriction and treatment duration (r = .31) as well as between presence of a mass and treatment duration (r = .26). Multiple regression analysis revealed that severity of restriction was the strongest predictor of treatment duration. The results of this study will make it possible for therapists to better predict treatment duration at the time of the initial assessment. By providing parents with more precise information about the length of treatment, parents may be more willing to adhere to the exercise program. [Emery C. The determinants of treatment duration for congenital muscular torticollis.
Article
The main objectives of this study were to define the clinical patterns and characteristics of congenital muscular torticollis (CMT) presented in the first year of life and to study the outcome of different treatment methods. This is a prospective study of all CMT patients seen in 1 center over a 12-year period with uniform recording system, assessment methods, and treatment protocol. From a total of 1,086 CMT infants, 3 clinical subgroups of sternomastoid tumor (SMT; 42.7%), muscular torticollis (MT; 30.6%), and postural torticollis (POST; 22.1%) were identified. The SMT group was found to present earlier within the first 3 months and was associated with higher incidence of breech presentation (19.5%), difficult labor (56%), and hip dysplasia (6.81%). Severity of limitation of passive neck rotation range (ROTGp) was found to correlate significantly with the presence of SMT, bigger tumor size, hip dysplasia, degree of head tilt, and craniofacial asymmetry. A total of 24.5% of the patients with initial deficits of passive rotation of less than 10 degrees showed excellent and good outcome with active home positioning and stimulation program. The remaining cases with rotation deficits of over 10 degrees and treated with manual stretching program showed an overall excellent to good results in 91.1% with 5.1% requiring subsequent surgical treatment. The most important prognostic factors for the necessity of surgical treatment were the clinical subgroup, the ROTGp, and the age at presentation (P < .001).
Article
Agreement measures are used frequently in reliability studies that involve categorical data. Simple measures like observed agreement and specific agreement can reveal a good deal about the sample. Chance-corrected agreement in the form of the kappa statistic is used frequently based on its correspondence to an intraclass correlation coefficient and the ease of calculating it, but its magnitude depends on the tasks and categories in the experiment. It is helpful to separate the components of disagreement when the goal is to improve the reliability of an instrument or of the raters. Approaches based on modeling the decision making process can be helpful here, including tetrachoric correlation, polychoric correlation, latent trait models, and latent class models. Decision making models can also be used to better understand the behavior of different agreement metrics. For example, if the observed prevalence of responses in one of two available categories is low, then there is insufficient information in the sample to judge raters' ability to discriminate cases, and kappa may underestimate the true agreement and observed agreement may overestimate it.
Article
This article examines and illustrates the use and interpretation of the kappa statistic in musculoskeletal research. The reliability of clinicians' ratings is an important consideration in areas such as diagnosis and the interpretation of examination findings. Often, these ratings lie on a nominal or an ordinal scale. For such data, the kappa coefficient is an appropriate measure of reliability. Kappa is defined, in both weighted and unweighted forms, and its use is illustrated with examples from musculoskeletal research. Factors that can influence the magnitude of kappa (prevalence, bias, and non-independent ratings) are discussed, and ways of evaluating the magnitude of an obtained kappa are considered. The issue of statistical testing of kappa is considered, including the use of confidence intervals, and appropriate sample sizes for reliability studies using kappa are tabulated. The article concludes with recommendations for the use and interpretation of kappa.
Article
To determine reference values for cervical range of motion (ROM) in rotation and lateral flexion and for muscle function in the lateral neck flexors in a sample of infants who were healthy. ROM was measured, and muscle function was estimated in 38 infants at the ages of 2, 4, 6, and 10 months. For rotation the mean ROM was 110 degrees and for lateral flexion it was 70 degrees. Infants of 2 months of age had a median muscle function score of 1 (interquartile range, 1-2). Muscle function increased to score 3 to 4 by 10 months. Infants below 1 year of age have good ROM in rotation (> or = 100 degrees ) and lateral flexion (> or = 65 degrees ) of the neck. These reference values for passive ROM and muscle function of the neck may have clinical utility in assessing and documenting the initial evaluation and progress of infants with congenital muscular torticollis.
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