Clinical characteristics and kinesitherapy treatment of congenital torticollis muscular

Abstract

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.

Full text

Vol 10, Issue 8, 2017
Online - 2455-3891
Print - 0974-2441
CLINICAL CHARACTERISTICS AND KINESITHERAPY TREATMENT OF CONGENITAL
TORTICOLLIS MUSCULAR
ZHERALLDIN DURGUTI, ARDIANA MURTEZANI, EQREM GARA*, TEUTA DURGUTI
Physical Medicine and Rehabilitation Clinic, University of Pristina, Kosovo. Email: eqremgara3@gmail.com
Received: 20 May 2017, Revised and Accepted: 29 June 2017
ABSTRACT
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.
Keywords: Torticollis, Kinesitherapy, Infants, Clinical features, Neck mobility.
INTRODUCTION
Torticollis is a deformity characterized by the lateral flexion of the
head to the arm on the side of the localization of the deformity and
its rotation on the opposite side [1]. Congenital muscular torticollis
by the frequency is the third deformity in the children’s orthopedics,
following the developmental disorder of the skeletal and congenital
equinox [2]. It is a unilateral consequence of the sternocleidomastoid
muscle contractility (MSCM) [3]. Observation and physical therapy,
with or without ortho, is in the most of the cases an effective treatment,
especially if it is done within the first year of life [4]. Usually, it is
associated with facial and head asymmetry and with the amplitude
movement limitation of the cervical pillar [5].
Regarding the etiology of torticollis is still unclear, but many different
authors think that the presentation of congenital musculoskeletal
neoplasm in babies has to do with polyethiology factors, such as fetal
position in the uterus, limited space inside the uterus, rotation of
the baby’s head during baby birth, positioning, and manipulation of
the baby after birth, and in some cases, genetic factors may also be
affected [6,7].
Diagnosis is done on the basis of a clinical examination of the cervical
region, where the cervical axis radiography is necessary to exclude
bone modifications, as well as examining otorhinolaryngology and
ophthalmology are necessary too [8,9]. Meanwhile, the clinical signs
of torticollis are characterized based on the position of babies head.
The head of the baby is humble on the sick side, there is movement
restriction on that side, and muscle tone is increased, while MSCM is
short and strong [10].
For the physical treatment of torticollis, these procedures are applied:
Thermotherapy, electrotherapy, kinesitherapy, and work therapy,
which are functional orthopedic aids [11,12]. The primary role in
treatment is kinesitherapy, which is used to prolong MSCM extension
and strengthening of other structures around the neck, as well as
eliminating the muscular contraction [13].
In most of the cases, the problems of infants with torticollis with
the application of physical therapy are cured. In rare cases, surgical
intervention is needed, which it comes due to the non-presentation
of the infant’s baby with torticollis for physical treatment because it is
much more effective to treat infants when it begins in the early days of
the baby’s birth [14,15].
The main purpose of this paper is to identify the clinical characteristics
that have an impact on the progression of congenital muscular cramping
and to show the role of the kinesitherapy in the infant’s cramping/
torticollis treatment.
METHODS
Due to the realization of this prospective paperwork, partial research
methods were conducted through a questionnaire obtained by Anna
Marie Ohmman PT.MSC.PHD at Queen Silvia Children’s Hospital
“Questionnaire for torticollis in infants,” which includes general patient
data, patient examination, as well as the achieved results at the end of
the treatment [16].
The research was conducted in the “Therapy”- Physical Therapy Clinic
in Pristina in the 2-year period since February 2014 until 2016. The
© 2017 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (http://creativecommons.
org/licenses/by/4. 0/) DOI: http://dx.doi.org/10.22159/ajpcr.2017.v10i8.20085
Research Article

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Durguti et al.
total number of infants diagnosed with torticollis is 160, ranging from
0 to 9 months. The babies involved in the research were divided into
three groups by age and number of sessions applied. The first group
included 53 infants (33.13%), in the second group 52 infants (32.5%),
and the third group included 55 infants (34.38%).
At the beginning of the research, all of the infant’s examinations were
made, all the necessary tests, measurements, and motor function.
Afterward, they were rehabilitated for 3 consecutive weeks with
5 sessions per week, in total 15 sessions per each. After the rehabilitation
was completed, over again, the same tests were made as it was done
in the beginning. In the first and last visit, the questionnaires were
completed for all infants. All parents were informed and agreed on the
manner and the purpose of the research.
Throughout the clinical examination cervical spine mobility was
examined, cervical spine muscle force, the shape of head and face was
assessed and also the presence of concomitant anomalies.
The criteria for introducing infants were between 0 and 9 months, a
diagnosis with torticollis set by the pediatrician, orthopedics, and
physiatrist, as well as the infants with good health in general, verified
with anamnesis and clinical examination. Whereas those infants who
have not been treated in time have been diagnosed with torticollis as
a result of other pathologies who have been surgically treated - the
tenotomy is not included in the research.
The presentation of data is done through tables and graphs while data
processing is done with the SPSS program. As regarded to statistical
parameters structure index was calculated, arithmetic average, standard
deviation (SD), minimal and maximal values. The data were tested by
t-test and the verification of the tests was done for the confidence or
credibility level 95% and 99%, respectively, p<0.05 and p<0.01.
RESULTS
Table 1 lists the demographic data and the clinical features of 160 infants
involved in the research. There was no significant difference according
to the treated groups, which means that the three of the groups were
the same for the number included in the study (Chi-test=0.96, p=0.1).
Out of 160 infants, 87 (56%) were girls while 73 (44%) were boys with
an imprecise distinction p=0.27. The average weight of babies in the
study was 3218.3 g. Of the 160 examined babies, 95 (59.4%) are of
natural origin while 65 (40.6%) are of caesarean origin.
The largest number of the cases were at the first-born child (74 or 46.3%),
followed by second-born children (67 or 41.9%), and the lowest number
of cases were on the third child born in the order of 19 or 11.9%. On the
total number of babies, 93 or (58.1%) of the cases had facial asymmetry
while 67 (41.9%) had no facial asymmetry. From the 160 babies involved
in the paperwork, 94 babies or (58.8%) had regular head shape whereas
66 babies or (41.3%) had irregular head form. In 8 babies or (5%) of
them, there was present the tumefaction while in 152 or (95%) of cases,
we did not conclude the tumefact in the muscle region.
In Fig. 1 data on the other abnormal infants were reported, wherefrom
118, out of the total number of babies (73.8%) have no other
accompanying abnormalities; 13 or (8.1%) cases had subluxatio coxae,
12 cases or (7.5%) had brachial plexus injury, and 11 of the cases or
(6.9%) had coxae dysplasia.
Table 2 shows the data for the average improvement of lateral
anesthesia where we reached the highest level in the 0-3 months of
the infants in groups(different mean = −31.0±10.0, 95%, CI: 33.7 up
to - 28.2, p<0.001), and then, in the group ages 3.1-6 months (different
mean = −29.3±8.7, 95%, CI: 31.7-−26.9, p<0.001) whereas the lowest
improvement in the group age is 6.1-9 months (different mean =
−27.8±12.6, 95%, CI: 31.2-−24.4, p<0.001).
Table 3 shows that the results of the examinations that were made
at the end of the treatment according to the number of sessions
applied. The first group of the (infants from 0 to 3 months) was
needed only 15 sessions for their full treatment because the timing
of their appearance in the therapy was earlier, so the result was
better and faster. The second group (infants from 3 to 6 months)
needed 30 therapeutic sessions. The third group (babies aged from
6 to 9 months) needed 45 therapeutic sessions for achieving normal
amplitude of the neck mobility because of the appearance for physical
treatment was delayed, so the treatment lasted longer than to the first
and second group.
Table 1: Demographic data and clinical characteristics of the
infants
Baseline demographic and clinical
characteristics
Total n=160 (%)
Gender
Girls 87 (54.38)
Boys 73 (45.63)
Body weight
2500-3000 53 (33.13)
3001-3500 82 (51.25)
3501-4000 16 (10.00)
4001-4500 9 (5.63)
Way of birth
Natural birth 95 (59.40)
Caesarean birth 65 (40.60)
Line of the infant born
First 74 (46.30)
Second 67 (41.90)
Third 19 (11.90)
Facial symmetry
Asymmetric 93 (58.10)
Symmetric 67 (41.90)
Shape of head
Regular 94 (58.80)
Irregular 66 (41.30)
Tumefaction
Yes 8 (5.00)
No 152 (95.00)
Table 2: Improvement of lateral anion by comparative groups
Age
group
Mean±SD SE 95% CI
Before After Different
1-3 m 58.0±9.7 88.9±3.0 −31.0±10.0 1.4 −33.7-−28.2
3.1-6 m 60.0±9.7 89.3±2.4 −29.3±8.7 1.2 −31.7-−26.9
6.1-9 m 62.2±12.6 90.0±0.0 −27.8±12.6 1.7 −31.2-−24.4
Total 60.1±10.9 89.4±2.2 −29.3±10.6 0.8 −31.0-−27.7
SD: Standard deviation
Fig. 1: Concomitant abnormalities among infants with torticollis

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DISCCUSION
Traumas during childbirth are the risk factors for the appearance of
torticollis. As a consequence of the trauma, it comes to the tearing or
prolongation of the neck muscles, especially when the baby’s head
is born slowly or very soon, or when the baby’s head is snatched by
force or violently, or when “pelvic” gets out first then the head. 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].
Of the total number of infants 160, the largest number belongs to the
age group 0-3 months. As far as gender is concerned, there are 87 cases
or (56.0%) with female infants attacked by torticollis. As far as it
concerns to the number of births, the largest number belongs to the
infants born at the first birth, with 40 cases or (47.6%).
The earliest start of kinesitherapy treatment in the cases diagnosed
with torticollis gives better results in the degree of neck’s mobility, and
a shorter physiotherapeutic treatment is required to achieve normal
baby’s cervical mobility [19]. After the application of the kinesitherapy,
we achieved high results in AEL growth, which were significantly better
in the group of age from 0 to 3 months. From the total number, at 152
infants or (90.5%) after the treatment, we achieved full amplitude of
mobility.
In our study of the total number of examiners, 36 cases or (22.5%) had
other associated anomalies, such as 13 or (8.1%) subluxatio coxae,
12 cases or (7.5%) brachial plexus injury, and 11 cases or (6.9%)
dislocation coxae. Our data correspond to the data of a work done in
1086 babies with torticollis where it was noted that besides cotyledons;
there was also a high incidence of podalic presentation (19.5%), difficult
birth or (56%), and stomach displacement (6.81%). Furthermore, the
limitation of the passive neck rotation correlated with the craniofacial
asymmetry and irregular shape of the head [20]. From our data, we
have come to the conclusion that a small limitation of mobility has
left only on some third group infants in the age of groups from 6 to
9 months because the appearance of time for physical treatment has
been delayed.
This is also noted in a study involving one hundred and one child
(mean age = 4 months) who were diagnosed with congestive muscular
twitching and referred to the physical therapy in the Children’s Hospital
in the British Columbia (Vancouver, British Columbia, Canada), before
they fulfill 2 years old.
Full recovery (full passive motion angle) is achieved for all the children
except one. The average duration of treatment was 4.7 months. There
was a correlation between the severity of the restriction and the
duration of the treatment (r = 0.31) [4]. Similar data were also obtained
in a prospective study of 45 infants (26 boys, 19 girls) with congenital
muscle cramps; their average age at the beginning of the therapy was
38.6 days or (15-120 days). The average duration of the treatment
was found to be 3.2~1.3 months. All of the patients were treated with
intensive, prolonged prophylaxis protocol (with 100% success). No
case was treated surgically. In early-treated muscular-infant babies,
there is no room for surgical treatment. This group of patients has been
successfully treated using an intensive protocol of passive exercises
extension [1].
Clinical characteristics of our patients coincide with those of other
works. For example, the patients included in this study were 81 boys
and 89 girls, younger than 24 months, who had congenital torticollis.
The average age at the time of the diagnosis was 4 months, 54.1% had
the left side of the affected neck, over 90% had an irregular shape of the
head, and 2.4% had difficulty eating due to the disorder. Plagiocephaly
was present in 63.6% of the patients.
Neck tumefaction was present in 18.2% of subjects and facial
asymmetry in 15.9%. Passive movements were the initial treatment
recommended for 65.3% of the patients. Most of the children achieve
a total improvement in symptoms. Nearly 85.5% have achieved total
improvement and 14.5% have achieved partial improvement or long-
term abnormalities [21].
In our study, kinesitherapy, respectively, passive exercises have been
applied to all infants and a large number of them have achieved
a successfully full recovery. This coincides with the data from the
literature. A total of 311 infants were treated consecutively for
congenital torticollis during an 8-year period since 1999 until 2003
at the Clinic of Pediatric Neurology at Istanbul’s Faculty of Medicine.
Istanbul University, Turkey was revised in a retrospectively manner.
The average age at diagnosis period was 2.3 months. The included
patients in this study were 138 boys and 173 girls. Passive movements
were recommended with the initial treatment for all the patients.
Nearly 95% have achieved total improvement and 5% have achieved
partial improvement [22].
We conclude that most of the babies born with muscular torticollis reach
the full/complete neck movement. The success rate of conservative
treatment it is depended largely on the age of infants when they start
with ultrasonography exercises and findings [23]. Furthermore, in a
retrospective study of 277 infants with torticollis muscular congenital,
90.6% of the cases were of average level. Hip dysplasia was directly
related with the worst cases of torticollis (10.5%). Within 12 months,
torticollis had been conservatively cured of nearly on approximately
70% of babies regardless of the severity. Tenotomies were realized or
performed in only ten children, eight of whom were first introduced after
the age of 12 months. The long-term effects were light and consisted of
craniofacial asymmetry, temporary head bend, and mild scoliosis [24].
However, a wide and long-term of research would give a better
and clear insight to the effect of treating torticollis infants with the
kinesitherapy method. Special researches should be conducted on the
role of kinesitherapy and other physical methods with larger samples,
with randomized, double-blind and controlled or checked groups.
In this way, stratification of the patients in the treatment groups
according to the disease, weight, gender, and age would be enabled.
Various and diverse researches are needed because all of this cannot
be achieved within a single research. However, based on our results
and the literature of published work so far in internationally reviewed
journals, there is a lot of evidence that supports the recommendation of
the kinesitherapy usage for a period of 3 weeks (a period of time that
is needed in order for the effect to be shown) because it will have an
impact on the effect release of AEL, to the release the muscle of spasms
and the improvement of muscle function.
CONCLUSIONS
From the results of our research, we conclude that kinesiotherapy has
a primary and very successful effect on the treatment of the infants
with torticollis. Kinesitherapy has been shown to be effective in MSCM
extension, growth of the AEL on the neck mobility, and improvement
of muscle function. The results of this study will enable therapists to
better predict the duration of treatment based on early onset of the
physical therapy.
Table 3: Number and percentage of infants at the end of the
treatment according to the number of applied sessions
Number sessions Total (%)
45 63 (39.4)
30 44 (27.5)
15 53 (33.1)
Total 160 (100.0)

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Durguti et al.
ACKNOWLEDGMENTS
We would like to thank all the infants who participated in this study
and all their parents who without hesitation helped us by answering
the questionnaire.
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