Understanding Torticollis and positional Plagiocephaly

Torticollis is the shortening of the Sternocleidomastoid muscle, the big muscle that goes from the base of the ear to the collarbone, caused by constriction in the womb or a forceful delivery. The shortened or torn muscle causes the child to look in the direction of the shortened muscle. Without physical therapy it can cause permanent alignment and postural challenges.

The incidence of Torticollis and Plagiocephaly  in babies has risen since the American Academy of Pediatrics initiated the national Back to Sleep Program in 1994. The program was created to decrease the incidence of SIDS, which it accomplished by decreasing the incidence by 40%. Unfortunately, it also created a marked increase in the incidence of positional head deformities in newborns.

When diagnosed at an early age, Torticollis can be decreased by positioning changes and neck stretching. If left untreated in can limit a child’s ability to turn his or her head, see to both sides, hear and interact with the environment. It can also lead to cognitive and motor delays as well as delayed body awareness, muscle weakness and poor balance. Limiting the neck movement makes it difficult and at times painful for babies to be on their tummy which then leads to being on their backs most of the time. And this leads us to “positional plagiocephaly”.

Treatment for Torticollis by an Occupational or Physical Therapist usually consists of family education that focuses on positioning, muscle stretches and exercises. Emphasis is placed on increasing “tummy time” so that pressure on the back of the head is relieved and the baby can learn to move in a more symmetrical manner. Treatment for Torticollis can vary depending on the severity and the age of the baby, and will usually be recommended weekly for 3-6 months. Babies who are treated from an earlier age tend to recover much more quickly that those who are diagnosed after they are 5-6 months old. Early intervention is key.

Plagiocephaly is a condition in which a child’s head is not shaped correctly. Plagiocephaly occurs when there is a flat spot on the back of the head on one side. (Brachiocephaly is an overall flatness of the back of the head.) Symptoms of plagiocephaly are; a flat area on the back or side of the head. The child’s forehead and cheek may bulge on one side, one eye may appear larger than the other, the ear on the flattened side may be pushed forward, and/or the jaw may be tilted.

At the evaluation the therapist will review you and your medical history of pregnancy and delivery and discuss our current concerns. The therapist will assess your child’s neck movement and strength, neck posture in sitting, lying down, on tummy, and supported standing. He will assess your child’s gross motor skills. The therapist will measure the degree of flatness of the head and screen for other diagnosis. If upon assessment the “flatness” is found to be moderate to severe, the therapist will refer you to the Craniofacial specialist if they feel that therapy alone may not be as effective. Where they will then help you decide if you want to go ahead with a helmet- as this is entirely your decision. The specialist will explain the benefits to wearing the 
helmet.

-An important item for consideration during this decision process is the long-term consequences.-

One question you can ask yourself is, “Would I be comfortable with my child’s head shape in the future?” Think about how this decision potentially impacts your child’s future. Can you see them being happy with this head shape when they are 5, 16, 25 and 45?
While there are no clinical studies showing definitive long term side effects associated with an abnormal head shape, there are many studies that are currently looking at a variety of problems.

Physically, the implications can include a wide range of challenges. If the child faces lifelong facial asymmetry, there may be difficulty fitting them with glasses in the future. TMJ or jaw misalignment (i.e., cross bite or under bite) is also something to consider.


What You Can't See
When parents are making their treatment decision, one of the most frequently asked questions is "what effect does this have on my baby's head?" While many doctors originally viewed plagiocephaly as only a cosmetic issue, many now realize that there are structural skull problems associated with plagiocephaly.

The below photo shows a CT scan of a normal shaped infant skull (left) compared to a CT scan of an infant head with plagiocephaly (middle) and an infant head with brachycephaly (right).

What does Plagiocephaly look like?

Here are examples of some of the varying degrees of plagiocephaly. Normal Head shape MildPlagiocephaly ModeratePlagiocephaly Severe Plagiocephaly

If you should decide to have your baby sport the helmet, keep in mind it will just be a few months of your baby’s life that he or she won’t remember, but will thank you later on in life. We are more affected then they are. Always know that you are doing right by your baby!!!