Orthotic Treatment of Head Tilt in Children with Congenital Muscular Torticollis

SYLVIA COTTRILL-MOSTERMAN, BSc,OT, OTR,* CAROLE JACQUES, BSR, OTDOREEN BARTLETT, BSc, PT, RICHARD BEAUCHAMP, MD, FRCS,AND BARBARA DEVLIN, BSc, BSR, PT


A treatment program and a new cervical orthosis may correct head tilt in young children with congenital muscular torticollis which is characterized by contracture of one sternocleidomastoid muscle. The head is flexed to the affected side and rotated to the opposite shoulder. "Torticollis posture" may lead to a lopsided head and high thoracic scoliosis if not corrected (Fig. 1 ).

Children with torticollis identified before one year of age should have nonoperative management. Treatment incorporates stretching, positioning, and facilitating normal righting reactions. The physical therapist teaches the regime to the parents, recommending that it be carried out several times daily. Parents are also educated in methods of carrying and positioning the baby to maximize active rotation and lateral flexion.

Orthoses have also been a part of therapy for those children who have been on the stretching regime without full correction of head tilt. Historically, various types of cervical collars have been fabricated by occupational therapists. These collars attempted to stabilize the head and neck in a midline position. Designs ranged from simple foam through reinforced foam, such as Plastazote, to rigid thermoplastic Doman (Fig. 2 ), based on a collar described by Lango and associates1 which was primarily intended for short-term, postoperative use with older children.

Doman offered the best correction; however, it had several drawbacks. This orthosis incorporates a chest piece with a head yoke attachment which inhibits all neck movement and, as a result, can disrupt motor development to a significant degree when worn for long periods of time. The orthosis required three hours for fabrication. Precise fit was difficult, because of a lack of cooperation by the children. Thus, pressure areas were common. Parents' compliance in enforcing the extensive wearing schedule was poor. Their complaints were that it was ugly, hot, heavy, bulky, and difficult to apply.

BOCH-MERU Pilot Study-Orthosis Design

The Medical Engineering Resource Unit (University of British Columbia Department of Orthopaedics) designed a collar with components from "Tubular Orthoses" -a National Health Research and Development Program grant.2 The collar is the "Tubular Orthosis for Torticollis" (TOT).

A circle of soft PVC tubing is doubled over and fastened behind the child's neck. Two short, rigid tubes span the tubing (one below the ear and one behind the ear) on the affected side (Fig. 3 ). Fabrication and fitting take approximately a half hour.

This collar specifically limits lateral flexion to the affected side, with minimal restriction of rotation to the affected side, which is not desired but present. No other movements are restricted. The collar is lightweight, unobtrusive, and readily accepted by the parents. The child quickly adapts to it and within one week is wearing the collar full-time during waking hours. We apply the collar to children from age 4 to 12 months.

Rationale

Our hypothesis is that the addition of this orthosis, which promotes active head posture correction, yields significantly better results than stretching alone in the correction of head tilt in children with congenital muscular torticollis. The residual head tilt apparent after standard conservative treatment can be viewed as a consequence of the small amount of time a child receives proper head posture training (in therapy sessions for approximately 4 hours per week) versus the large remainder of time spent with the head in an abnormal "torticollis posture" Righting reactions and vestibular and occular reflexes are modified by feedback from the external environment.3 Doing stretches may gradually correct the muscle length; however this does not provide sufficient stimulus to change, and thus does not restore proper head posture.

In the TOT, the child moves away from the pressure created on the skull when the head is tilted. It is a noxious stimulus, like the throat plate of a Milwaukee brace. The TOT provides new data and a stimulus for change to the reflex system. A child must actively correct head posture to be comfortable. As the child is maintained in this new position for long periods of time, the nervous system receives considerable new data. The approach is in agreement with the active correction which is often recommended 4-1.

A controlled study is now underway to evaluate our new treatment program and collar design.

Acknowledgments

British Columbia's Children's Hospital Department of Orthopaedics supported the completed pilot project. British Columbia Health Care Research is providing support for the ongoing research project.

Supplier

The TOT is marketed under the name "Interlink Orthotics" by G.A. Remington Ltd, Vancouver, British Columbia.

British Columbia's Children's Hospital, 4480 Oak Street, Vancouver, Britsh Columbia V6H 3V4

References:

  1. Lango, S. E. P. Schwentker and J. Sweigart: Orthotic Treatment for Muscular Torticollis. Inter-Clinic Information Bulletin 16:13-14, 1977
  2. Hannah, R. Tubular Orthoses for Stabilization of Body Joints: Final Report. Health and Welfare Canada Project #6610-1290-51. Principal Investigator, James Foort. Period 19821985.
  3. Willard, H.S., and C.S. Spackman: The Principles of Occupational Therapy. 6th ed Philadelphia: J.B. Lippincott, 1982.
  4. Clarren, S.K.: Plagiocephaly and Torticollis: Etiology, Natural History and Helme Treatment. Journal of Pediatrics 53:92-95, 1981.
  5. Fabian, K., and M. Marshall: Conservative and Surgical Treatment of Congenital Muscular Torticollis: A Literature Review. Physiotherapy Canada 36:146-151, 1984
  6. Morrison, D. L., and G. D. MacEwen: Congenital Muscular Torticollis: Observations Regarding Clinical Findings, Associated Conditions and Results of Treatment Journal of Pediatric Orthopedics 5:500-505, 1982.
  7. Tachdjian, M. 0.: Congenital Muscular Torticollis, in Pediatric Orthopedics, W W, Lovell and R. B. Winter, eds., Philadelphia: W, B. Saunders Company, 1972. Page 65-76.