Lauren Clemson, Josh Hardy,

1
Congenital Muscular Torticollis and Plagiocephaly

• Lauren Clemson, Josh Hardy,
• Liz Weiss
• Regis University DPT Program

2
Objectives

• By the end of this presentation you will be able
  to
• Write a PICO question to direct your literature
  search
• Describe the level of evidence present in
  pediatric literature concerning plagiocephaly and
  congenital muscular torticollis (CMT)
• Understand current literature supporting
  treatment for plagiocephaly and CMT
• Apply statistical findings to patients with
  plagiocephaly
• Identify shortcomings in the body of knowledge
  concerning plagiocephaly and CMT

3
Our Case

• 4 Months old
• Mild right congenital muscular torticollis (CMT)
• Left rotation (lackinglt15 right rotation), right
  side bend
• Mild plagiocephaly (8mm)
• Therapy sessions 1x/week
• for the last 4 weeks.

4
PICO Question

• Patient - Description of the patient or the
  target disorder of interest.
• Intervention - Therapy, exposure, diagnostic
  test, prognostic factor, or patient perception.
• Comparison Main alternative to the intervention
  in question.
• Outcome - Clinical outcome of interest to you ,
  your patient, and your patients
  caregiver/family.

5
Formulated 2 PICO questions

• Congenital Muscular Torticollis (CMT)
• For a 4 month old male infant with right-sided
  congenital muscular torticollis, is manual
  stretching in conjunction with a home program and
  education more effective than a home program and
  education alone to increase available cervical
  range of motion?
• Plagiocephaly
• For a 4 month old male infant with mild
  plagiocephaly secondary to congential muscular
  torticollis, is repositioning more effective
  than helmet therapy to decrease head/facial
  asymmetry?

So we searched the literature
6
Hierarchy of Evidence
7
And Found

• CMT treatments
• No Randomized Controlled Trials (RCTs)
• Only low-level evidence available
• All studies had numerous biases, methodological
  flaws, and glaring inconsistencies.
• Plagiocephaly treatments
• No RCTs
• BUT a 2008 systematic review
• of cohorts was identified.

8
Current Childrens Hospital Plagiocephaly Protocol

• Younger child (lt5mo) Treat the child
  conservatively with repositioning and caregiver
  education. (positioning, tummy time, feeding,
  etc.)
• Older child (gt5mo) Examine the extent of
  plagiocephaly via anthropometric measurement or
  imaging. Based on the results, helmet therapy may
  or may not be indicated. (deviation of gt5 mm in
  sagittal plane is considered pathologic)

9
Critical Appraisal of Systematic Review on
Plagiocephaly

• Cochrane database plagiocephaly
• No Cochrane reviews available
• Three other systematic reviews available
• PubMed, CINAHL, and MEDLINE plagiocephaly
• No RCTs or cohort studies of high methodological
  quality were found.
• Xia J, Kennedy K, Teichgraeber J, et al.
  Nonsurgical treatment of deformational
  plagiocephaly A systematic review. Arch Pediatr
  Adolesc Med. 2008162(8)719-727.

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Nonsurgical treatment of deformational
Plagiocephaly

• Review included 7 cohort studies (Level III
  Evidence)
• Studies not analyzed for homogeneity of subjects
  or treatment
• Inclusion Criteria
• Deformational plagiocephaly with or without CMT.
• Healthy in terms of conditions that may interfere
  with treatment of plagiocephaly.
• No previous treatment
• for plagiocephaly
• Studies designed to compare
• helmet/molding therapy to
• another nonsurgical intervention.

11
Data Extraction

• 2 reviewers used Critical Appraisal Skills
  Program critical review form for cohort studies.
• Are the results of the studies valid?
• What are the results of the study?
• Will the results help me locally?
• Effect size reported by a point
• estimate and a 95 confidence
• interval.
• Robustness of each study
• was evaluated and potential
• biases of each study were
• identified.

12
Results

• 5 of 7 studies utilized an objective outcome
  measure
• These 5 found helmet/molding therapy to be more
  effective than repositioning therapy as
  determined by anthropometric measurements.
• Selection bias identified resulting in more
  severe cases of plagiocephaly being placed in the
  helmet/molding groups.
• No mention of blinding during outcome assessment,
  measurement bias may have occurred
• 2 of 7 studies found repositioning
• and helmet/molding therapies to
• be equally effective, but helmet/
• molding had significantly shorter
• treatment durations.

13
Results continued

• Only 1 of 7 studies was included in calculation
  of treatment effects.
• Poor or incomplete reporting of statistics
• Significant measurement bias
• Presence of repositioning intervention
  indeterminable
• Helmet/molding utilized after failure of
  repositioning therapy
• Helmet/molding therapy relative risk
• 1.3, CI95, 1.2-1.4
• Absolute risk reduction, improvement with
  helmet/molding therapy
• 0.21, CI95, 0.15-0.27
• Number needed to treat
• 5.0, CI95, 4-7

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Application to our kiddo

• Literature suggests that he may benefit from
  helmet/molding therapy.
• Expert opinion suggests waiting to utilize
  helmet/molding therapy until he is 6 months old.
• Helmet/molding therapy is a low-risk option.
• Helmet/molding therapy is expensive and rarely
  covered by insurance as it is seen as a primarily
  cosmetic intervention.

15
Our recommendations

• Continue with manual stretching and home program.
  
• Re-evaluate severity of plagiocephaly once the
  infant reaches 6 months of age.
• If a deviation is still present, contact the
  infants physician to discuss helmet/molding
  therapy.
• Present the infants family with options for
  treatment.
• All recommendations based on low-level of
  evidence.

16
Current Childrens Hospital Plagiocephaly Protocol

• Younger child (lt5mo) Treat the child
  conservatively with repositioning and caregiver
  education. (positioning, tummy time, feeding,
  etc.)
• Older child (gt5mo) Have the child measured to
  evaluate the extent of skull deformity. Based on
  the results, helmet therapy may or may not then
  be indicated. (deviation of gt5 mm in sagittal
  plane is considered pathologic)
• AVAILABLE EVIDENCE SUPPORTS THIS PROTOCOL!

17
Current Childrens Hospital CMT Protocol

• Manual stretching, home program, and caregiver
  education
• Kinesiotape
• TOT Collar
• Botox
• KISS manual therapy
• Surgical Intervention

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Is There Evidence to Support the Protocol?

• Manual stretching (Cheng, 2001 Van Vlimmeren,
  2006)
• Safe and effective if initiated before 12 months
  of age.
• 3 x 15 repetitions of gentle force for 1 second,
  with 10 seconds of rest between repetitions.
• Home program and caregiver education (Van
  Vlimmeren, 2006)
• Fair to excellent results when physical therapy
  treatment and caregiver education is utilized.
• TOT Collar (Cottrill-Mosterman, 1987)
• Stretching and TOT collar showed significant
  improvements in head tilt after six months of
  treatment compared to stretching alone.

19
Is There Evidence to Support the Protocol?

• Botox (Oleszek, 2005)
• 74 had improved cervical rotation or head tilt
  after the injections, and 7 experienced
  transient adverse events (specifically, mild
  dysphagia and neck weakness)
• KISS manual therapy (Brand, 2005)
• No scientific evidence that manual therapy is
  effective in treatment of KISS syndrome. Some
  evidence suggests that it may be a risky option.
• Surgery (Shim, 2008 Van Vlimmeren, 2006)
• In patients operated on at age 6 months to 2
  years of age, excellent results can be achieved
  by releasing the sternocleidomastoid.
• Kinesotape (no published articles, based on
  expert opinion)
• Microcurrent or other modalities (Kim, 2009)

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Current Childrens Hospital CMT Protocol

• Manual stretching, home program, and caregiver
  education
• Kinesiotape
• Tot Collar
• Botox
• KISS manual therapy
• Surgical Intervention

MOST OF THE AVAILABLE EVIDENCE SUPPORTS THIS
PROTOCOL!
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Current body of knowledge

• Current evidence cannot definitively conclude
  that one treatment option is superior to another.
• Evaluation criteria for treatment outcome needs
  to be standardized within the literature.
• RCTs need to be performed with homogenous
  samples.
• Selection and measurement biases must be
  alleviated.

22
Contribute to the body of knowledge

• Track your patients and their progress
• Documentation of severity of plagiocephaly via
  anthropometric measurement or diagnostic imaging
• Documentation of head position via arthrodial
  protractor

23

• Thank You!

24
References

• Xia J, Kennedy K, Teichgraeber J, et al.
  Nonsurgical treatment of deformational
  plagiocephaly A systematic review. Arch Pediatr
  Adolesc Med. 2008162(8)719-727.
• Grigsby K. Cranial Remolding Helmet Treatment of
  Plagiocephaly Comparison of Results and
  Treatment Length in Younger Versus Older Infant
  Populations. J Prosth Orth. 2009 21(1)55-63.
• Cheng J, Wong M, et al. Clinical Determinants of
  the Outcome of Manual Stretching in the Treatment
  of Congenital Muscular Torticollis in Infants A
  prospective study of eight hundred and twenty-one
  patients. J Bone Joint. 2001 83A(5)679-687.
• Van Vlimmeren L, Helders P, Van Adrichem L.
  Torticollis and plagiocephaly in infancy
  Therapeutic strategies. Ped Rehab.
  20069(1)4046.
• Cheng J, Tang T, Chen M, Wong M, Wong E. The
  Clinical Presentation and Outcome of Treatment of
  Congenital Muscular Torticollis in Infant.sA
  Study of 1,086 Cases . J Ped Surg . 200035(7)
  1091-1096.
• Brand P, Engelbert R, Helders P, Offringa M.
  Systematic Review of Effects of Manual Therapy in
  Infants with Kinetic Imbalance due to
  Suboccipital Strain (KISS) Syndrome. J Man Manip
  Ther. 200513(4)209-214.
• Kim M, Kwon D R, Lee H. Therapeutic Effect of
  Microcurrent Therapy in Infants With Congenital
  Muscular Torticollis. Am Acad Phys Med Rehab.
  20091736-739.
• Cottrill-Mosterman S, Jacques C, Bartlett D,
  Beauchamp R. Tubular orthosis for torticolis
  (TOT) A new approach to the correction of head
  tilt in congenital muscular torticollis.
  Abstract.