Muscle texture features on preoperative MRI for diagnosis and assessment of severity of congenital muscular torticollis.

OBJECTIVES: To develop an objective method based on texture analysis on MRI for diagnosis of congenital muscular torticollis (CMT). MATERIAL AND METHODS: The T1- and T2-weighted imaging, Q-dixon, and T1-mapping MRI data of 38 children with CMT were retrospectively analyzed. The region of interest (ROI) was manually drawn at the level of the largest cross-sectional area of the SCM on the affected side. MaZda software was used to obtain the texture features of the T2WI sequences of the ROI in healthy and affected SCM. A radiomics diagnostic model based on muscle texture features was constructed using logistic regression analysis. Fatty infiltration grade was calculated by hematoxylin and eosin staining, and fibrosis ratio by Masson staining. Correlation between the MRI parameters and pathological indicators was analyzed. RESULTS: There was positive correlation between fatty infiltration grade and mean value, standard deviation, and maximum value of the Q-dixon sequence of the affected SCM (correlation coefficients, 0.65, 0.59, and 0.58, respectively, P < 0.05).Three muscle texture features-S(2,2)SumAverg, S(3,3)SumVarnc, and T2WI extreme difference-were selected to construct the diagnostic model. The model showed significant diagnostic value for CMT (P < 0.05). The area under the curve of the multivariate conditional logistic regression model was 0.828 (95% confidence interval 0.735-0.922); the sensitivity was 0.684 and the specificity 0.868. CONCLUSION: The radiomics diagnostic model constructed using T2WI muscle texture features and MRI signal values appears to have good diagnostic efficiency. Q-dixon sequence can reflect the fatty infiltration grade of CMT.

Unipolar myomectomy for congenital muscular torticollis: A retrospective study.

In this study, unipolar myomectomy was used to address limited neck movement and tight muscles in pediatric, adolescent, and adult patients. A retrospective chart review was performed for patients from January 2006 to February 2023, who were diagnosed with congenital muscular torticollis and underwent a unipolar myomectomy. Outcome evaluation, adapted from the Cheng and Tang system - cervicomandibular angle (CMA), facial asymmetry, cranial asymmetry, tilting limitation (TL), rotation limitation (RL), subjective assessment, and residual contracture - included various parameters scored from 0 to 3 points and categorized as poor, fair, good, or excellent. In total, the data for 36 patients (21 males and 15 females) were analyzed. Participants were aged 0.8-38 years. Surgery improved CMA, RL, and TL, with no complications (12.2°-1.2°, 18.6°-5.2°, and 17.6°-6.5° for CMA, RL, and TL, respectively; p < 0.001). The mean overall score was comparable among different age groups (2.8 ± 0.5, 2.2 ± 0.62, and 2.1 ± 0.37 for the pediatric, adolescent, and adult groups, respectively). Within the limitations of the study it seems that unipolar myomectomy is a promising, effective surgical option for individuals of multiple age groups.

Perception-Action Approach Versus Standard Care for Infants With Congenital Muscular Torticollis: A Pilot Single-Blind Randomized Controlled Trial.

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-posttest 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. Participants in both groups attended 3 intervention sessions. Their behavior exhibited during therapy was compared using the Therapy Behavior Scale 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 Functional Symmetry Observation Scale, and the Therapy Behavior Scale Version 2.2 scores were higher in the P-AA group; however, these results did not reach significance. CONCLUSION: 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. LAY SUMMARY: Compared to standard treatment, the Perception-Action Approach (P-AA) provided similar short-term benefits to infants with congenital muscular torticollis. The P-AA group participants demonstrated higher symmetry and behavior scores, which needs to be confirmed in a larger future study.

TOT Collar Use in Complex Case of Congenital Muscular Torticollis With Persistent Head Tilt.

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.

Using Flexible and Stretchable Surface Electromyography Electrode Array to Evaluate Congenital Muscular Torticollis in Children.

Congenital Muscular Torticollis (CMT) is a neuromuscular disease in children, which leads to exacerbation of postural deformity and neck muscle dysfunction with age. Towards facilitating functional assessment of neuromuscular disease in children, topographic electromyography (EMG) maps enabled by flexible and stretchable surface EMG (sEMG) electrode arrays are used to evaluate the neck myoelectric activities in this study. Customed flexible and stretchable sEMG electrode arrays with 84 electrodes were utilized to record sEMG in all subjects during neck motion tasks. Clinical parameter assessments including the cervical range of motion (ROM), sonograms of the sternocleidomastoid (SCM), and corresponding histological analysis were also performed to evaluate the CMT. The muscle activation patterns of neck myoelectric activities between the CMT patients and the healthy subjects were asymmetric during different neck motion tasks. The CMT patients presented significantly lower values in spatial features of two-dimensional (2D) correlation coefficient, left/right energy ratio, and left/right energy difference (p < 0.001). The 2D correlation coefficient of activation patterns of neck rotation and extension in CMT patients significantly correlated with clinical parameter assessments (p < 0.05). The findings suggest that the spatial features of muscle activation patterns based on the sEMG electrode arrays can be utilized to evaluate the CMT. The flexible and stretchable sEMG electrode array is promising to facilitate the functional evaluation and treatment strategies for children with neuromuscular disease.

[Surgical treatment of congenital muscular torticollis]. / Operative Behandlung des Torticollis muscularis congenitus.

OBJECTIVE: Surgical treatment of congenital muscular torticollis with tripolar release of the sternocleidomastoid muscle, followed by modified postoperative treatment with a special orthosis. INDICATIONS: Muscular torticollis due to contracture of the sternocleidomastoid muscle; failure of conservative therapy. CONTRAINDICATIONS: Torticollis due to bony anomaly or other muscular contractures. SURGICAL TECHNIQUE: Tenotomy of the sternocleidomastoid muscle occipitally and resection of at least 1 cm of the tendon at the sternal and clavicular origin. POSTOPERATIVE MANAGEMENT: Orthosis must be worn for 6 weeks 24 h/day, then for another 6 weeks 12 h/day. RESULTS: A total of 13 patients were treated with tripolar release of the sternocleidomastoid muscle and modified postoperative management. Average follow-up time was 25.7 months. One patient presented with recurrence after 3 years. No intra- or postoperative complications were observed.

Sternocleidomastoid Muscle in Fetuses: Classification, Morphometric Analysis, and Clinical Significance.

PURPOSE: This study aimed to examine variations and morphometric properties of the sternocleidomastoid muscle (SCM) in fetuses in terms of infancy and early childhood surgeries. MATERIALS AND METHODS: Neck regions of 27 fetuses (mean age: 23.30±3.40 wk, sex: 11 boys and 16 girls) fixed with 10% formalin were dissected bilaterally. Photographs of the dissected fetuses were taken in the standard position. Morphometric measurements, such as length, width, and angle, were performed on the photographs using the ImageJ software. In addition, the origin and insertion of SCM were detected. Taking into account the studies in the literature, a classification consisting of 10 types associated with the origin of SCM was carried out. RESULTS: No statistically significant difference was observed in the parameters in terms of side and sex ( P >0.05), except from the linear distance between the clavicle and motor point where the accessory nerve enters SCM (20.10±3.76 for male, 17.53±4.05 for female, P =0.022). Two-headed SCM (Type 1) was detected in 42 out of 54 sides. Two-headed clavicular head (Type 2a) was detected on 9 sides, and 3-headed (Type 2b) on 1 side. A 2-headed sternal head (Type 3) was detected on 1 side. A single-headed SCM (Type 5) was also detected on 1 side. CONCLUSION: Knowledge related to variations of the origin and insertion of fetal SCM may be helpful in preventing complications during treatments of pathologies such as congenital muscular torticollis in early period of life. Moreover, the calculated formulas may be useful to estimate the size of SCM in newborns.

Effect of physical therapy treatment in infants treated for congenital muscular torticollis - a narrative review.

Congenital muscular torticollis is a problem that arises at birth or immediately after birth in which the sternocleidomastoid muscle is shortened on the afflicted side, leading to an ipsilateral rotated of the head and a contralateral rotation of the face and jaw. To determine the effectiveness of physical therapy treatment in infants treated for congenital muscular torticollis, relevant articles published between 2011 and 2020 were located using electronic databases. A total of 9 studies out of 24 potentially relevant articles were reviewed. All studies were randomised controlled trials with 6-8 score on the Physiotherapy Evidence Database scale (Pedro scale) which showed high quality of methodology. The studies typically found significant statistical effects in the management of congenital muscular torticollis. Additionally, most of the studies reported increased adherence to exercise as another essential advantage. Conservative physical therapy management showed positive outcomes, and early physiotherapy referral showed significant reduction in treatment duration.

Informing the Physical Therapy Management of Congenital Muscular Torticollis Clinical Practice Guideline: A Systematic Review.

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.

The tilts, twists, and turns of torticollis.

PURPOSE OF REVIEW: The purpose of this review is to outline the most recent understanding of torticollis in the pediatric population. RECENT FINDINGS: It is important to diagnose the underlying condition of torticollis early in childhood, as some conditions that cause torticollis may result in major developmental delays in early motor milestones. Recent studies have highlighted that many of the rarer causes of torticollis are often misdiagnosed as congenital muscular torticollis, suggesting that physicians should pay close attention to the results of clinical and radiographic examinations when patients present with torticollis. SUMMARY: Congenital muscular torticollis is the most common cause of torticollis. Other, less common causes of torticollis include vertebral abnormalities, ocular torticollis, gastrointestinal disorders, soft tissue infections of the neck, posterior fossa tumors, and benign paroxysmal torticollis. Although rare, these differential diagnoses should be considered during a clinical work-up for a patient who presents with torticollis.

Factors influencing and long-term effects of manual myotomy phenomenon during physiotherapy for congenital muscular torticollis.

PURPOSE: To investigate the factors influencing and long-term effects of manual myotomy (MM) occurring during physiotherapy for congenital muscular torticollis (CMT). METHODS: We retrospectively collected the clinical data of children with CMT receiving physiotherapy between 2008 and 2018. The children were divided into manual myotomy (MM) and non-manual myotomy (NMM) groups according to whether MM occurred during treatment. We assessed physiotherapy outcomes in children with CMT using craniofacial asymmetry parameters and the Cheng-Tang rating score. By measuring the ear-eye distance, ear-nose distance, eye-mouth distance, ear-mouth distance, half-head circumference, and half-head top at two sides to evaluate craniofacial asymmetry. Based on the Cheng-Tang assessment criteria, we recorded the range of rotation, range of lateral flexion, the status of the contracted muscle, the hardness of the mass, the extent of head tilting during activities and sleeping, the status of daily activities, face size, type of head shape, cranial changes, and subjective head tilting to assess the effectiveness of treatment. Clinical data and outcome indicators (craniofacial asymmetry parameters and Cheng-Tang rating score) were compared. RESULTS: The MM group had a significantly higher total Cheng-Tang rating score than the NMM group (P < 0.05). Age at initial physiotherapy session was the risk factor for MM during physiotherapy. CONCLUSION: Children with CMT developing MM during physiotherapy generally have a good outcome, although we do not recommend MM as a goal of treatment. Physiotherapists should understand this phenomenon, assess relevant factors to predict risk, and carefully observe treatment to prevent possible complications.

The usefulness, reliability, and quality of YouTube video clips on congenital muscular torticollis: A STROBE compliant study.

This study aimed to evaluate the usefulness, reliability, quality, and related characteristics of YouTube video clips on congenital muscular torticollis (CMT). This cross-sectional study analyzed 47 YouTube video clips on CMT. They were classified as either useful or misleading by 2 rehabilitation doctors. The modified DISCERN tool and the Global Quality Scale (GQS) were used to evaluate their reliability and quality. An analysis was conducted using the characteristics, such as presenters, ownership of YouTube channel accounts, countries, contents, and the video popularity. Of the 47 YouTube video clips, 8 (17%) were evaluated as misleading, which indicated that they included at least one scientifically unproven piece of information on CMT or more. They were less reliable and of lower quality than the useful video clips. The video clips presented by healthcare professionals were more useful compared to those presented by others (P = .015). However, the video popularity was not related to its usefulness. The reliability and quality (3.70 ± 0.82 vs 0.75 ± 0.50 and 2.95 ± 1.21 vs 1.50 ± 1.00) assessed by the modified DISCERN tool and GQS, respectively, were significantly higher in the video clips presented by healthcare professionals compared to those presented by others. There were misleading YouTube video clips on CMT. Video clips presented by healthcare professionals could be more useful, reliable, and of better quality. The popularity of the video clips does not indicate more usefulness, reliability, and better quality. YouTube viewers should be aware of these findings. We recommend that the viewers preferentially choose video clips on CMT presented by healthcare professionals, not by the video popularity.

Incidence of Congenital Muscular Torticollis in Babies from Southern Portugal: Types, Age of Diagnosis and Risk Factors.

Congenital torticollis (CMT) is the most common type of torticollis and is defined as a unilateral contracture of the sternocleidomastoid muscle resulting in lateral head tilt associated with contralateral rotation, and early detection and treatment may present a high probability of recovery of head posture symmetry. This study aimed to verify the incidence of torticollis in babies born in southern Portugal types, age of diagnosis and the risk factors. This study comprised 6565 infants born in the south of Portugal at Algarve University Hospital Center, Portimão unit during a 5-year period (January 2016 to December 2020). The cases diagnosed with torticollis referred to the Pediatrics and Pediatric Physiatrist consultations at this hospital were included. 118 babies­77 (65.3%) male and 41 (34.7%) female­were diagnosed with torticollis. The incidence of a 5-year period was 1.5%. Spontaneous vaginal delivery was prevalent (n = 56; 47.5%), with 106 (89.8%) deliveries with cephalic presentation. 53 (44.9%) cases of torticollis were classified as postural, 37 (31.4%) as muscular torticollis with joint limitation and 28 (23.7%) as congenital torticollis (with the presence of a nodule). Postural torticollis was diagnosed at an average age of 70.14 days, muscular torticollis with joint limitation at an average of 64.12 days and congenital torticollis at 33.25 days (p < 0.001). Plagiocephaly was present in 48 (40.7%) babies with torticollis (p = 0.005) and joint limitation in 53 (44.9%) babies (p < 0.001). The data obtained revealed a low incidence of CMT, with the majority being classified as postural. The age of diagnosis varied between 33 to 70 days from birth. The baby's gender, mode of delivery and the fetal presentation during delivery did not show a statistically significant association with the presence of torticollis. Despite presenting a low incidence, it is important to mention the importance of professional health intervention in the implementation of prevention strategies.

Infants With Congenital Muscular Torticollis: Demographic Factors, Clinical Characteristics, and Physical Therapy Episode of Care.

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.