Experiences of Parents of Infants Diagnosed With Mild or Severe Grades of Congenital Muscular Torticollis.

PURPOSE: The primary purpose of this study was to describe the experiences of parents of infants diagnosed with congenital muscular torticollis (CMT). A secondary purpose was to compare the experiences of parents of infants with mild grades versus severe grades of involvement based on the CMT severity classification system. METHODS: Through semistructured interviews, a qualitative phenomenological approach of inquiry was used to investigate the lived experiences of 12 parents. RESULTS: Eight themes common to both groups of parents were identified. Findings indicated having an infant with CMT has a significant effect on the parents and other caregivers. Two themes were unique to parents of the infants with severe CMT. CONCLUSIONS: Parents are faced with a diagnosis that requires regular therapy visits and a challenging home program. A multimodal approach by clinicians for teaching and supporting parents during the episode of care may best address their unique challenges and stresses.

Walking kinematics in young children with limb loss using early versus traditional prosthetic knee prescription protocols.

The traditional treatment protocol for young children with congenital or acquired amputations at or proximal to the knee prescribes a prosthesis without a working knee joint, based in part on the assumption that a child learning to walk cannot properly utilize a passively flexing prosthetic knee component. An alternative to this Traditional Knee (TK) protocol is an "Early Knee" (EK) protocol, which prescribes an articulating prosthetic knee in the child's first prosthesis, during development of crawling and transitioning into and out of upright positions. To date, no study has compared samples of children with limb loss at or proximal to the knee using TK and EK protocols. The purpose of this multi-site study was to examine kinematic outcomes during walking in separate groups of young children in an EK and a TK prosthesis protocol, along with a population of children without lower limb amputations. Eighteen children aged 12 months to five years were recruited for this study at two clinical sites, six in each of the three groups. Children in the two prosthesis groups had unilateral limb loss and had been treated either at one site with the TK protocol or at another with the EK protocol. Children in the EK group achieved swing phase prosthetic knee flexion averaging 59.8±8.4 degrees. Children wearing prosthetic limbs walked slower than age-matched peers. In most instances, walking speed and step length increased with age in the EK group, similar to the control group. However, this trend was not observed in the TK group. Clearance adaptations were present in both limb loss groups. Observed adaptations were twice as prevalent in the TK group versus the EK group; however, the groups differed in age and etiology. Children with limb loss provided with an articulating knee component in their first prosthesis incorporated knee flexion during swing phase and showed fewer gait adaptations than children in the TK protocol.

Congenital Muscular Torticollis: Bridging the Gap Between Research and Clinical Practice.

Congenital muscular torticollis (CMT) is a common postural deformity evident shortly after birth, typically characterized by ipsilateral cervical lateral flexion and contralateral cervical rotation due to unilateral shortening of the sternocleidomastoid muscle. New evidence is emerging on the pathogenesis of CMT, the negative long-term consequences of delaying intervention, and the importance of early identification and early intervention to maximize outcomes. Our purpose in this article is to inform pediatricians and health care providers about new research evidence and share selected recommendations and implementation strategies specifically relevant to pediatric practice to optimize outcomes and health services for infants with CMT.

Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy.

BACKGROUND: Congenital muscular torticollis (CMT) is a postural deformity evident shortly after birth, typically characterized by lateral flexion/side bending of the head to one side and cervical rotation/head turning to the opposite side due to unilateral shortening of the sternocleidomastoid muscle; it may be accompanied by other neurological or musculoskeletal conditions. Infants with CMT should be referred to physical therapists to treat these postural asymmetries as soon as they are identified. PURPOSE: This update of the 2013 CMT clinical practice guideline (CPG) informs clinicians and families as to whom to monitor, treat, and/or refer and when and what to treat. It links 17 action statements with explicit levels of critically appraised evidence and expert opinion with recommendations on implementation of the CMT CPG into practice. RESULTS/CONCLUSIONS: The CPG addresses the following: education for prevention; referral; screening; examination and evaluation; prognosis; first-choice and supplemental interventions; consultation; discontinuation from direct intervention; reassessment and discharge; implementation and compliance audits; and research recommendations. Flow sheets for referral paths and classification of CMT severity have been updated.

Interrater and Intrarater Reliability of the Congenital Muscular Torticollis Severity Classification System.

PURPOSE: To establish inter- and intrarater reliability for determining severity grades of the congenital muscular torticollis severity classification system (CMT-SCS). METHODS: A prospective reliability study with 145 physical therapists recorded severity ratings on 24 randomly-ordered patient cases including age of infant, cervical range of motion, and presence or absence of sternocleidomastoid mass. To compute intrarater reliability, cases were randomly reordered and graded by 82 of the original raters. RESULTS: For the CMT-SCS, overall reliability was good with an interrater reliability intraclass correlation coefficient (ICC) (2,1) of 0.83 (95% confidence interval [CI], 0.74-0.91) and an intrarater reliability ICC (3,1) of 0.81 (95% CI, 0.66-0.91). CONCLUSIONS: The CMT-SCS has good reliability for infants up to 12 months of age. Physical therapists can use the scale for initial assessment of infants suspected to have CMT. The CMT-SCS should be standard documentation for infants with CMT.

Plagiocephaly Severity Scale to Aid in Clinical Treatment Recommendations.

Studies have attempted to categorize infant cranial asymmetry in a variety of ways using both observational and quantitative techniques, but none have created a clinical tool that can serve as a treatment guide based on clinical outcomes. In 2006, a research team from Children's Healthcare of Atlanta published the results of a prospective analysis of 224 patients with cranial asymmetries and their treatment outcomes. As a continuation of the previous work, the researchers have identified a plagiocephaly severity scale based on those outcomes to assist medical professionals who treat patients with cranial abnormalities. Our hypothesis is to validate the proposed severity scale that categorizes the clinical presentation and severity of plagiocephaly.Of the 224 patients enrolled, 207 patients were placed in an experimental group and 17 patients who refused treatment were placed in a control group. Digital head shape data were collected. Cross-correlation matrices were computed across variables and regression models resulted in the identification of 5 meaningful variables. A 5-level clinical classification scale was created. Five 1 × 5 analyses of variance were computed to compare each classification level.Four of the 5 analyses of variance identified significant overall effects for classification. A model was developed from the empirical data and the model was tested for accuracy, resulting in 12.1% overall error. The model was validated for both experimental and control groups.The results show that the severity scale is a meaningful outcome-based scale that assists clinicians in developing a treatment plan for treating plagiocephaly. The scale has been validated across a large heterogeneous study sample.

Congenital limb deficiency disorders.

Congenital limb deficiency disorders (LDDs) are birth defects characterized by the aplasia or hypoplasia of bones of the limbs. Limb deficiencies are classified as transverse, those due to intrauterine disruptions of previously normal limbs, or longitudinal, those that are isolated or associated with certain syndromes as well as chromosomal anomalies. Consultation with a medical geneticist is advisable. Long-term care should occur in a specialized limb deficiency center with expertise in orthopedics, prosthetics, and occupational and physical therapy and provide emotional support and contact with other families. With appropriate care, most children with LDDs can lead productive lives.

Analysis of locomotor adaptations in young children with limb loss in an early prosthetic knee prescription protocol.

BACKGROUND: Traditionally, clinical protocols for the treatment of young children who require a knee prosthesis have favored stability, with the prosthetic knee locked into full extension until after the child has learned to walk. Recently, an Early Knee protocol has been investigated, in which children receive an articulating knee in their first prosthesis and use it while learning to crawl and walk. OBJECTIVES: This study investigated the presence of swing phase clearance adaptations in the walking gait of seven young children aged 18-92 months, who had been fitted according to the Early Knee protocol. STUDY DESIGN: Before-and-after experimental design. METHODS: Each subject completed walking trials with the knee freely flexing and trials with the knee locked into full extension to mimic a traditional knee protocol. RESULTS: Subjects utilized the articulating knee in walking, with an average of 70.4° of peak swing phase knee flexion. Some clearance adaptations were present with the flexing knee; more were present and their magnitude was increased when the knee was locked. In particular, there was a statistically significant increase in circumduction. CONCLUSIONS: These results suggest that the Early Knee protocol can reduce the adoption of clearance adaptations while walking is developing. CLINICAL RELEVANCE: Treatment of young children who require a knee prosthesis is inconsistent. Traditionally, no knee is provided until independent walking is achieved. A newer Early Knee protocol provides an articulating knee in the first prosthesis. This study found that children use the articulating knee in walking and develop fewer clearance adaptations.

Physical therapy management of congenital muscular torticollis: an evidence-based clinical practice guideline: from the Section on Pediatrics of the American Physical Therapy Association.

BACKGROUND: Congenital muscular torticollis (CMT) is an idiopathic postural deformity evident shortly after birth, typically characterized by lateral flexion of the head to one side and cervical rotation to the opposite side due to unilateral shortening of the sternocleidomastoid muscle. CMT may be accompanied by other neurological or musculoskeletal conditions. KEY POINTS: Infants with CMT are frequently referred to physical therapists (PTs) to treat their asymmetries. This evidence-based clinical practice guideline (CPG) provides guidance on which infants should be monitored, treated, and/or referred, and when and what PTs should treat. Based upon critical appraisal of literature and expert opinion, 16 action statements for screening, examination, intervention, and follow-up are linked with explicit levels of evidence. The CPG addresses referral, screening, examination and evaluation, prognosis, first-choice and supplemental interventions, consultation, discharge, follow-up, suggestions for implementation and compliance audits, flow sheets for referral paths and classification of CMT severity, and research recommendations.

Developing evidence-based physical therapy clinical practice guidelines.

PURPOSE: Recommended strategies for developing evidence-based clinical practice guidelines (CPGs) are provided. KEY POINTS: The intent is that future CPGs developed with the support of the Section on Pediatrics of the American Physical Therapy Association would consistently follow similar developmental processes to yield consistent quality and presentation. Steps in the process of developing CPGs are outlined and resources are provided to assist CPG developers in carrying out their task. These recommended processes may also be useful to CPG developers representing organizations with similar structures, objectives, and resources.