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.

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.

Infants With Congenital Muscular Torticollis Requiring Supplemental Physical Therapy Interventions.

PURPOSE: To describe supplemental intervention (SI) frequency in infants with congenital muscular torticollis (CMT) and compare groups of infants who received first-choice intervention only to infants who received SI. METHODS: Data were retrospectively extracted from a registry. Baseline and treatment variables were collected and analyzed. RESULTS: The cohort included 907 infants with 85 receiving SI. Order of SI frequency was kinesiological tape, manual techniques, tubular orthosis for torticollis (TOT) collar, and the Benik system. Statistically significant differences were found in baseline age, passive cervical range of motion (ROM), muscle function, and treatment time between groups. A positive association was found for CMT presentation, classification grade, plagiocephaly type, and external referrals between groups. CONCLUSIONS: Nine percent of infants received SI, most frequently kinesiological tape. Infants who received SI had larger baseline passive ROM and muscle function differences and more visits over a longer duration but had similar CMT resolution. Education is needed when using SI.

Infants With Torticollis Who Changed Head Presentation During A Physical Therapy Episode.

PURPOSE: The purpose of this study is to describe infants with congenital muscular torticollis (CMT) who changed head presentation during an episode of physical therapy. METHODS: Data were extracted from electronic medical records between January 2015 and December 2018 to describe infants with CMT who changed presentation. RESULTS: Eighty-nine infants met criteria (predominantly male, non-Hispanic, White, with private insurance). Torticollis symptoms were noticed by 3 months in 90% of infants with a physical therapy examination before 6 months in 100% of infants. Most infants had early mild CMT with abnormal head shape and greater limitation in active cervical range of motion (ROM) than passive cervical ROM. Clinicians frequently recommended weekly physical therapy that included first- choice and supplemental interventions. Episodes of care averaged 7 visits over 64 days with 73% of infants meeting goals. CONCLUSION: Physical therapists should recognize that infants with CMT may change presentation but benefit from physical therapy to resolve symptoms.Digital Abstract available at: http://links.lww.com/PPT/A366.

White matter characteristics in children with cerebral palsy prior to selective dorsal rhizotomy: a multicenter diffusion tensor imaging study.

OBJECTIVE: The aims of this study were to 1) assess and quantify white matter (WM) microstructural characteristics derived from diffusion tensor imaging (DTI) in children with cerebral palsy (CP) prior to selective dorsal rhizotomy (SDR), and 2) investigate potential associations between WM diffusion properties and gross motor function and spasticity in children with spastic CP who underwent SDR. METHODS: This study is a multisite study based on DT images acquired prior to SDR as well as postoperative outcome data. DTI data collected from two sites were harmonized using the ComBat approach to minimize intersite scanner difference. The DTI abnormalities between children with spastic CP and controls were analyzed and correlated with the severity of impaired mobility based on the Gross Motor Function Classification System (GMFCS). The improvement in gross motor function and spasticity after SDR surgery was assessed utilizing the Gross Motor Function Measure-66 (GMFM-66), the Modified Tardieu Scale (MTS), and the modified Ashworth scale (MAS). Alterations in these outcome measures were quantified in association with DTI abnormalities. RESULTS: Significant DTI alterations, including lower fractional anisotropy (FA) in the genu of the corpus callosum (gCC) and higher mean diffusivity (MD) in the gCC and posterior limb of the internal capsule (PLIC), were found in children in the SDR group when compared with the age-matched control group (all p < 0.05). Greater DTI alterations (FA in gCC and MD in gCC and PLIC) were associated with lower mobility levels as determined based on GMFCS level (p < 0.05). The pre- to post-SDR improvement in motor function based on GMFM-66 was statistically significant (p = 0.006 and 0.002 at 6-month and 12-month follow-ups, respectively). The SDR efficacy was also identified as improving spasticity in lower-extremity muscle groups assessed with the MTS and MAS. Partial correlation analysis presented a significant association between pre- to post-SDR MTS alteration and DTI abnormalities. CONCLUSIONS: The findings in the present study provided initial quantitative evidence to establish the WM microstructural characteristics in children with spastic CP prior to SDR surgery. The study generated data for the association between baseline DTI characteristics and mobility in children with CP prior to SDR surgery. The study also demonstrated SDR efficacy in improving motor function and spasticity based on the GMFM-66, MTS, and MAS, respectively, in association with DTI data.

Outpatient hospital utilization after single event multi-level surgery in children with cerebral palsy.

PURPOSE: This study aimed to examine outpatient hospital utilization (number of specialties seen and number of visits to each specialty) in the year after single event multi-level surgery (SEMLS) in children with cerebral palsy (CP), and to determine if utilization differs across the medical center in the year after compared to the year before SEMLS. METHODS: This retrospective cross-sectional study used electronic medical record data of outpatient hospital utilization in children with CP who underwent SEMLS. RESULTS: Thirty children with CP (Gross Motor Function Classification System Levels I-V, mean age of 9.9 years) were included. In the year after surgery, a significant difference (p = 0.001) was found for the number of specialties seen, with non-ambulatory children seeing more specialties than ambulatory children. No statistically significant difference was found between the number of outpatient visits to each specialty in the year after SEMLS. Compared to the year before SEMLS, fewer therapy visits occurred in the year after SEMLS (p < 0.001) but significantly more visits to orthopaedics (p = 0.001) and radiology (p = 0.001). CONCLUSION: Children with CP had fewer therapy visits but more orthopaedic and radiology visits the year after SEMLS. Nearly half of the children were non-ambulatory. Examination of care needs in children with CP undergoing SEMLS is justified with consideration of ambulatory status, surgical burden, and post-operative immobilization.

Neuromuscular electrical stimulation to augment lower limb exercise and mobility in individuals with spastic cerebral palsy: A scoping review.

Background: Neuromuscular Electrical Stimulation (NMES) is an emerging assistive technology applied through surface or implanted electrodes to augment skeletal muscle contraction. NMES has the potential to improve function while reducing the neuromuscular impairments of spastic cerebral palsy (CP). This scoping review examines the application of NMES to augment lower extremity exercises for individuals with spastic CP and reports the effects of NMES on neuromuscular impairments and function in spastic CP, to provide a foundation of knowledge to guide research and development of more effective treatment. Methods: A literature review of Scopus, Medline, Embase, and CINAHL databases were searched from 2001 to 2 November 2021 with identified inclusion and exclusion criteria. Results: Out of 168 publications identified, 33 articles were included. Articles on three NMES applications were identified, including NMES-assisted strengthening, NMES-assisted gait, and NMES for spasticity reduction. NMES-assisted strengthening included the use of therapeutic exercises and cycling. NMES-assisted gait included the use of NMES to improve gait patterns. NMES-spasticity reduction included the use of transcutaneous electrical stimulation or NMES to decrease tone. Thirteen studies investigated NMES-assisted strengthening, eleven investigated therapeutic exercise and demonstrated significant improvements in muscle structure, strength, gross motor skills, walking speed, and functional mobility; three studies investigated NMES-assisted cycling and demonstrated improved gross motor skills and walking distance or speed. Eleven studies investigated NMES-assisted gait and demonstrated improved muscle structure, strength, selective motor control, gross motor skills, and gait mechanics. Seven studies investigated NMES for spasticity reduction, and five of the seven studies demonstrated reduced spasticity. Conclusion: A growing body of evidence supports the use of NMES-assisted strengthening, NMES-assisted gait, and NMES for spasticity reduction to improve functional mobility for individuals with spastic CP. Evidence for NMES to augment exercise in individuals with spastic CP remains limited. NMES protocols and parameters require further clarity to translate knowledge to clinicians. Future research should be completed to provide richer evidence to transition to more robust clinical practice.