Torticollis: What is Torticollis?

Devinf

Devinf

Torticollis means “wry neck” and refers to the position of your baby’s head and neck.  A common presentation is if your baby prefers to tilt his head to one side and/or look to the opposite side. Parents usually first notice that their baby only prefers to look one way and has difficulty or resists looking the other way. (Note: every baby with torticollis will present differently.)


How can I tell if my baby has torticollis?

Does your baby tilt his head to one side or prefer to look to one side more than the other? Does your baby only reach with one hand? Can your baby look all the way to each shoulder while on his back, belly, and sitting? If you notice some of these signs, you can ask your pediatrician for a physical therapy referral for an evaluation and assessment of your baby’s alignment, range of motion, and strength. An early referral is always best!

What causes Torticollis?

Torticollis can occur for a few reasons. It is commonly caused due to your baby’s position in utero. Some additional factors include a larger size baby, a larger size head, a smaller uterus, or a twin pregnancy. Additionally, if your infant gets accustomed to looking to one way, this can become a habit and cause some muscle tightness that will further compound the head position.

Due to his position in utero or post-birth, your baby can develop muscle restrictions in his neck, trunk or pelvis that cause him to develop a lateral head tilt and rotation preference to look one way. Subsequently, often his trunk and pelvis will also be asymmetrical.

Another factor that can exacerbate the torticollis is your baby’s head shape. If a baby spends too much time on his/her back, especially looking to one side, your baby can develop a flat spot on one side of the head which then will reinforce the head tilt/rotation. This is called plagiocephaly. Sometimes, a shaping helmet is required to address your baby’s plagiocephaly in addition to the torticollis. Your pediatrician can give insight on whether a shaping helmet is required for your baby and will work with an orthotist or plastic surgeon to decide. (Note: Helmets are only needed if a baby’s head shape is moderate or severely misshapen, and also depends on baby’s age. It’s important to note that not all babies with torticollis have plagiocephaly.)


How can physical therapy help Torticollis ?

Every baby with torticollis may present a little differently, and a physical therapist should evaluate your baby in each developmental position (on his back, tummy, sitting, on all fours, crawling, standing, walking) to determine specific positions, exercises and activities that are optimal for your baby to obtain symmetrical alignment and strength.

Physical therapy treatment sessions will incorporate positions, stretches, and exercises that are specific to your baby’s head and neck alignment. Treatment sessions will consist of passive or active stretches, strengthening exercises, and positioning to achieve postural symmetry with symmetrical muscle length and strength. A large part of physical therapy treatment will include parent education and a home exercise program so that the baby’s parents can be empowered to help the baby at home throughout the week to ensure good carryover from physical therapy sessions for optimal results.



Torticollis Treatment: The Traditional Way


My baby has torticollis. What can I do to help?

Torticollis exercises will be specific to your baby’s presentation, alignment, muscular restrictions, and head tilt. At a physical therapy evaluation, your therapist will determine a treatment plan, goals, and home exercises.

Note: all described exercises need to be prescribed and demonstrated by a physical therapist.


Torticollis exercises

Positioning

If you tend to lay your baby down on the crib and changing table the same way each time, try switching it up. Sometimes a child will look more to the right because there is a wall on the left of his crib, and it is more interesting to look to the right. Additionally, if a baby consistently is bottle or breastfed in the same orientation, try switching up the way you hold your baby for feeding to allow your baby a different orientation and place to look around. Your physical therapist can provide further details on this.


Active stretches

Depending on your baby’s muscle length/strength, active stretches can be indicated to gain muscle length and strength. For example, if your baby prefers to look to his left, you can place toys to his right to get him to look further to his right and hold his gaze. During such exercises, always follow your baby’s lead and allow the baby to perform the motion on his own. A physical therapist can help educate you on the best way to help your child to look the other way safely and comfortably. Sometimes passive stretches are indicated however, most babies do not tolerate passive stretching and should only be performed under supervision of a physical therapist and with the baby’s tolerance.



Strengthening

Depending on your baby’s muscle length/strength, strengthening exercises can be indicated to gain muscle strength to obtain symmetrical posture and development. Strengthening is important to make sure both sides of his body are equally strong in order to hold his head, neck, and trunk in the middle and use both arms and legs equally to play and move within his environment. Your physical therapist will educate you on gross motor milestones and will guide you to ensure your baby develops symmetrically, with assisted reaching, assisted rolling, tummy time, assisted sitting, etc., until your baby performs on his own.



Massage

Typically, your baby’s muscles will be tight on one side, so your physical therapist can help educate you on techniques to gently massage your child’s neck.



Home Exercise Program

Your physical therapist will demonstrate and teach prescribed exercises to the baby’s caregiver to ensure good carryover from physical therapy sessions for optimal results.



Torticollis Treatment: Total Motion Release Tots and Teens


What is Total Motion Release?

Total Motion Release (TMR) is a postural release technique founded by physical therapist Tom Dalonzo-Baker over 15 years ago1 to help his adult orthopedic patients with back pain, gain range of motion. These techniques release restrictions in muscle/fascia to encourage improved range of motion and symmetrical alignment in the pelvis/trunk, that leads to functional improvements in patients with pain, decreased range of motion, or atypical presentations. These techniques have been used on generations of orthopedic adult patients. 

Tom connected with a pediatric physical therapist Susan Blum in 2006 to modify these techniques to be utilized for the pediatric population, which is now called TMR Tots and Teens (TMR TNT).2 Susan now teaches TMR TNT courses for physical and occupational therapists in pediatrics all over the United States. You can reference the TMR website at www.tmrTots.com3 for more information!

Who is TMT TNT for?

TMR TNT is indicated for the many pediatric diagnoses including torticollis, Down Syndrome, cerebral palsy, hyptonia, motor control, scoliosis and more, however here, we will focus on using TMR to treat torticollis. It can be performed on babies and children of any age and it will be specific to your child!


Why is TMT TNT different?

While the traditional way to treat torticollis works, TMR TNT is a different way to treat torticollis. Using TMR TNT, therapists look for interconnected areas of limited range of motion elsewhere in the body which are associated with the torticollis. For example, TMR TNT therapists will focus on the entire body, not only the neck, when treating torticollis. Results can often be limited when only the neck is treated. From TMR TNT’s website2, it lists five features that make TMT TNT different than traditional therapy:


1. Focus: “Treatment is precise to get to the root problem and quickly fix it.”

2. Build on What They Know: This builds on your child’s strengths. “We reinforce the patient's successes with positive motor experiences, which aid in motor recruitment.”

3. Empowerment of Caregiver and Child: “Therapeutic activities are incorporated into daily routines at home, school and daycare.  Instead of 1 or 2 hours of therapy a week, treatment becomes 24/7 for even more accelerated results.”

4. No Tears - Parent Satisfaction: “The language of TMR is comfort!”

5. Results: “Many patients with incomplete correction of torticollis achieved full correction once TMR was used to identify and treat the associated restrictions"



What does TMR TNT treatment look like?

It involves placing the child in positions to their preferred/easy side to "unlock" the restriction to gain improved active range of motion, so it does not involve any stretching. It then allows your child to explore in his new range of motion and achieve symmetrical alignment, improved gross motor skills, gain motor control, and more! It is tears-free, feel-good therapy! 

The home exercises are simple and can be worked into the parent's day for two minutes at a time, so allows for easier carryover. For example, positions can occur while being bottle or breastfed, being held, while reading a book, and while playing! This empowers the caregiver!



Who can perform TMR TNT?

A physical or occupational therapist who has taken a TMR TNT continuing education training course seminar can utilize the TMR evaluation tool and protocol to treat your baby or child. There are three levels of TMR TNT. Three physical therapists at Lumiere Children’s Therapy have taken TMR TNT Level 1!



Torticollis Tips, Tricks, and Toys


  • Utilize your pediatrician and physical therapist to help get you started! Don't let the internet or anyone else scare you. We will work with your family for an optimal treatment plan to help your baby.


  • Perform exercises when your baby is the most energized and ready to play, such as after your baby has slept, eaten, and has a clean diaper, to ensure your baby is the best mood to “exercise”!


  • Some babies will need to wait an hour after eating before tummy time to minimize spitting up, especially babies with reflux. Ask your doctor about specifics if your baby has reflux.


  • Utilize toys listed below to help your baby have the most fun during exercises!



Toys

  • Tummy time mat: a comfortable tummy time mat will motivate your baby to stay on his tummy, engage in the toy, and be comfortable!

  • Small rings: small rings are initially easier to grab, so it promotes your baby to reach. Your therapist can show you positions for your baby to reach on his back, belly, and in sitting!

    Bright Starts Lots of Links: https://www.amazon.com/Bright-Starts-Lots-of-Links

  • Music toys: toys that play music will distract your baby to look to one side and keep him focused on the toy, so he maintains his gaze. This toy is a parent favorite because of the soft music, and a baby favorite because of the size, colors, and sounds!: Baby Einstein Take Along Tunes Musical Toy

  • Cause and effect toys: Toys that encourage your child to reach in order to produce a song/sound/movement on a toy will encourage reaching and further gross motor development. Kids and therapists love this spin toy!: Leap Frog Spin and Sing Alphabet Zoo


Next Steps


If you have any questions or require an evaluation or therapy plan for your baby’s torticollis, please contact Lumiere Children’s Therapy.

Written by: Morgan, PT, DPT, a licensed physical therapist at Lumiere Children’s Therapy.