LAUREN CLEMSON, JOSH HARDY, & LIZ WEISS REGIS UNIVERSITY DPT PROGRAM Congenital Muscular Torticollis and Plagiocephaly

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

Our Case 4 Months old Mild right congenital muscular torticollis (CMT)  Left rotation (lacking<15° right rotation), right side bend  Mild plagiocephaly (8mm) Therapy sessions 1x/week for the last 4 weeks.

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 patient’s caregiver/family.

Formulated 2 PICO questions: 1. 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? 2. 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…

Hierarchy of Evidence

And Found: 1. CMT treatments  No Randomized Controlled Trials (RCTs)  Only low-level evidence available  All studies had numerous biases, methodological flaws, and glaring inconsistencies. 2. Plagiocephaly treatments  No RCTs  BUT a 2008 systematic review of cohorts was identified.

Current Children’s Hospital Plagiocephaly Protocol 1. Younger child (<5mo): Treat the child conservatively with repositioning and caregiver education. (positioning, tummy time, feeding, etc.) 2. Older child (>5mo): Examine the extent of plagiocephaly via anthropometric measurement or imaging. Based on the results, helmet therapy may or may not be indicated. (deviation of >5 mm in sagittal plane is considered pathologic)

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 RCT’s 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. 2008;162(8):

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.

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.

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.

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, CI=95%, Absolute risk reduction, improvement with helmet/molding therapy:  0.21, CI=95%, Number needed to treat:  5.0, CI=95%, 4-7

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.

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 infant’s physician to discuss helmet/molding therapy. Present the infant’s family with options for treatment. All recommendations based on low-level of evidence.

Current Children’s Hospital Plagiocephaly Protocol 1. Younger child (<5mo): Treat the child conservatively with repositioning and caregiver education. (positioning, tummy time, feeding, etc.) 2. Older child (>5mo): 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 >5 mm in sagittal plane is considered pathologic) AVAILABLE EVIDENCE SUPPORTS THIS PROTOCOL!

Current Children’s Hospital CMT Protocol 1. Manual stretching, home program, and caregiver education 2. Kinesiotape 3. TOT Collar 4. Botox 5. KISS manual therapy 6. Surgical Intervention

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.

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)

Current Children’s Hospital CMT Protocol 1. Manual stretching, home program, and caregiver education 2. Kinesiotape 3. Tot Collar 4. Botox 5. KISS manual therapy 6. Surgical Intervention MOST OF THE AVAILABLE EVIDENCE SUPPORTS THIS PROTOCOL!

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.

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

Thank You!

References Xia J, Kennedy K, Teichgraeber J, et al. Nonsurgical treatment of deformational plagiocephaly: A systematic review. Arch Pediatr Adolesc Med. 2008;162(8): 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): 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): Van Vlimmeren L, Helders P, Van Adrichem L. Torticollis and plagiocephaly in infancy: Therapeutic strategies. Ped Rehab. 2006;9(1):40–46. Cheng J, Tang T, Chen M, Wong M, Wong E. The Clinical Presentation and Outcome of Treatment of Congenital Muscular Torticollis in Infant.s—A Study of 1,086 Cases. J Ped Surg. 2000;35(7) : 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. 2005;13(4): Kim M, Kwon D R, Lee H. Therapeutic Effect of Microcurrent Therapy in Infants With Congenital Muscular Torticollis. Am Acad Phys Med Rehab. 2009;1: 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.