Torticollis

General Guidelines

Toriticollis has several root causes and they need to be assessed before beginning the treatment process. Some common causes are reflux issues either known or silent (unknown), neurological, visual problems, birth injury, cyst, or positional issues in utero. 

Reflux: When a child has difficulty with reflux, they will often turn their head to the side to relieve the pain. This can result in a muscle imbalance in the neck.

Neurological: When a child has some type of brain injury, this can result in a muscle imbalance. The child may have some other neurological problems that result in this as well. In most instances, the neck tilt may switch sides. This is the clue that the torticollis needs a different course of treatment, and your child needs to be seen by a neurologist.

Visual: A head tilt can be directly related to or in conjunction with eye muscle problems. Make an appointment with a pediatric ophthalmologist to have your child’s eyes thoroughly checked to make sure that this is addressed early.

Birth Injury: If the muscles of the neck are stretched during birth, this can lead to a head tilt.

Cyst: There can be a small cyst in the muscle on one side of the neck that can lead to a head tilt. The cyst will usually go away on it’s own, but the tightness needs treatment.

Position in Utero: When a child makes it to a full-term pregnancy, the room inside is limited and cramped. Sometimes the child can become positioned in such a way to cause a head tilt.

Treatment:

If your baby is diagnosed with neurological torticollis, your PT will have to guide you carefully through the treatment. The ideas below are not always appropriate.

1.) Help your baby to stretch the affected muscle after a professional physical therapist has properly trained you. This doesn’t need to be done in all types of torticollis and many babies are very resistant to stretching. Follow the simple guidelines below only if you have been insturcted to do so. You would NOT do these with some types of torticollis (neurological).

The protocols for times and amounts do change with new research, so please follow the instructions given to you from your PT.  While the child is lying on his back, the head is tilted away from the affected muscle. Lay your baby on his or her back. Cradle his/her head in your hand, place your other hand on the same shoulder, and gently stretch away from the tilt. The other stretch is with your baby still on his or her back and the face is turned toward the tilt or affected side just enough to apply a gentle stretch.

Remember: We are much stronger than them and can easily be too rough with this. It is a GENTLE stretch.  Distract your baby by singing gently or talking, and watch their response for signs of the stretch being too much, like pulling away or getting fussy. When done correctly, a little stretch can be held for 20 to 30 seconds without distress. I only recommend stretching like this in selected cases. I prefer using positioning to improve the range of motion.

2.) Keep your baby active to promote the exercise of the neck muscles. When playing, hold toys in the same direction of the tilt, bottle feed so the baby must stretch the affected muscle, and place your baby in the crib so that stimulating pictures and activities are in the same side direction of the tilt. Strengthening the opposite side of the neck and the upper body and arms can also help to stretch and relieve the affected muscle.

3.) Carry your baby in a position facing away from you so that the affected side rests against your forearm. Place your opposite arm between your baby’s legs to support her body. You should carry your baby in this position as much as possible.

4.) Frequently apply gentle massage to the affected muscle to help relieve pain and allow the muscle to relax. Massage and stretching exercises should never hurt, so only use as much strength as your baby can handle comfortably.

This can get confusing, so think of it this way:

The head is tilted in one direction, which causes your baby to turn to the side. We want to encourage your baby to look the OTHER way.

Activities for children with torticollis

For children with torticollis, it is very important to play in all the positions: prone (on tummy), lying on their side, sitting, and supported standing. These are appropriate and necessary at any age. Encourage them to look at and interact with toys that promote rotation of the head and body to the child’s non-preferred side. Set up the child’s environment (i.e. orientation of toys, crib, and play mat) to promote exploration toward the baby’s non-preferred side.

Prone (tummy):

1.) During stroller rides, place grasp toys in front of or to the baby’s non-preferred side.

2.) Put your baby on your stomach over your lap. Hold toys above and to the non-preferred side.

3.) Carry your baby horizontally by scooping your hand under the baby’s chest, so his legs straddle your forearm. Play airplane or “so big” in this position in front of a mirror.

4.) Get down on the floor facing your baby with or without toys placed between you. Approach the baby from the non-preferred side. Hold toys above and to the non-preferred side.

Lying on their side:

1.) Encourage bilateral hand play (this promotes midline alignment).

2.) Place toys in a way that encourages downward gazing.

This is an easy posture to start rolling to the stomach.

Sitting and standing (supported or independent): 

1.) Encourage head turning to the non-preferred side with toys or visual engagement.

2.) Encourage looking and reaching with the baby’s non-preferred hand.

3.) Encourage bilateral hand play in midline.

Carry your baby:

1.) Against your chest with baby facing out.

2.) Over or up against your shoulder.

3.) From under their tummy like a football.

Tummy time (see tummy time page for more info)

All infants must spend time awake on their stomachs (tummy time). Tummy time allows babies to strengthen and stretch muscles that are important for developing basic valuable motor skills such as crawling, standing, sitting, and walking. Tummy time also facilitates visual development as your baby learns to move his/her head to look at objects and track movement. Tummy time should always occur while the baby is awake and be supervised by an adult. To reduce the risk of Sudden Infant Death Syndrome (SIDS), all healthy infants should sleep on their backs until they can easily roll from their tummies to their backs.

Babies who do not spend enough time on their tummy and spend too much time on their back generally:

–Walk later than babies who have spent time on their tummy.

–Have tight muscles in their necks.

–Have flat spots on the back of their heads.

–Have weaker back and stomach muscles which may lead to difficulty sitting, standing straight, or balancing in upright positions.

Aim for your baby to spend half their waking time throughout the day on their tummy. Start tummy time on the day of your baby’s birth, if possible. The sooner a baby spends time on his/her tummy, the more comfortable this position will be as he/she continues to develop. If a baby is not used to spending time on his/her tummy, they may not enjoy it at first. Try introducing small amounts of tummy time and build up to the half day slowly. Try the following positions to give your baby some quality tummy time:

1.) Place a thin blanket and toys on a firm surface (such as the floor) and lay your baby on his/her tummy to play. This is a great position for babies to look at toys and practice lifting their head.

2.) Place your baby on his/her tummy on your stomach while you are lying on your back. This way, your baby can easily make eye contact with you.

3.) Put your baby on his/her tummy over your lap.

4.) Carry your baby horizontally by scooping your hand under the baby’s chest, so his legs straddle your forearm. Play airplane or “so big” in this position in front of a mirror.

For more information about playing with a purpose with your child, see available books HERE

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