Okay, everyone looks like we have a pretty good group here so I think we can go ahead and get started. It's actually pretty high amount for it only being 1203 so I guess. Thanks to our great lecture everyone is excited to hear about this. So Dr. Amy can now I can is an assistant professor at the University of Colorado School of Medicine department of PM&R and a pediatric physiatrist at the Children's Hospital of Colorado. After completing medical school at the University of Minnesota, she migrated west to complete a five year pediatrics and PM&R combined residency program at the University of Colorado. She joined Colorado faculty in 2014 and is currently the program director of the Peds Rehab Medicine Fellowship, and the pediatrics and PM&R combined residency program. Most notably she survived her infant life with plush crib bumpers as a tummy sleeper while raised in Minnesota prior to the APS back to sleep campaign. So we are very excited to hear about this topic today. So with that, I'm going to hand it over to Dr canal again. Wonderful. Thank you, community. This is just a pleasure. Thank you, Emily for having us and also for everyone showing up, as far as learning a little more about tortoise and plagio So I look forward to talking a little more about a slice of my practice which I know is not necessarily in all pediatric rehab practices and speaking a little bit about about babies about older kids who might present with tortoise and then how we manage that. So, with that being said, please use the chat for questions. This is a recorded talk. And so some of what we'll be doing is thinking about you all here, but also people who may listen to this afterwards. So I hope this talk is something that people can use for themselves or even steer learners to asynchronously in the future if you find it useful. And then I'll kind of share some tidbits along the way. So I'm going to transition here to my screen share and go into presentation view. And Emily, if you give me a thumbs up if that sounds and looks okay on your end. Wonderful. Okay, I made the transition. So, again, I'm from Colorado, but I did survive being an 80s baby sleeping on my tummy. I have a fairly round head. However, I now say with my children and kiddos who I take care of that we manage the consequences of babies having less risk of SIDS, so being back sleepers. Next, we'll be talking about just objectives. So at the conclusion of my presentation, I'd like you to be able to identify a differential diagnosis for torticollis, name evidence-based treatment options for torticollis, describe torticollis home exercise program, interpret cranial 3D scan measurements of plagiocephaly, be able to educate families on interventions and options to treat plagiocephaly, and also be able to identify some skull-shaped red flags for craniosynostosis. I have nothing to disclose. And today, we'll kind of start off discussing torticollis, defining it, talking about anatomy, our history, differential diagnosis and treatment. And then because a consequence of torticollis is often positional plagiocephaly, we will discuss that too. And kind of the second part, talk about head shape, talk about how to examine, make measurements, 3D scans, and interpret maybe some of these spreadsheets that come from either an orthotist or maybe an outside sort of orthotics or helmet-only clinic that you may see treatment and also craniosynostosis. So to start, we'll talk a little bit about torticollis and neck anatomy. So it's a derivative of the Latin language, tortus, meaning twisted and column neck. So really, literally, it means twisted neck. And so torticollis is a symptom or sort of something we see, but finding out the etiology is sort of where we come in as diagnosticians. We want to look at, it sort of is caused by an asymmetric length and strength of what is often the sternocleidomastoid muscle involvement. And then babies in congenital muscular torticollis are born with this. And so it's thought that in utero positioning, scarring down at the sternocleidomastoid muscle can be a piece of what can cause this twisted neck. Fibromatosis coli is a name for sort of, it's almost like a bulb-like feeling within the sternocleidomastoid muscle. That's thought, as babies are in the position in utero like this, that they can get some venous occlusion and have some scarring in the sternocleidomastoid muscle. MRIs even show some changes in the musculature, similar to compartment syndrome. And then there's other sort of anatomic things in the neck other than muscles that can cause this, like a cystic hygroma or brachioclepsis. These are just things sometimes to keep in mind on the back burner when you're treating a child. How do we approach a family who comes in with concerns about torticollis? This is kind of a list of history questions that I include with both my learners and also with myself whenever I talk with families about torticollis. When did it start? What is your child's preferred head position? Sometimes they use sort of rotated or turned or tilted, sometimes interchangeably. And so this is where, you know, sometimes with an initial history, I'd try to ask some clarifying questions of like, what is the actual position? Can you show me some pictures of what the baby has looked like from early on? Asking how does this change over time? So since you first noticed it, what have you noticed? Are they more tilted? Are they less? What have you tried so far? Tummy time? Repositioning? Have you seen anyone else about this? Do you have any head shape concerns? Some parents present to the clinic being worried about the head shape and unaware of maybe a head turning preference. And some might start with a chief complaint about the head position. How has the head shape changed over time? Developmental history is super important, especially not just as pediatric rehab specialists, but also in treatment of the torticollis and looking at hand symmetry and motor skills. Birth history is important because there's risk factors with torticollis associated with it. Gestational age, were they vertex? Were they breech? Are they a twin? Any complications in pregnancy? And then just a good past medical history and also family history. What are some risk factors associated with torticollis? So first, pregnancy. Multiple gestation. I say it's a packaging issue. There's just only so much space and so one baby sometimes is a little bit twisted up. Oligohydramnia, so you think about low fluid in the uterus being a little bit less roomy to move around in. Decreased fetal movement, breech positioning, male, sorry guys. And then even a laterality, so the right sternocleidomastoid being more common than the left. And then to this 1992 back to sleep campaign, which I predated. Torticollis is also associated with other conditions, so there's consequences of it and why we'll talk about early treatment. So plagiocephaly or flattening of the head. We got sternocleidomastoid fibromatosis coli. There could be facial asymmetries, and if you have difficulty rotating your head as a baby, then latch or even breastfeeding feeding can be challenging on sometimes one side more than the other. There could be motor asymmetries with the hand and even hip dysplasia, so we do a good hip screening. And then I even read metatarsus adductus. So when we're evaluating torticollis, first we're kind of looking for what would I expect when I walk into the room? And so for some families, if like this little picture of the baby, he appears to be rotated right and maybe with a little bit of a lateral tilt. And so I'd call that a left-sided torticollis. So that means if you're a left side, and it's OK to act it out because I encourage all learners to like rotate your head in clinic and move it around. But if you have flatness on the right posterior side, it's your left sternocleidomastoid muscle that's rotating you over, and then sometimes your left upper trap tilting over to the left side. So you're rotating to the right and tilting left with like a right posterior flattening. Takes a lot of repetitions to get this. So in assessing sort of the traditional posture, sometimes there's babies who are, we say, sort of like a left-left, like left tilt, left rotation, and that can happen. And so we just think and evaluate each baby individually. Often sort of walking into the room, I'm looking for maybe a traditional posture and then going from there. We're assessing range of motion. We also are looking at head tilt, not when the child is like 45 degrees lateral supine, just feeding with their parent. I'm looking at them when they're vertical. And then also taking a peek at the head. We'll talk about head shape kind of after we discuss torticollis. When we evaluate it, I'm also looking for any facial differences that might be associated with this. So sometimes on the same side, there could be ear cupping on that one side of the ear, jaw flattening, even mandibular asymmetries noted, eye asymmetries. And then even on this side where it's pulling and maybe you're flat on the opposite side, there can be some flattening of the forehead. And so these are just some things I'm looking at as I'm evaluating the child visually. Next, how do we assess range of motion of the necks? So this is important because it helps us grade the severity of torticollis, but also informs like where we are and how closely we need to follow them and what interventions we need to do. So to start, I want to walk into the room, make sure the child is kind of in a midline position, that there aren't too many distractors off to the side. I want to be right in front of them. And then I want to look at active range of motion. So I'm using sometimes like a blinky ball or some type of toy with some visual stimuli that gets them interested and moving it over to the side. If that doesn't work, move your whole body with the toy over to the side because babies love faces. And so bring your face with it. And then if you're super on it, maybe wear something really high contrast. And so sometimes I joke that I have like a blouse that I wear on plagiocephaly day for the babies to get some high contrast black and white, which I'm not wearing today. So a baby who's three months old, they may need to be supine. And so you're looking at range of motion each way. But as soon as they get enough head and neck control, adding in sort of supported sit, or they have the caregiver making sure that they kind of have them in a trunk neutral to look at active range. So I'm looking at rotation. And then what I'm doing once we get them over to the side is I'm checking to see what is their passive range. And babies actually have more rotation range than adults and older kids. So even looking up to 110 degrees, and then lateral flexion, I'm often testing sort of on the table in lateral flexion to normal would be 70. But really with the baby being their own internal control. So you're looking for the symmetry kind of from one side to the other. Next, I'm palpating the neck. So I'm feeling that chubby little neck, feeling the sternocleidomastoid muscle, the upper trap, even as I'm checking range, I'm checking for tightness. I also palpate the spine all the way down. And then I check for strength doing what we call head writing. So I hold the baby sort of suspended vertically, and then I tilt their trunk over 45 degrees to one way, and I'm looking for activation of the neck. And I'm looking for 45 degrees the other way, and I'm looking for a symmetric activation of the neck. So that's me testing strength. You can even test the fatigability, but you got to kind of be goofy with it to keep the baby interested and happy. A screaming baby is sort of like what you're avoiding because you're trying to get a really good exam. Next, what is the treatment of torticollis? So if you've identified a child with a head tilt, tightness in the neck, or rotation asymmetries, then referral to PT is really important and also caregiver education. And so PT, physical therapy, is effective because I say to families, often with their first baby, like there's so much to learn and understand that you're working on feeding, sleeping, and now you're going to try to get comfortable evaluating and stretching your baby's neck. And they often look at me like a deer in headlights. And so I say, these are some simple exercises, but I am going to pair you with a skilled PT that we're going to work on treating the torticollis. And so the fundamentals of like your treatment are involved cervical strengthening, so that head righting or lateral neck strengthening. I'll show you some pictures shortly. And then you're also working on symmetric gross motor skills, sort of through that active range. So as they're working on rolling, as they're working on eventually sitting, they're working on the symmetry of these movements. And then caregiver education is very important. It's actually the pillar to torticollis care is there is any caregiver's understanding of what are the stretches? Which way do we go? How do I hold them? What do I do when they cry? Doing tummy time. So I can't, you're going to hear that word a lot today. Tummy time, tummy time, tummy time. And environmental changes. So if you have a baby who has a left-sided torticollis and a right rotation preference, that's kind of when I ask, so which side of the, when they're in their bassinet next to your bed, which way do they have to turn to look at you? And so sometimes parents are like, oh, it's to the right. And so I say, what can you do to flip them around sort of like rotisserie baby in their crib and make sure that they're encouraged to look to the left. Or if they're in any type of like car seat situation, they can put toys off to the left side. And so some of that counseling of some of those simple things are things that parents can kind of take home and enact right away. And so what is the, what are, is evidence-based physical therapy for torticollis? I think that the quality of intervention of PT is variable depending on if the pediatric PT is experienced in torticollis. And this clinical practice guideline is really the pillar of evidence-based care for physical therapy interventions. And so if you're working with anyone where, you know, you're wanting them to add in some more passive stretching, some manual therapy, this guideline is something that a pediatric PT familiar with torticollis should be using. And so it was updated last in 2018. There were some recommendations that came out that really, I think, are going to reinforce this sort of the next go around. But this multi-page PDF document is a PT algorithm for sort of the referral of children of torticollis to PT, when to refer back to physicians for reevaluation and the recommendation pathway. So it talks about age of diagnosis, classification, severity, response to treatment. And so I know this is a lot of diamonds and figures, but this is sort of one figure from there where they're talking about the flow diagram from physical therapy. The pillar of this is early referral to PT. And then also that if a child is first referred to PT, they should really be referred back to a physician to look at if there's any red flags or if they're not making progress in four to six weeks. So sometimes patients come to me after starting physical therapy, after their PT and their PCP have, you know, noticed that this isn't getting better, or sometimes with red flags. So sometimes a PT says, I am really concerned about the shape of this child's head. Would you take a look? So things in this guideline are abnormal vision screening, non-muscular asymmetries, moderate to severe cranial asymmetries, abnormal orthopedic screen or neurologic screen. The next figure I actually find interesting, mostly I'm going to kind of pull out the highlights. A, this clinical practice guideline is very detailed. B, the physical therapists classify torticollis, and I've actually learned a lot just about torticollis care from this clinical practice guideline based off of age. And then also the type of congenital muscular torticollis, another version of a CMT in our profession, as postural, and then also muscle tightness or an SCM mass. So an SCM mass would be like the fibromatosis coli, muscle tightness severity being in three categories, less than 15 degrees, 15 to 30 degrees, or more than 30 degrees. And then again, sort of this whole pathway is like, if not improving, if you go off to the sort of right area here, it says initial consultation, consider surgical release, release or botulinum toxin action options. So we'll talk about some of that later. But this is sort of the algorithm of like who's getting better, worse, or if you're reading through PT notes when they say grade three, early severe, it's based off of these guidelines. And so I think it's important that we share a common language with our physical therapists as we kind of work together collaboratively in the treatment of torticollis. What is important with the referral to PT is early timing. And so I think that this is one big change from just even pediatrics education, a decade ago to now, was like early on, pediatricians in training were told like, granted, you have to look at the newborn visit, and then at the two-month visit, at the four-month visit, if by chance you notice head position concerns, counsel families on active repositioning. Now that's a lot to accomplish in like a 20-minute visit with new parents. And so the evidence is now supporting early referral to skilled PT. So if someone identifies torticollis, getting the families in with a skilled PT right away, not worrying about adding all this stuff for the families. Granted, sometimes I meet families who are really on it and find great YouTube videos to get started. But the importance of it is that the prognosis to achieve cervical range of motion is much higher and the duration of PT and thus the cost of care is much lower, the sooner babies and families get started. So as you can see, sort of if you think about the kid who might have a head tilt at two months, if they've been at the two-month well-child check, if they've been counseled to do some active repositioning and they're not seen again till four months, the prognosis for full cervical range of motion drops significantly. So down to even 63% and the duration of PT much longer. In my clinical experience, this duration of PT is seven months seems quite long. So with that being said, I think the whole point here is early referral to PT. It's also been validated and endorsed by the Congress of Neurologic Surgeons that has put out sort of a clinical practice guideline on PT referral as well as the AAP. Some of what I'm doing in clinic is sort of counseling families on some things to get started with, but I am really relying on them to learn the nitty gritty and really get comfortable with some of the maneuvers and exercises when they work with their pediatric physical therapist. What do we do for repositioning? So tummy time, tummy time, tummy time. So we don't leave babies on their tummy, we still have them put in the bed on their back. So tummy time should be each day, multiple times a day and supervised. So not just leaving a baby alone. If a baby is quite little, so even in the first few months, first few weeks of life, sometimes I say a modified tummy time, so chest to chest, like on a recline can be an effective way. And then also you don't just put babies on their tummy. So trying to get those little forearms propped underneath them, having a face to look at with some interaction can really help with their engagement. Using a floor mirror as well can be a trick to getting more out of tummy time. And then also repositioning. So changing sort of the crib bassinet direction, changing which direction maybe you're holding the baby or which direction you have the baby lying when you're doing diaper changes, because they tend to look at their caregiver. Placing toys on the less preferred side. So the baby on the bottom here is rotated to the right. And so this baby may have like a left rotation preference and like a left-sided flattening. And so trying to get those toys over to the right side is an encouraging or active rotation in the less preferred direction using something fun like a toy. It's important. Parents asked about like car seats, bouncy seats, rock and play swings. And so limiting time in those is important. However, if they're used, using them for short periods of time and making sure babies are taken out of them, but then put in a crib without bumpers, without blankets in order to sleep. So I say, because the risk of SIDS decreases laying on your back, we want babies to be alive and we'll manage the flatheads or the torticollis. Here's some pictures that we have for demonstrating some home exercises. And so this top one is a picture of a baby lying down. The caregiver or the physical therapist is stabilizing the shoulder and rotating the baby's neck over to the right side for sort of a passive stretch and rotation. And to do a lateral neck flexion stretch, the caregiver in the lower left is sort of cradling the head in the right hand and then holding the shoulder in the left and trying to bring the left ear to the left shoulder and some space on that right upper trap muscle. So that's a little lateral neck flexion exercise. And then there's some held exercises. And so these little cradle holds or football holds can be particularly effective, both for strengthening and stretching. And I think the nice thing about it is it's a stretch and activity that brings the baby towards the caregiver. It can be done in front of a mirror. You make it fun, you make it silly. And in this cradle hold, the caregiver or the physical therapist is opening up space on the right lateral neck flexor. This is another method that they're using. And then this same hold can be actually used to sort of carry a baby around. So if this baby came in with a right tilt and some tightness on the right side of the neck, we wanna open up space on this tight side, but also strengthen the left side. And so that is what this person is doing by holding this baby on a right trunk tilt. So we're encouraging head writing. So I say like, it's like if you're sitting on a yoga ball or if you're from Colorado skiing the bumps and you're keeping your head upright, but your trunk's moving side to side, it's the same type of thing. We move our body to the side, we wanna keep our head upright. And so we're trying to use that same technique with the baby in their home program. In the middle is a transitional movement. So the baby is either going from supine up into sitting, propping on that right arm. And so when the baby's doing that, they're leaning over to the right side, which encourages active contraction of the left side of the neck. And so it was actually, this is a method to strengthen the left side of the neck, which you'd want to do in a right tilt. Lots of lefts and rights. It's okay if it seems confusing, but with repetition and kind of even acting out, like if you're a visual learner, like check, do the maneuvers on yourself as far as trying to figure out what the laterality. When is the, what is the outcome of PT? So when do we resolve to horticollis? So by definition in the clinical practice guideline, when full passive range of motion is within five degrees of the unaffected side, and then you're looking for symmetric active movement patterns. So symmetric movement patterns with trunk riding through the full passive range. And then also it should be a midline head. So it's always hard when the baby comes in with just a little bit of a tilt. What we're assessing there is, is there ongoing tightness or is it more muscle weakness? So really the end goal where you say, hey, we're done is when the head is midline at rest. There might be some fatigability when a baby is tired or maybe with a cold or something like that. That's kind of when you're like on the verge of resolving the torticollis. But I always say with families, our goal is a midline head. And then we wanna have age appropriate symmetric gross motor skills too. So what happens when things aren't improving? So we're gonna, I'll sort of a caveat that this is an off-label discussion from one of the publications in 2021 from our pediatric rehab group called The Consensus Statement on the Use of Botulinum Toxin in Pediatric Patients. So first line intervention is PT in a home program. Next is reassessment. So in my practice, once I've referred someone to skilled PT and started a home program, I wanna give them some time but I wanna make sure they're supported. So I like to follow up in the next two to three months depending on like if I know they've gotten in with some skilled PT. If I follow up then and they're still tilted tight but they're making progress, I'm kind of drawing like an improvement curve in my head. Are we on the way up? If we continue on, do I expect this child and this family to continue to be successful? And so then I'll follow up again like after a couple more months. If we are at that time really haven't started PT, we're not confident in our home program. I mean, what I do to find out that is I ask the family to teach me back, hey, show me what you're doing. Hey, can you show, oh, they're like, oh, I do rotation stretches. Can you show me how you do that? So what I'm looking for is are they comfortable with it? Are they performing it correctly, meaning in the right direction? And are they holding the baby in a way to really get maximal effectiveness from the stretch? And then I wanna see some more of those things, the lateral neck, the head riding, the lateral neck flexor strengthening and also a few sort of of those core exercises. You know, sometimes that's a time to really work on education or I say, hey, if this doesn't improve, the next step short of surgery might be some injections in your neck as an off-label option. And the parents sometimes are like, I can do some more home program. No, I can get better at this. So sometimes even in discussing sort of all the treatment options on the table, I'm trying to really optimize like what is this conservative management? So those babies who aren't progressing, I'll talk about the differential diagnosis of other causes of torticollis that we might consider. But if this really seems like a congenital muscular torticollis, things aren't getting better, they're plateauing, parents are frustrated, they wanna quit PT, then sometimes we discuss the off-label use of botulinum toxins. So specifically on a botulinum toxin A. So this is, it acts to weaken kind of contracted or tight neck muscles, allowing for opposite strengthening of the contralateral side. The concentration shared in this particular review was 100 units mixed with 0.5 ml. So a more concentrated version, so 200 units per ml. And then I'll defer to dosing on this off-label topic to the table two in it. And there's sort of some different low doses for the different muscles involved. And then the next thing is that sometimes insurance companies say, hey, in the most recent up-to-date, it says that you should have surgery. To which, if I refer to a plastic surgeon here, she'll refer it back to me to consider off-label injections. And so the safety of botulinum toxin injections in CMT was reviewed in this article from 2020, where it actually includes some of the case reports and case studies of use of this off-label treatment in congenital muscular torticollis. And so I've used this in writing letters to some insurance companies advocating for why as a next step short of surgery, I might consider this. The next thing is surgery. So this is something that's like if you failed conservative management and sort of like thrown the whole kitchen sink at effective, skilled PT was in the hands of someone who knows what they're doing. Home program that parents are confident in and performing correctly. And then also if they have ongoing tilt and tightness. So the procedure is like an SCM lengthening. Occasionally, as I'm sort of considering a second round of botulinum toxin injection as an off-label indication, I have the families meet with the plastic surgeon just to find out a little bit more about it. But more often than not, we kind of are able to move through this muscular torticollis and get on the other side non-surgically. So I'm gonna take a quick peek at this chat. Um, let me see here. Does my timeline change for offering Botox if the child is older? I think first and foremost, I think any type of injection treatment is most effective if parents really know how to do a home program or how to do an exercise program. So I'm always pairing any type of injection offering with sort of a PT intensive afterwards. So sometimes I'll even have them meet with the PT, do an evaluation, kind of start to get going on what's gonna be expected for that intensive, then plan an injection and doing the intensive anywhere from two to three weeks afterwards. So I wanna make sure that I'm not just sort of doing this without the complement of the PT afterwards. And then I think when the child is older, we'll discuss the differential, like older meaning two, three is a little bit different or older being like onset of torticollis later. I'm more concerned about sort of an acquired torticollis clinically and also congenital muscular torticollis at an older age, it's a lot harder. So I think it would sort of change my timeline, but also from the stance of, I wanna make sure that we're moving towards some effective manual therapy, which is really hard in a toddler. And then how do we handle referrals to rehab due to failed PT because a child didn't tolerate PT or the parents felt it didn't help? I think through this is a very careful discussion about what PT entailed, how often was it? What was the quality of it? Were they doing these specific manual therapy interventions? And then also, I think I'm not just getting referrals to do an injection, I'm getting a referral to kind of weigh in on what are the next steps in treatment. And so sometimes that's when if I'll chat maybe with the referring PT, I'll ask them a little bit about their comfort level with managing complex torticollis, and then even consider some different hands on the kid, at least as an initial few visits. So, and then the next thing comes into play is why do they have torticollis? So we'll be talking a little bit about the differential. So we'll be talking about congenital muscular torticollis, which we just reviewed, looking at considering the structural causes, so sort of the bones, vertebral anomalies, GI disorders that can lead to twisting of the head, visual differences, and even MSK infections in the neck, tumors, which we never wanna miss, and then a condition called benign paroxysmal torticollis. Two, I've had some babies present with hemiparesis when the chief complaint is torticollis, and so we'll talk a little bit about that presentation too. So this is a review slide, we already talked a little bit about the presentation of congenital muscular torticollis, which sometimes is abbreviated in literature as CMT, not to be confused with Charcot-Marie-Tooth. The next is vertebral anomalies. And so there's some mixed literature and opinions on when do you get an X-ray in a patient with torticollis? And so for me, it's often when they've kind of failed the initial steps, or if I'm not finding red flags in their history or their physical exam. And so an X-ray of the cervical spine or spine, why are we doing it? It'll show sometimes rotation, so don't be surprised if you see that, but we're looking for things like hemivertebrae, block vertebrae, butterfly vertebrae, or curvatures. So sometimes, and I had a patient who was seen in PT, sort of hadn't improved at all after four visits, was then seen by me, and on the cervical, and she was quite severe, I wanna say she was about 40 degrees lateral tilt, 30 degrees rotated, and it's sort of like a more severe case, and I'm like, why are you not improving in the hands of this very skilled PT who I know you're working with? We got an X-ray of the neck, and at the cervical thoracic junction were some costovertebral anomalies. And so I ended up then getting an X-ray of the full spine, and it showed scoliosis and some costovertebral anomalies. And so from there, I kind of dove earlier into my career into now what do I do? Welcome to early practice, and maybe why I'm still an educator. But I was like, okay, I'm gonna have him see the spine surgeon, but what else do I need to do now? And so I needed to get an echocardiogram and make sure to get a renal ultrasound, communicate with the PCP, of course. And then we put kind of the PT on hold for a moment just until we figured out the nature of this diagnosis. So this was the reason for her torticollis. Another condition that we have to think about is sort of if there's an abnormality in the odontoid process, and between that C1-2 level, it can affect instability called os odontoidium. And so in a very severe case, the child could present with myelopathy. But hopefully we noticed things a little bit earlier on, such as a head tilt. And so imaging with an X-ray, and then if there are abnormalities, just remembering that really bones are best imaged with CT. In the case of congenital scoliosis, sometimes the, at least orthopedic spine doctors are getting an MRI of the spine to look at the anatomy in more detail. Sort of a board pearl. If you have a female with a short neck, limited cervical range of motion, and low posterior hairline, thinking about a genetic, or a syndrome called Kipple-Feel syndrome comes to mind. So block vertebrae cervical fusions. And so with the Sprengel's deformity, which might be another board pearl, like failure of the scapula to descend. And so this condition, again, is like a torticollis cause from vertebral anomalies, and spine surgeons get involved. As far as GI disorders, I think that this baby's face reflects things well. If you had GERD and reflux. And so Sandifer's syndrome is the referral to a baby who might have GERD with some hiatal hernia and have sort of intermittent torticollis with epistatonic posturing. They're super irritable. It can look like infantile spasms or seizures. And so the treatment for sort of a reflux or a more severe thing like Sandifer's syndrome would be actual treatment of the GERD. And so if sometimes babies come in with torticollis and I think it's muscular and maybe they were told like, oh, it's just their GERD, it'll get better. It's like, let's sprinkle on some early PT and some home program and work on loosening up the neck. So I think I also see PTs and also some pediatricians also wondering about the visual system, which I wonder about too. So head tilt due to ocular causes or ocular torticollis is an abnormal head posture, AHP in the literature, due to different alignment to the eyes. And now neuro-ophthalmology, I don't claim to be an expert in, but what do we need to watch for? How do we need to figure out if we need to worry about the eye system? I asked Dr. Olzek, one of my colleagues and mentors in this area, I said, when have you seen this and what has it looked like in your torticollis population? And what she shared with me is actually the few particular patients she's had is more like the range of motion of the neck's actually good, but they are holding their head tilted or rotated. And so what commonly is involved is like a superior oblique palsy, which might be in a head tilt or a homonymous hemianopsia or a head rotation in a child that at least in my practice, it was in the setting of cerebral palsy and torticollis. So how do we figure this out? So if a child is holding their head in a particular posture, they're actually holding their head with their eyes aligned in the best way that they can view the world. And so this child has a left superior oblique palsy. And so he's actually holding his head tilted to the right and sort of with a gaze a little bit over to the left side, which aligns the eyes best. And so on the left gaze, eyes are aligned. On a more severe right tilt, eyes are aligned. But when you get the head of the child back out of their preferred posture, that's when you notice maybe some deviations of the eyes. And so if you notice any ocular alignment issues in a child, once you get their head midline and you test them in all different areas, then I think referral to a pediatric ophthalmologist would be really helpful. So ocular torticollis isn't super common, but it's treatable. And then two, also know that some of these diagnoses aren't exclusive. So sometimes you can have muscle tightness, but you also can have some visual challenges. And so just, I know it makes it complicated, but just remember that it's still okay to still treat the congenital muscular torticollis as we go along. Next, MSK issues within the neck, soft tissue, retropharyngeal abscesses, or even something called Grasel's syndrome. So this is like an atraumatic subluxation at the C1-2 interval due to some inflammation. So on MRI, it could look like a T2 hyperintensity in that area. And again, these are just things that need to be treated differently, even outside of rehab and PT. We never want to miss tumors. So brain tumors, spinal cord tumors, presenting as torticollis. So in this review from 2014, they looked at a series of 54 tumor presentations in the cervical and posterior fossa and said about 22% actually presented with torticollis initially. Again, this usually isn't a congenital tumor, rarely, but it's usually acquired. So let's say the two-year-old had typical development, a neutral head posture, and then started to tilt and started to have other issues or walking funny. Like don't just refer to PT, start to take a look at the full neuro exam. And then occasionally, like if it's a C-spine tumor in a young baby, they may be holding their head to sort of stented or held in a position of maximal function. And so looking at babies in different positions and don't hesitate to get neuroimaging if there's concerns there. Benign paroxysmal torticollis of infancy sometimes shortened to BPTI or BPT in the literature. This is something that seems super scary, but with time is actually benign and self-resolves. And so this often is sort of a torticollis that comes on a little later. So isn't from day one of birth, maybe a few months in. And then sometimes parents say, yeah, they're tilted and turned right after waking up from a nap. And then it stays that way for three days and then stops. And then occasionally they say it changes directions. And so about a quarter might stay on the same side, but they'll like parents sometimes they'll come in with like it was like a whole calendar of like when it was tilted, what happened, how it resolved. And then it can be associated with sweating, skin changes, irritability, migraines, which actually in babies, a little challenging to assess. But a lot of babies who present with this type of story have maybe had a big workup. You're worried about tumor. You've had imaging, eye exam, EEG. But there's a family history often of migraine and it's self-resolves. And so I've had a few kids like this that they've seen me, they've seen child neuro. And we agree that this is benign paroxysmal torticollis of infancy. Occasionally the question is whether or not you do PT for it. And I think it's really only if there's tightness or motor issues associated with the child. And then I say we'll follow until resolution. Next are the neurologic things. So rotation of the neck like this or an ATNR can be present. It starts 18 weeks in utero, diminishes sort of in that first year of life, usually even before six months. And if it persists, there's kind of difficulty crossing midline over to the less preferred rotation side, difficulty looking in the opposite direction and sometimes even asymmetries in the hand. And so sometimes in a couple of times in my practice, I've had someone present with the chief complaint to torticollis. And when I come in, the baby is off looking using this left hand really well. And the right is nice and closed and the left is vigorously kicking and the right is kicking a little less. And I do a full exam and we may get an MRI and then our relationship pivots from torticollis care into talking about cerebral palsy. And so thinking about your infant exam, thinking about your infant motor exam, using your kind of hammersmith infant neurologic evaluation skills or HINE exam techniques is important. And I think the fun thing about having a torticollis and plagiocephaly practice is lots of baby exams. And so lots of learning about this as well. So before we get going, I'm just gonna check this chat quick before we start talking about plagiocephaly. Okay, if there's other questions, let me know I'm watching the clock too. So next we're gonna talk about head shape. We're gonna talk about examining the head, manual measurements and also 3D scans. This is an example of some of the measuring or caliper devices for body segment measuring that we use in clinic. And actually learning to do it is a little bit tricky on a moving target. So first we look at the head. So I look always top down from the head, look at the general shape. Where is the flatness? How does the fontanelle feel? Is it flat? Is it open? Also, do I see any other differences? So on the flat side in general, sometimes I say that the infant head is moldable to fit through the vaginal canal, but it's also moldable like a pumpkin in a field or like a dough ball being squished. So on the flat side, the structures move forward. So if you have a right flatness, like down in this corner or in these pictures, the ipsilateral same side ear shifts forward, the ipsilateral forehead or the same side forehead shifts forward, something called frontal bossing. I'm also looking at sutures. So I'm looking to see as I sort of point this out to families, I say, yeah, I see this little flattening in the back, the right ear shift forward, the right forehead. And this looks positional to me. I know that's what you expected, but I'm also looking for other causes of head shape differences. And so that's why I'm looking at the suture lines for any overlapping sutures. And then I'm also sort of describing the head. Do I see that ear cupping on a side? Do I see any jaw or facial differences? Or do I see kind of a red flag, something called mastoid bossing, which I'll show or discuss later. What are the skull measurements we do? So I always have a good holder. One of the nurses I work with and our trainees, I say, let's make a little C collar out of our hands and be really goofy as we talk to the baby and keep them distracted. And what I do is I measure, I tend to measure kind of the head over the ears first, and then front to back. And then I go the long dimension over to the shorter dimension. And so I'll talk about these measurements and kind of what they mean. And so the first measurement I do usually is between the ears. And so I look for the space where the head is kind of fullest, not where it's maybe narrowest right above the ear. And I'm going over there, I start there because it's most tolerated by the baby. And then I go front to back because it's easiest to line up. So I go for the the cephalic index win. So I take that as a ratio. So between the ears front to front to back medial lateral to AP is something called the cephalic ratio or the cephalic index. And so there's severity scale. So I say that this is a test that you want a B on. So you want 80s percent ideally, you know, low A that's okay. But if you are an overachiever, and you get 106% or 102% on this test, you're brachycephalic. So on the brachycephaly scale, you want to be you want 80s percent. And so that I think can help you remember, wait, which goes first, do I go medial lateral or front to back. And then also 100% is like a perfect square head, which is never our goal. And so the severity cephalic index or cephalic ratio used interchangeably less than 90% normal, mild 90 to 93, moderate, and then severe is anything greater than 97%. This is kind of what's used in the literature. The next are the oblique measurements. And so where do we place this? Usually we place it on the one one area of the measuring device on the lateral border of the eyebrow. And then you're finding the longest dimension at about a 30 degree angle from the nose. And so if you were to draw a line down the middle of this head, this angle is 30 and so is the short one. And so sort of some people just sort of go the maximal area and they might be 40 degrees over. Most of the literature and standardization for helmet and severity scales are 30 degrees. So if you if you really want to get your goniometer out, but you're trying to kind of visually mark that and I've worked on improving my measurements by measuring manually, getting a 3D scan and then trying to find it again on a very like compliant baby. So you go diagonal one compared to diagonal two. And then the delta of that or the difference between that is your cranial volt asymmetry, your CVA, not a stroke. And then your cranial volt asymmetry index is what we use to do severity. So it's the delta. So the difference between the two times 100 divided by the biggest dimension, so the longest diagonal and so that's why like a delta or a difference the CVA of 10 millimeters might be a lot more significant on a tiny head compared to a much bigger head. And so that's where even though the same difference could persist, it's actually getting better because the head is getting bigger and then the cranial volt asymmetry index is going down. So that's math and geometry. So this is a severity scale. Thank you to the Children's Healthcare of Atlanta team for publishing this. And this is used in plagiocephaly literature. And so the categorization is in the CVAI or that index. And then categorization type one is normal, two is mild, three is moderate, four is severe and five is very severe. So now what we'll do quickly is look at a few 3D scans. And this is like a pictorial version of head shape in these different types. And so some of these descriptors in in this scale two are like the asymmetries are more significant. And what do you do? So in the moderate to severe, you might consider helmeting as an option. And normal, mild, maybe into moderate, you're doing conservative management like repositioning. Moderate type three or in that severity scale of 6.25 to 8.75 is a little bit you might watch and wait and talk with a family about options. So what do we do? We observe no treatment, do positioning changes, treat torticollis, and maybe even consider helmeting. So how do we decide about helmets to helmet or not to helmet? First, parent preference. So this is a cosmetic treatment. Generally speaking, it can help with head shape rounding out over time. Also, it's age dependent. So if someone is presenting to me at 15 months, I really don't helmet. And then the ideal time is four to six months with like moving into the single digit ages. As you move into 10, 11, 12 months, if parents are dead set on helmeting, and it's severe, I just counsel that it might be a really long time and what are our expectations, and then also severity of head shape. So I used to say this is like a Venn diagram. And so all these factors go into the discussion. And then what we're doing is really counseling families on how this could improve, how time alone can change the head, what are the goals of helmeting, what are the expectations. This treatment, as I said, moderate to severe severity benefits the most 23 hours a day is how often you need or how long you need to wear it. And then it takes some time commitment. So orthotist scans like one to two times per month, with some rescans, sometimes every six weeks until you kind of plateau out or have that CVA or that delta and oblique difference of six millimeters. Helmet treatment costs some money. So insurance is variable as far as its coverage. And then out of pocket expenses, at least in our community are about $2,600 for helmets for the checkups. And really, they just need one helmet. But insurance sometimes covers a piece of it. I counsel families on expectations, will this be a perfectly round head versus improved, and then also the risks of skin rashes, breakdown, sweating in the summer, tolerance of the helmet, they actually get used to it pretty quickly, but do need to be counseled on checking in with the orthotist if there's any skin issues or redness. So I usually say if there's skin redness that persists 15 to 20 minutes after taking the helmet off and lasts even longer than that, then give the orthotist a call and have them do an adjustment. Essentially, it's sort of a plastic cap with a foam inside that's not squeezing the head, but it's doing guided growth. So it's containing the head in the longest dimension, whether it's the width or the length, but allowing the as the head grows to kind of fill in on the areas where there might be a little more space to encourage rounding out. So what do scans look like and how do we interpret them? Really, a scan is just showing you a three dimensional, much sometimes well on us easier to acquire measurements that you're trying to do manually. And so what do we do with this? It looks like geometry from back in middle school and a big table. What do I do with it? So what we're going to do here is just talk about what some of these numbers mean. So we talked about when we start measuring, I start over the ears front to back. So I'm finding my isophalic ratio here, 0.907. So 90.7%. Okay. And then what was my cranial volt asymmetry? Here we have 15.3. And then they actually got these diagonals. And so I can kind of look, this sometimes gets confusing, but this diagonal running over here moves from the right posterior. And this diagonal over here moves to the left posterior. So this is on the flat side, the shorter one. What does it mean? So those numbers fall, actually, I should go back, the CBAI on this patient, the cranial volt asymmetry index is 10. And so if you're trying to say, huh, mild, moderate, severe, okay, Children's Healthcare of Atlanta, plagiocephaly severity scale, you are in the four. So this is the severe area. And so this child could, we might discuss helmet options, depending on their age and parent preference. And then the brachycephaly falls into mild. So we have some mild brachycephaly, width to length ratio and some severe plagiocephaly. This is an example of a helmet and progression. And so what we see with serial scans, so this one is at ending at 37 weeks. And so over time, this child had serial scans 15.7 down to 6.8 of the CBA down to 6.2. So the last few were just a few weeks apart, but really it plateaued. And you can see that on sort of the subsequent views there. And then here's like a 3D picture of a graphical. What does brachy cephaly look like? So brachycephaly is that width to length ratio being elevated, but that craniovult asymmetry or that oblique difference may or may not be significantly involved. In this patient, they have both. They have the cephalic ratio of 106.2%, a craniovult asymmetry of 9.1, which if you only looked at that, it would look like mild plagiocephaly. However, on the brachycephaly scale, we have to look at the cephalic ratio. So 106% is quite wide. And so this child was helmeted, the helmet kind of contained the width and allowed for posterior growth of the head. And so you can see that on the subsequent curves that it kind of filled out in the back. Next, we're going to kind of briefly look at red flags just for the sake of time. We need to understand our suture lines, our anatomy, and when things aren't positional. So we want to be able to identify what we call craniosynostosis. This is a rare condition. It's taken my career, 10 years of independent practice and lots of heads to start to recognize this and find this over time. But I think the important thing is when our head's not positional. So red flags, a super long, narrow head. So cephalic index in the D range, 75% and under like grades back in the day, dolichocephaly or otherwise known as scaphocephaly. This long, narrow head, sometimes a closed fontanelle really should be referred to either craniofacial or if you're comfortable in your practice getting a CT of the head to look for fusion of the sagittal suture. Another one is in the middle of the head, we have a metopic suture. And so there can be ridging, there also can be peaking. And so this trigoncephaly is essentially like a triangle shaped head due to fusion of this metopic suture. The next is lamboid synostosis. And so this is the lamboid suture back in the posterior side. And so flatness can be apparent there. Sometimes the babies have what they call a scoliotic head or a curved head and mastoid bossing. If you're ever wondering what mastoid bossing is, it's kind of this like fullness behind the ear that looks really odd. And look it up, search it up on the internet, look at examples because it's perplexed me until I saw it last year. And I identified it in a child with like moderate plagiocephaly, but absolutely no history of torticollis. And I was like, why do you have a flat head? You turn your head great. And lo and behold, he had unilateral lamboid synostosis. Coronal synostosis, so unicoronal can look like a facial curve difference and a little curved nose. Bicoronal synostosis more concerning for syndromic conditions. So what did we cover? We covered what's a differential of torticollis. We covered a little bit on evidence-based treatment options for torticollis. We talked about a home exercise program for torticollis, and how to interpret some 3D scan measurements. So what is a craniovult asymmetry? What is the significance of craniovult asymmetry index? What is brachycephaly and cephalic ratios and then the use of severity scales? And then how do we educate families on treating both plagiocephaly and torticollis, tummy time, position changes, home exercise program and early referral to PT. And then we just talked about some red flags that we need to think about when it's not positional. Our differential and then my references as well, which are awesome. It's where I've learned the most about evidence-based practice in this area, which, you know, it's hard to do a sham helmet. But I want to thank my mentors. I want to thank the AAPMNR Peds Rehab group and all of you all for listening. Thank you. I know it's noon. Please let me see here. I think one question about asking to document the medical necessity for a helmet. Yeah. So usually what my notes will do is share the measurements specifically. So I will reference the specific I'll do manual measurements. But if we have 3D measurements, I'll kind of put those in my note. And then sometimes you can include severity scale information. And so the references to outcomes from helmets and severity scales, however, here's the thing, private insurance sometimes says, at least some of the companies around here, we won't pay for anything that changes the shape of a body part. And so this is where a challenge is the cost of helmeting. And then it also is sort of the fact that this is a cosmetic treatment. And so it is unfortunately, like not covered by everyone. And then there was even a recent publication just on the variable, like equity and coverages within the Medicaid populations of different states. And so not everyone in every state kind of has the same coverage for this type of treatment. And then I think the big thing with like medical necessity is getting the L code from the orthotist that you're working with. And then sort of using that with your clinical notes for authorization. So usually what we'll do, at least in our practice, is an orthotist will do an initial scan. Even if even if we're kind of monitoring, they'll take my notes, they'll send for authorization, they'll let families kind of know what their coverage is. Families then have to make a decision. Is this something you want to do? Do we want to watch and wait? How old are they? What is Dr. Konelekin sort of our discussion? And then if they want to watch and wait, then sometimes they'll just do a re-scan four to six weeks later, depending on how old the kid is, and then make a decision. So if things are improving, you know, some or they say, it's not bothering us. And I say, okay, this isn't brain surgery, this is your choice. And so I think I take a discussion of their options is my approach. Do you see kids with osteogenesis imperfecta and plagiocephaly? Absolutely. Do you helmet those kids? I think it depends on their gross motor skills and what is the priority. So I've had a child with plagiocephaly and osteogenesis imperfecta because I in our multidisciplinary clinic, and the family was really bothered by the head shape. And so they actually did like a clamshell helmet, because we don't want to have skull fractures at all, as you're getting it on. And, and this child did well. And then there is a publication on plagiocephaly and OI out there. But I say even in my population, if, if they're, if they're working on sitting in that added weight, you know, with the risk of invagination of the, you know, brainstem, etc, is outweighs the benefit of a cosmetic improvement. Great. And then I've also witnessed just anecdotally some a lot of my severe OI patients like over time round out well, so I think that there's this balance between the natural progression is rounding out over time, but then sort of who benefits from a helmet more than rounding out. And I think that's when you get into autonomy and choice with families talk about family preference, age of the kids severity. And then I think what I can't emphasize more is just don't miss torticollis in that early PT referral. Let's see other questions. Thank you. Any Pascal pillows. So there's pillows out there. There's there's like tort collars with sort of like a little hat that has like a almost like a kickstand over to the side. I think there's things out there right now. If anyone finds really great literature on the evidence base or their intervention, please like share it. Let me know. I think the questions come up with families. They kind of want something like this. What can we do? I still say like, don't put pillows in the crib. You know, wedges only flat things. And mostly tummy time, tummy time, tummy time, early PT referral, getting comfortable with your home program. And really the treatment of positioning and torticollis is key early on for even treating head shape. I do a lot of the early detection of cerebral palsy clinics. And sometimes I'll see kids who get referred for some early asymmetry, but they had a history of torticollis and their symmetry is improving. And normally, that's a huge red flag for me. But I've had some in this past year that I'm like, I think it was kind of just related to them not paying attention to that side because they were stuck over here. And I always I'm a little uneasy about that, because I want to catch everything. But sometimes I feel like I'm seeing that I just wanted to see what your experience was with that. Yeah, you mean just the the rotational differences in babies CP? Yeah, yeah. Like it, you know, coming in for early preference, wondering if it's hemiplegia, or is this just kind of leftover from them? ignoring one side? Yeah, yeah. Well, and I think, I think let's say you have a blank slate, you don't even know that the child has, is at neurologic risk. You know, I think, for one, you can see those developmental asymmetries in kids who have a typical birth history. And getting them going with PT is important. But then one thing I've added in my practice is that our OTs are like, I want to see them too, if they have a hand asymmetry, I want to do the infant hand assessments, I want to follow them. And then motor asymmetries, both gross motor and fine motor should really get better in the context of congenital musculoskeletal. If things are persisting, that's kind of when we flip into thinking about early detection, you know, rechecking behind, you know, watching things more closely, including both PT and OT in their care. And then and then I think in the CP population, I mean, you're, you're, you're then moving into your evidence based practice, whether it's baby constraint, or, you know, you're still working on your motor progression. And then I think developmentally, and with everything going on in complex kids, when you're talking about head shape, like what is the priority, you know, so I think for some kids, like GMFCS, four or five parents are like, we're good, flathead, we're fine, we just want to make sure that like, we check it out and know what our options are. And I totally support that. Or some parents, I think sometimes like parents who've had a NICU baby, they kind of come through the weeds and things even out and then suddenly they enter when they're worried about the head. And I say, hey, it's really great that we can now worry about things like a head shape, you know, and so we talk about it. And, you know, we think about corrected gestational age too, both in motor skills, but also in maybe some of this helmet timing, if that's part of the discussion. But I think as rehab doctors, we're focused on development, focused on what interventions need to happen for motor symmetry of kids of all like, neuro experiences, and then matching them, you know, with with that as well. And then some families come to clinic, and they're like, someone told us to see you and their kids like head, it might be really abnormal. And they're like, we're not worried about it. And if their kids exam is normal, and, you know, granted, I'm always thinking like, if you're, if your head shapes really abnormal, do you have craniosynostosis or do you have torticollis? And if the answer is, you may have had prior torticollis, and now it's resolved, and your head's like 13 millimeters, these are your options, you know, and parents sometimes are like, doesn't bother us, or some come in saying, like, we want to do this. And this is what we are coming for, you know, in in the case where say, a helmet, like, they're in the mild, I'll talk to them that that, you know, really, we're only two, like they're eight millimeters, we're really only two millimeters away from the end, I wouldn't recommend it, you know, so I think, with, with position statements out there being less certain, because you can't really sham helmet, it's a little bit tricky. And you're really just educating families on options. And I think thinking holistically, as well as a pediatric physiatrist on what's going on with this kid's development? Are there any red flags? Do we need to involve anyone else? And then monitoring and, you know, kind of always reassessing. So thank you all for your time. And also, I did recognize that this is not a chapter in the Pete's Rehab textbook. I don't know, maybe we'll have to change that. But it was it is a delightful part, I think of, of practice, because I think sometimes this is what families and pediatricians notice, but they may not notice like the little hand asymmetry right away. And so I think the overlap with early detection, and type clinics, I think is is important. And then also knowing kind of what what options are out there? And what is the evidence base behind it? Yeah, this is great. Thank you so much. Yeah, thank you, team. I appreciate it. And reach out if there's questions at all afterwards. My email is amy.canalican at children's colorado.org. Or, you know, find me in the group, group Facebook if people are on there. But it's really been a pleasure. Thank you all.

torticollis

pediatric physiatry

congenital muscular torticollis

early intervention

physical therapy

botulinum toxin injections

plagiocephaly

cranial orthoses

multidisciplinary approach

differential diagnosis