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Pediatrics: Exam 2 - Torticollis and Brachial Plexus Injury

Terms in this set (43)

What is congenital muscular torticollis (CMT)?
Posture of head and neck from unilateral shortening of the SCM, causing the head to tilt toward and rotate away from the affected SCM muscle
What are the theories of CMT?
- Direct injury to muscle
- Ischemic injury
- Rupture of mm
- Infective myositis
- Neurogenic injury
- Hereditary factos
- Intrauterine compartment syndrome
- Head position in utero
What is the relationship between CMT, Plagiocephaly (flat head), and sleep position?
Leads to plagiocephaly:
- infant sleeping on back, due to SIDS
- flat head syndrome may identify neurocognitive difference or delay disorders among patients - may have been normal prior to change in sleep position

Cranial deformation begins in utero, deformational forces on occiput may continue after birth if the infant sleeps supine and also spends time in supine
What are the risk factors of CMT and plagiocephaly?
• Difficult labor and delivery • Vacuum or forceps delivery
• Breech positioning
• Uterine abnormalities
• Presence of nucal cord
• Multiple birth
• Male gender
Typical impairments of CMT?
• Neck Rom decreased for ipsilateral rotation, contralateral lateral flexion, and contralateral asymmetric flexion and extension
• Not able to maintain midline head alignment
• Neck muscle imbalance and muscle contracture
• Many facial problems if this persists
What is important in determining nonmuscular vs muscular torticollis?
Differential diagnosis

1/5 children = nonmuscular
What are typical nonmuscular causes of CMT?
• various skeletal abnormalities (babies with torticollis should all have X-ray) - Klippel-Feil syndrome

• neurological causes such as: brachial plexus injuries

• acquired nontraumatic torticollis resulting from:
o Posterior fossa pathology
o Arnold-Chiari malformation
o Syringomyelia
o Postencephalitis syndromes
- ocular lesions
- sandifer syndrome
- benign paroxysmal torticollis
- dystonic syndromes
Typical activity limitations in this population?
• Purposeful symmetric movement of the neck
• Neck muscle strength imbalances
• Neglect of the ipsilateral hand
• Decreased visual awareness
• Delayed propping and rolling over
• Limited vestibular, proprioceptive, and sensorimotor development
• Asymmetric weight bearing in sitting, crawling, walking
What should be assessed during PT examination?
1. Prenatal and birth hx
- vag/c-section
- vacuum or forceps use
- birth presentation
- nuchal cord
- birth order, weight, length
2. Sleep position and head rotation preferences
3. Musculoskeletal system
- Restrictions in ROM
- Muscle length (ipsi neck rotation)
- muscle and soft tissue extensibility
4. Gentle traction to assess infant aligning spinal vertebrae in neutral
5. Prone AROM/PROM of head - to support head and clear airway
6. Reach and grasp
7. Ipsi. shoulder girdle and UE - assess active mvmt to midline; ballistic shldr mvmt
8. Trunk mobility c elongation and ability to weight shift
9. Spinal motion for assessment of restrictions
10. Palpation of effected mm for tumor and tonal quality
11. Hip symmetry - look for hip dysplasia
12. Documentation of plagiocephaly and facial asymmetry c photos
13. Tape measure head circumference and calipers
14. Mm of mastication are weaker on affected SCM mm side - contribute to TMJ dysfunction
15. TIMP good for up to 5 months
16. Primary behavior state during assessment, tolerance to stretching, ability to self-regulate should be documented
What instructions should be given to caregivers?
Caregiver education is important and should consist of providing ways in which a caregiver can encourage range of motion, strength, and postural control. (p 303). The caregiver should be given ways in which to:

• Carry and hold the infant to promote muscle length
• Position for prolonged stretching during sleep
• Encourage midline play and development
• Encourage active reaching to the involved side
• Encourage looking towards the involved side
• Incorporate activities for balance reactions to strengthen
How often is stretching recommended?
Every 2 hours, if possible, for maximum benefit

Include additional stretching exercises of UE and LE; shoulder girdle, hip complex, and trunk
What should be done to maintain ROM?
Infant must develop strength and active use of muscles that are antagonists to involved SCM - develop good midline control
Why is it important to address plagiocephaly early?
The majority of skull growth takes places prior to one year of age and any plagiocephaly present after this time will be less effective through nonsurgical means.
What is a sleep positioning program?
key concept of this positioning program is to position the infant in ways which prevent the infant from lying on the flattened areas of the skull.

This type of program is most efficient in the first few months of life
What is a DOC band?
Dynamic Orthotic Cranioplasty band - used up to 24 months of age

Designed to redirect growth and improve craniofacial symmetry of cranial vault, face, and cranial base

Uses immediate mild holding pressure to most anterior and posterior prominences of cranium where growth is not desired

Allows room for growth in adjacent, flattened regions

Worn for 23 out of 24 hours

Constant BIWEEKLY adjustments to band made for DYNAMIC Treatment
Action Statement #7 of CPG torticollis?
Examination of body structures:
- infant posture and tolerance to various positions for body symmetry w/ or w/o support
- bilateral passive cerv. rotation and lateral flexion
- bilateral active cervical rotation and lateral flexion
- PROM and AROM of UE/LE
- pain or discomfort at rest, during passive and active mvmt
- skin integrity, symmetry of neck and hip skin folds, location of SCM mass
- Craniofacial asymmetries and head/skull shape
What is Action statement #12 for CPG torticollis - 5 components for first choice intervention?
1. Neck PROm
2. Neck and Trunk AROM
3. Development of symmetrical mvmt
4. Environmental adaptations
5. Parent/caregiver education
What is CPG recommendation on how to measure PROM/AROM?
Measure PROM bilaterally with Arthrodial protractor
- passive cerv. rotation
- lateral flexion/side bend

Measure AROm to indicate symmetrical development and neck strength and integration of PROM for functional activities
- challenging to measure due to infant behavior

PT's use this method:
- Look for active full range in all planes + diagonals: use toys, sounds, or other forms of stimuli
Passive cervical rotation:
Infant supine, head neutral, nose aligned to 90˚ vertical reference
What is most commonly referenced standard for measuring passive cervical rotation and lateral flexion?
Arthrodial protractor

Mimimum 2 adults: one to stabilize infant's trunk on support surface and other to rotate head/neck while measuring range

Goniometer may also be used with infant in supine or in horiz. plane
Lateral flexion:
Measured in supine with shoulders stabilized and in cervical neutral

use oversized or arthrodial protractor to measure
How would younger than 3 months be tested?
Head rotation tested supine
Older than 3 months testing?
Test neck rotation while infant sits in clinician's lap who is sitting on rotating stool

- parent entices baby to maintain eye contact while rotating baby away from parent
- PT observes neck rotation from above using baby's nose as midline indicator
- Neck flexion and ext. screened in sitting
- Muscle function scale - older than 2 months
What is a tortle?
Head repositioning beanie to prevent and treat flat head syndrome

Prevents head from resting in same area, allowing even distribution of baby's head weight

Support roll used for 2-3 hours at a time; reposition support roll behind baby's other ear
- over flat spot or placed on favored side to gently stretch neck muscle

Worn from birth to 6 months for entire 6 months.
What are recommendations for repositioning infants to help avoid plagiocephaly?
1. Placed on backs for sleep - change position by alternating childs direction in crib
2. place mobile on side of crib to encourage baby where to look
3. Consider moving crib to different areas of the room
4. Have plenty of tum rums time, 30-60 min/day
5. Reduce time spent in car seats, carriers, swings etc.
6. alternate arm used to hold baby while breastfeeding
When does BPI usually occur
Most often during difficult vaginal delivery

Also wide variety of traumas to shoulder and spine
What is pathophysiology of BPI?
Damage occurs at:
- level of nerve rootlet attached to spinal cord
- anterior to posterior rootlets merge
- roots, trunks, divisions, cords, and peripheral nerves all suffer
- partial or complete rupture may involve neuroma and mass of fibrous tissue
- hemorrhage into subarachnoid space - blood in CSF
How long does recovery take for BPI?
Very limited after ruptures

Prognosis after axonotmesis is better due to neurons reconnecting more successfully

Axon regrowth proceeds at ~1mm/day

4-6 months in upper arm
7-9 months in lower arm

Continues for about 2 years in upper arm and 4 years in lower arm
When does recovery occur for neurapraxia for BPI?
Occurs as edema resolves - usually quick and complete within days or weeks
What are the three types of BPI?
Erb's palsy

Klumpke's palsy

Erb-Klumpke's palsy
Which type of BPI is most common?
Erb's palsy
What is Erb's Palsy? What does it affect? what is the position of the shoulder, elbow, forearm, wrist and fingers? What is this position known as?
Upper roots (C5 and C6)
Paralysis of major muscles
Grasp intact

Shoulder held in:
- extension
- Internal rotation
- Adduction

Elbow:
- extension

Forearm:
- Pronation

Wrist and fingers:
- Flexion

Waiter's Tip position
What is Klumpke's Palsy? what is not impaired? what is resting position? what has paralysis?
Lower roots (C7-T11)

Shoulder and elbow not impaired

Resting position is with:
- Forearm supination

Paralysis of:
- wrist flex/extensors
- instrinsic wrist and hand mm
What is Erb-Klumpke Palsy?
Upper and lower roots (C5-T1)

Initial total arm paralysis, but it recedes

Total paralysis limited to upper roots
What activity limitations result from BPI?
1. Lack of UE function
- cannot reach, grasp, perform bilateral manual tasks

2. ADLs requiring bilateral UE will be compromised
- donning/doffing shirts and pants
- tying shoes
- buttoning

3. ROM limitations

4. Typical developmental activities compromised
- move from prone to supine to sit from ONE SIDE
- Creeping on all fours due to deficit in WBINg - child may scoot instead

5. Neglect of self-abusive behavior
- absent or abnormal sensation

6. Shoulder pain and neuritis in adults is a complication that can interfere with function of involved arm
What is included in a PT examination for BPI?
1. AROM, PROM, SENSORY - establish baseline function

2. Screen: developmental status for pathologic conditions

3. Frequent reexamination of neonate to document motor recovery as regeneration occurs
- followed at 2 weeks and 1, 2, 3 months of age
- MRI can be done
- EMG

4. Muscle strength and function
- Observe limb movement or palpate muscle contraction
- Observe during play
- Muscle grading system: >Active movement scale
- Older children can use MMT and dynamometers

5. Sensation
- identify areas of involved extremity
- Sensory grading system for children with BPI
- Sensory loss may change to hyperesthesia with neural regeneration
How long is the initial rest period?
7-10 days is required following BPI

Important to allow edema and hemorrhaging to subside
Why is careful attention to scapula important? ratio for humeral to scapular rhythm?
Typical reaching requires 6:1 humeral:scapular rhythm during first 30˚ of motion

Paralysis of rhomboids and subsequent muscular contractures - this ratio is not seen

During overhead and ROM activities, assistance should be offered to stabilize the scapula and promote proper activation, while encouraging muscle elongation.
What positions can be used to promote use of involved arm?
Sidelying position on uninvolved arm to avoid stresses on involved arm

Frees involved arm to reach and play with toys placed in front of them

Use gravity or toys in hand can add resistance as muscles gain strength

Movement into sitting or other transitional can be practiced from involved side using manual guidance
- protective reactions
- bilateral UE use
- two-hand activities
What activities can help with sensory awareness?
Participation of involved limb in play activities

Holding a bottle to allow child to perceive extremity as purposeful part of body

Use objects of different temp and texture

Finding toys in rice or sand or water

Older children:
- blindfold and have them determine a familiar object when placed in their hand

Incorporate ROM into these activities by guiding hand to different parts of the body - tactile stimulation

Encourage parents to not neglect arm but caress and play as usual
How is splinting used?
Preserve tendons until motor function returns

Prevents contractures
When is surgery considered?
For small numbers 5-10% of children with BPI

Those that continue with significant impairments and limitations w/o showing improvements
Cranial brace?
reshaping of head, pressure on parts that need most reshaping
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