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articles: Richard Raffoul, Miguel Sousa Uva, Giuseppe Rescigno, Emré Belli, Marcio Scorsin, Frederic Pouillart, and Arrigo Lessana Clinical Evaluation of the Physio Annuloplasty Ring Chest 1998; 113: 1296-1301 [Abstract] [PDF]

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THE ROLE OF PHYSIOTHERAPY IN THE MANAGEMENT OF STERNOCLEIDOMASTOID TORTICOLLIS

Ikram U Din, Fazal Rahman   (8 December 2003)

THE ROLE OF PHYSIOTHERAPY IN THE MANAGEMENT OF STERNOCLEIDOMASTOID TORTICOLLIS 8 December 2003
Ikram U Din, Surgeon KTH Peshawar Pakistan, Fazal Rahman Send letter to journal: Re: THE ROLE OF PHYSIOTHERAPY IN THE MANAGEMENT OF STERNOCLEIDOMASTOID TORTICOLLIS driudin{at}hotmail.com Ikram U Din, et al.	Objective: To determine the role of physiotherapy in the management of sternocleidomastoid torticollis. Design: It was a prospective study. Place and Duration of Study: The study was conducted in the Department of Paediatric Surgery of Khyber teachig Hospital peshawar from Feb 2000 to Feb 2002. Methods and material: A total of 30 cases of sternocleidomastoid torticollis were studied. They were divided into two groups of fifteen each. Group A contain patients who were advised regular neck exercises, while Group B patients were observed without advising exercises. Results: Those patients who did regular neck exercises the torticollis resolved within two months while those who were observed took six to eight months to resolve. Sternocleidomastoid torticollis is the term used to describe the presence of a shortened, fibrosed sternocleidomastoid muscle, which results in traction of the mastoid process towards the sternoclavicular joint1. The head is therefore rotated away from and tilted towards the involved sternocleidomastoid muscle. Little is known about its etiology although several theories have been put forward to explain the condition. It may be due to an idiopathic intrauterine embryopathy 2or the manifestation of an intrauterine positional disorder with development of ternocleidomastoid compartment syndrome 3. The basic abnormality on histology is fibrous replacement of muscle bundles 4 .Jones has described endomysial fibrosis involving deposition of collagen and fibroblasts arround individual muscle fibre. The maturity of fibrous in neonates suggests that the disease may begin before birth 567 . Approximately 30% of patients presenting with sternocleidomastoid torticollis have a history of breech presentation at birth, with 60% involved in a complicated birth8. Bilateral fibrosis is seen in 2-3% of cases. About 50-70% of patients present at age 1-8 weeks with a hard 1-3 cm painless, discrete mass, or pseudotumour, located within the substance of the middle or inferior portion of the sternocleidomastoid muscle. This is often, but not always, accompanied by torticollis.In 30-40% of patients only diffuse fibrosis of the sternocleidomastoid is present with torticollis. The natural course of the disease is self resolution of the torticollis in 60-80% cases upto the age of one year. In about 10%, the tumour and sternomastoid shortening persist beyond 12 months of age.9,10 The indications for surgical intervention are plagiocephaly, fascial hemihypoplasia and age above 1-11/2 years. The role of physiotherapy in the management of sternomastoid torticollis is controversial. Those who advocate it say that with physiotherapy resolution of the pseudotuour and /or fibrosis is usually observed in the following 4 to 8 months in at least 70 % of patients. 11 Operative intervention is not necessary in most (90%) of neonates and infants. Those who appose say that in most of the cases it resolves by itself and physiotherapy is only for the satisfaction of parents that something has been done for their child.12 Material and methods: This prospective study was conducted in the department of paediatric surgery of Khyber Teaching Hospital Peshawar from Feb 2002 to Feb 2003. A total of 30 cases were studied. Only those patients who presented within the first 3 months of life were included in the study. Detailed history of each patient was taken and the mode of delivery was asked in specific. Physical examination was done and the side of involvement, presence of tumour/ fibrosis, plagiocephaly and fascial hemihypoplasia noted. These patients were divided randomly into two groups. Group A includes those patients who were advised regular passive full range neck exercises, which emphasize rotation towards and side flexing away from the affected sternocleidomastoid muscle. The parents were asked to do the exercises in front of us and were properly educated to do the same in home 4 times daily for 5-10 minutes. Group B include those patients who were reassured and were educated about the natural course of the disease process. The patients in both groups were advised to come for regular check up to the out patients department after every two weeks. On follow up visits they were examined and the progress noted. RESULTS: The average age of presentation of congenital sternocleidomastoid torticollis was 3 weeks. There were 18 (60%) males and 12 (40%) females. The left side was involved in 20 (66.67%) cases while right side in 10 (33.34%) cases. History of breech presentation was present in 14 (46.67%) cases.The pseudotumour was palpable in 14 (46.67%) cases. The groupA patients showed great improvement with physiotherapy. The torticollis resolved within 3 months.The patients in group B took 6-8 months in resolution of the sternocleidomastoid torticollis. The patients in both groups were followed for the next 6 months and no recurrence of the torticollis was noted. DISCUSSION: Congenital sternocleidomastoid torticollis is not a common disease in childern .The exact etiology is unknown, however the pathology is fibrosis of the muscle involved. The age of presentation of torticollis is 2-3 weeks ,in our study the average age was 3weeks. The reported incidence of breech deliveries is about 20- 30% much higher than the normal incidence 5-22, in our study it was 46.67%.The left side was involved more(66.67%) than the right side(33.34%). The affected males were 60% while the females were 40% in our study .The tumour was present in 47.47% cases while fibrosis was present in 53% of the cases. The role of physiotherapy in the management of torticollis is controversial. Some say that in most of the cases the torticollis resolves by itself, while others advocate the role of physiotherapy as it plays an important role in the management of sternomastoid torticollis. The purpose of this study was to know the effectiveness of physiotherapy in the management of torticollis. This study was conducted on thirty patients of different age groups ranging from 3 to 8 moths in one year . They were divided into two groups. Each group was having patients of age group 3-8 months. The patients in group A were advised passive full range exercises four times daily for five to ten minutes, while group B patients were reassured. After two months in ten out of fifteen patients (66.67%) the torticollis was completely resolved in group A, while in the observational group B no significant improvement was noted. After three months complete resolution of the torticollis was observed in all the cases in group A (100%), and in 6 patients (40%) in group B. The group B patients took another 5 months for complete resolutin of torticollis.All the patients were followed for the next 4 months but no recurrence of the torticollis was noted. From this study we concluded that physiotherapy has a definite role in the management of sternomastoid torticollis. It not only shortens the duration of resolution but decreases the worries of the parents. REFRENCES: 1. Wolfort FG,Kanter MA,MillerLB.Torticollis. Plast Reconstr Surg 1989; 84:682-92. 2. Jones PG: Torticollis in infancy and childhood, Springfield,III.,1967,Charles C Thomas. 3. Hirschl RB:Sternocleidomastoid Torticollis.In Spitz L,Coran A, editors:Rob&Smith, operative surgery: pediatric surgery, ed 5,London,1995,Chapman&Hall Medical. 4. Middleton DS : The pathology of congenital torticollis, Br J Surg18:188,1930. 5. Dunn PG:Congenital postural deformities:perinatal associations, Proc R Soc Med 65:735,1972. 6. Dunn PM: Congenital sternomastoid torticollis: an intrauterine postural deformity, J Bone Joint Surg 55B:887, 1973. 7. MacDonald D: Sternomastoid tumour and muscular torticollis, J Bone Joint Surg 41B:432, 1973. 8. Davids JR,Wenger DR, Mubarak SJ: Congenital muscular torticollis: sequela of intrauterine or perinatal compartment syndrome, J Pediatr Orthp 13:141, 1993. 9. De Chalain TMB, Katz A:Idiopathic muscular torticollis in children:the cape Town experience, Br J Plast Surg 45:297, 1992. 10. Thomsen JR, Koltai PJ: Sternomastoid tumour of infancy, Ann Otol Rhinol Laryngol 98:955, 1989. 11. Cameron BH, Langer JC, Cameron GS: Success of nonoperative treatmentfor congenital muscular torticollis is dependent on early therapy, Pediatr Surg Int 9:391, 1994. 12. Wright JE: Sternomastoid tumour and torticollis in infancy and childhood, Pediatr Surg Int 9:172, 1994.