Many of our NAPA friends have torticollis in addition to their primary diagnosis, or they are at increased risk for developing it. We know now that torticollis is not merely an infant diagnosis, as it can affect children throughout their lives if not treated completely. As it affects the whole child, torticollis may contribute to the development of other impairments, such as vision or feeding delays, difficulty with symmetry or weight-bearing, or further concerns like scoliosis, low back pain, and sometimes even neglect of one side of the body.
First, what is torticollis? Torticollis is defined as an abnormal and asymmetrical position of the head or neck. The Latin definition of torticollis is “twisted neck” – “tort” meaning twisted and “coll” meaning neck. In children with this condition, the neck tends to twist to one side, causing a characteristic head tilt to one side, a result of spasm or tightening of one sternocleidomastoid (SCM), a muscle that runs on both sides of the neck from behind the ears to the collarbone, or clavicle.
4-16% of babies have a diagnosis of torticollis, in which the SCM muscle is shortened. It is extremely important to have torticollis treated to prevent permanent shortening of the SCM muscle. This requires quality and timely intervention to lengthen the muscle, restore ideal alignment, and address any strength deficits. Appropriate intervention can help avoid surgery and decrease head and neck pain.
These torticollis therapy exercises and simple position changes can be done at home to help build baby neck muscles and establish preventive habits.
• When baby is born preferring to rotate head one direction, intentionally hold baby on your chest, turning baby’s head to rest looking the opposite direction for a gentle, easy stretch.
• See a licensed infant physical therapist for instruction on other stretches to perform that are specific to your child’s level of torticollis impairment and tolerance for neck stretches.
• Tummy time on therapy ball, rocking side to side and front to back. Toys, mirrors, pets, siblings, etc. can be used to encourage child to look away from restricted side.
• Seated on therapy ball to work on trunk strength and stability, lean side to side/front to back and have child work on returning to sitting position.
• Place child on soft incline wedge/ramp or pillow (Boppy works great) for tummy time to encourage head movement and arm weight-bearing. Increase challenge by decreasing size of support (pillow → rolled up swaddle blanket → small towel roll)
• Sitting activities: child will typically lean their trunk or fall away from the short side and toward the long side; place a toy on the shorter side to encourage weight-shifting to tight side and turning on muscles on weak side.
• Vary sleep and play surfaces; limit time in swings, bouncers, and plush surfaces to 15-20 min, as these restrict head and body motion and promote poor posture overtime if overused.
• Side-lying position is excellent to get child off their back and brings their hands to the middle of their body for midline play. Use a towel roll or pillow to help them keep this position.
• Football hold (side-lying carry): hold child with one arm between their legs and under their belly, with your hand at the shoulder on the shortened side of the neck. In this position, they are working to keep their head up and strengthening the long and weak side while stretching the short side.
• Hold your baby out in front of you and facing away – takes weight off the head and encourages neck strengthening.
• In infant carriers, have child face in until they show good head control and are able to right themselves
• Weight-shifting on ball: lying on back or belly, or sitting up on ball.
• When picking baby up from floor, crib, or changing table, first roll child to one side, then lift up; switch sides regularly.
• When putting baby down to sleep, turn their head so that they are not always looking one way.
→ TIP: Another way to encourage this is putting baby down with the head at a different end of the crib every day.
• Alternate sides whenever you feed baby a bottle (happens automatically with breastfeeding!) and change the hip that you hold your child on.
• Avoid leaving child in a car seat, infant seat, swing, carrier, etc., where head is likely to rest on the same spot.
• Tummy time: position toys away from shortened side to encourage child to rotate head to other side.
For specific torticollis physical therapy exercises and neck stretches, we encourage you to consult with a specially trained physical therapist. At NAPA Center, we offer both intensive and weekly torticollis physical therapy for neck strengthening, aligning, and lengthening – customized to your child’s needs.
Cait Parr is a pediatric physical therapist at NAPA Center. Her favorite animal is snails, because they remind her to slow down and enjoy the beautiful details about life. She loves desserts almost as much as she loves long walks with her husband on the beach at sunset.
Torticollis, also known as wry neck, is defined as an abnormal and asymmetrical position of the head or neck. The Latin definition of torticollis is “twisted neck” – “tort” meaning twisted and “coll” meaning neck. Torticollis refers to symptoms that arise when neck muscles twist, flex or extend beyond their normal position. In children with this condition, the neck tends to twist to one side, causing a characteristic head tilt to one side, a result of spasm or tightening of one sternocleidomastoid (SCM), a muscle that runs on both sides of the neck from behind the ears to the collarbone, or clavicle. Torticollis is measurable; clinicians define it as a difference in range of motion between right and left of 15 degrees or more.
4-16% of babies have a diagnosis of torticollis, in which the SCM muscle is shortened. It is extremely important to have torticollis treated to prevent permanent shortening of the sternocleidomastoid muscle. This requires quality and timely intervention to lengthen the muscle, restore ideal alignment, and address any strength deficits. Appropriate intervention can help avoid surgery and decrease head and neck pain. When diagnosed and treated early with simple position changes and stretching exercises, 80% of children recover completely with no long-term detrimental effects.
Torticollis can occur right at birth. In fact, the majority of diagnoses are the result of a baby being born with torticollis. This is referred to as congenital muscular torticollis. Congenital torticollis is most commonly attributed to how the baby was positioned in utero. Other causes of infant torticollis may be prematurity, birth trauma, abnormalities of the spine and neck, and in rare cases more serious genetic diagnoses. In very rare cases, a child may acquire torticollis as the result of an infection or trauma.
In the final months of gestation, space in the uterus becomes limited, so babies find a nice position for their head and tend to stay there. If the neck muscles are not stretched naturally in both directions after birth, it can lead to torticollis, which requires PT intervention and could eventually cause abnormal head shape, requiring a corrective helmet. Similarly, a pregnancy of multiples (competition for space), being in the breech position where baby’s bum faces the birth canal (also tight quarters), or simply having low amniotic fluid or an otherwise traumatic birth process can make a baby more likely to develop congenital torticollis.
Torticollis can also appear at 2-4 months of age; this is known as acquired or positional torticollis. As a result of the Back to Sleep campaign of pediatricians recommending babies sleep on backs instead of tummies to reduce SIDS, many parents place their babies on their backs as recommended but then leave them there for far too long. Young children often develop torticollis as a result of the amount of time spent lying on their back during the day in car seats, swings, bouncers, strollers, and on play mats. Babies’ skulls are soft and flexible when they’re born (to allow them to fit through the birth canal). Being placed on their backs during waking hours, before the child’s neck muscles are strong enough to control head rotation, can lead to flattening. The flat spot can cause the child to keep the head in one position, making it harder to move out of that position, leading to neck muscles further tightening in that position.
In rare cases, torticollis can occur because of vision problems (ocular torticollis), neurological imbalances (benign paroxysmal torticollis), or bony deformities in the spine. Additionally, it is the third most common musculoskeletal diagnosis behind hip dysplasia and clubfoot.
Studies reveal that as many as 3 in every 100 infants are impacted by torticollis. Parents may start to worry when a baby’s head starts tilting to one side or if they prefer to look only in one direction. Your doctor may have noticed a head tilt at your baby’s last check-up. Infant torticollis (tor-ti-col-lis) is easily diagnosable by tightened muscles on one side of the neck, which leaves your baby’s head at a tilt and/or rotation.
Torticollis Symptoms in babies and children include:
If you have concerns that your child may have torticollis, contact your pediatrician immediately. Your pediatrician will likely recommend pediatric physical therapy which will consist of stretches and developmental positions to help strengthen your child’s neck.
You can also be proactive at home! Here are 3 ways you can help improve your child’s torticollis.
Our therapists love the following products in conjunction with therapy for the treatment of torticollis.
The key to treating torticollis is to be proactive in seeking the appropriate treatment. At NAPA Center, we offer custom-designed treatment programs that will take your child’s unique needs into consideration. If you’d like to schedule a consultation to learn more, get in touch with us today.
Simply put, container baby syndrome is when a baby spends most of their day within some sort of device, such as a car seat or stroller, that limits their freedom to move and explore their environment on their own.
Infant development is amazing! Every movement your newborn makes serves a purpose in their development. It is very important for your baby to have the opportunity to explore and play in all developmental positions such as on their back, tummy, side, or supported sitting. Opportunities to play in these positions furthers their development both physically and cognitively.
When children are confined to a container, they lose out on freedom of movement to play and explore.
A ‘container’ is anything that confines the child from being able to be on the floor have freedom of movement. Some common containers are:
When children are just moved from container to container throughout the day, they run the risk of developing certain conditions:
I get it, life is busy with a newborn! You do not feel as if there is enough time in the day to cook, clean, take a shower yourself, and take care of your sweet new baby! There is a place for containers to help you get things done around the house throughout the day.
2. Outside of transport, limit container use to 15-20 min, 2 times throughout your baby’s day.
3. Limit the use of containers to when you need to keep your baby safe while you are trying to do something productive around the house!
4. Create a safe space on the floor for your baby to play, whether that be with foam mats, partitions to keep them away from pets; create an area where your baby is free to explore and play.
5. Supervised Tummy Time
6. The more tummy time the better!
7. Work towards a goal for at least 10-20 minutes during each of their awake hours of the day. If this is a lot at first, set small goals and break up the time more throughout the hour.
8. Opt to use a baby carrier more often than a container. Baby carriers are less restrictive than a container. There are still some restrictions, however it provides the infant with more opportunity to move and there is typically not pressure on the back of their heads as well.
9. Cuddle time! Take more time to engage in physical touch with your baby. It is bound to put a smile on you and your baby’s face!
Dana Thomsen has been a pediatric physical therapist for 8 years, with experience in working with a wide range of diagnosis. Her favorite part of working in the pediatric field is being able to get paid to play with such adorable children! She enjoys spending her time cuddling with her lovable dog and reading a good book.
TMR uses the ICF model and follows an 8 step process to identify limitations in mobility and their connection with functional outcomes which match caregiver concerns. Range of motion and/or control improves using indirect techniques by understanding the relationship between a hypo mobile area in one area creating hyper mobility elsewhere. When postural symmetry improves the patient can better access control. Caregivers are instructed in family friendly therapeutic play and position activities to incorporate into daily routines. Therapeutic positions are in the direction of ease which is well received by patients as it is a pain free concept. Functional outcomes are rechecked post treatment.
Total Motion Release‐Level 1 will provide extensive lab time for the therapist to learn the foundational TMR concepts, a systematic process to identify restriction in mobility, the single plane exercises, combos and alternative positions. The student will also be introduced to increasing range of motion with a pain free method, strengthening, postural control, transitions, weight shifting, pre‐gait and gait training.
A unique feature of the Tots course is individualized post course coaching and support for the attendees. Post‐course coaching by phone and email helps therapists master the TMR concepts and is included in the price of the course.
This training is specially designed for PT, OT, PTA and COTA, LMT professionals working in Early Intervention, School‐based Programs, Pediatric Sports Medicine, and Rehabilitation Programs.
After 16 hours of face‐to‐face instruction, plus post‐course support, participants will be able to:
October 17-18, 2020
11840 S. La Cienega Blvd.
Hawthorne, CA 90250
Live Course: CE Hours – 16 CE Hours
Price includes 16 hour live course, FREE retake of live course (online or in‐person) and access to a FREE home study “link” to review course material.
Basic Registration fee includes FREE 1:1 post‐course coaching via email or phone.
NAPA Center Contact – Larissa Perry
Susan Blum obtained her Bachelor’s degree in Physical Therapy in 1975. She is the owner of Susan Blum Pediatric Physical Therapy, a private practice specializing in treatment of children in natural environments. Susan provides PT services in the York, Pennsylvania area both in Early Intervention and private consultation. In addition to using traditional pediatric strategies, Susan employs the step by step TMR approach, and is able to create more effective care plans. Earlier in her 40 year career Susan had extensive experience treating adults with neurological, orthopedic and women’s health disorders using a variety treatment techniques which she has incorporated in her approach with children. She has adapted TMR for the pediatric population and has witnessed a dramatic improvement in the functional outcomes of her patients. Her practice includes patients with a wide variety of pediatric issues including cerebral palsy, orthopedic issues, gait asymmetries, torticollis, developmental delays and other neuro‐motor disorders. All have benefited from TMR and exceeded former expectations.
|7:30‐8:00 AM||Sign-In & Continental Breakfast|
|8:00‐9:30||Morning Program: Learning the TMR System
‐TMR Program Overview
‐How the Process Works
‐Single Plane Motions
|9:45‐12:00||System of Assessment: the Process of Identifying & Ranking Issues, Testing, The Feedback Loop|
|1:00‐3:15||Afternoon Program: Applying the Method
‐ADLS & Therapeutic Positioning to Incorporate into Daily Routines
‐Assessment Lab & Practice
‐Case Examples & Videos
‐Children w/CP & Hypotonia
|3:30‐5:30||Lab: Practice the Concept on Self & Dolls
Problem‐Solving & Discussion
|7:30‐8:00 AM||Sign-In & Continental Breakfast|
|8:00‐9:30||Morning Program: Applying the Method
‐Review of Basics—Progressing from Assisted to Active
‐Torticollis & Lower Tort—The Equal Opposite Action
-Contralateral Lengthening Lab: Assessment & Treatment Practice in Small Groups
|9:45‐12:00||Review Patient Demo Video—Proficiency in Documentation
Beyond Symmetry—Progression to Motor Control
|1:00‐3:30||Afternoon Program: Introduction to Advanced Techniques
‐Treatment Progression: Know When to Continue Treating
Lab: Optional Positions—Practice Modified
Techniques & Optional Motions
‐Home Exercise Programs
‐Complex Cases: Children with SMA, Gait Asymmetries, Spina‐Bifida & Shaken Baby Syndrome
|3:45-5:30||‐Introduction to the TMR 2 Concepts— Building Blocks for Motor Control
‐Task Analysis System Selection of Motor Activities Based on Objective Data
‐Adolescents & Complex Cases Caregiver Empowerment
“This course is the heart of the PT body, pumping vital knowledge that is improving the lives of our kiddos. This course is a MUST for the future benefit of all children requiring any therapy.”
– Letitia Borelli DPT
“This is a must attend course. Every PT & OT needs this information so they can modify their treatment plans and techniques. You will wish you took this course years ago. Don’t wait!”
– Mark Michalski PT
“I really like the info & I am ready & excited to use it! I learned way more treatment techniques than any other cont. ed. course I’ve ever taken.”
-Melody Kentrus PT
OCCUPATIONAL THERAPY & PHYSICAL THERAPY
State PT Boards & PT Associations
For Details – visit our website link – https://tmrtots.com/ce‐approvals
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Approved By Texas Physical Therapy Association
Approval # 60756TX
AOTA Provider # 6471
Jenn is excited to be a part of the NAPA Center Boston team! She earned her Doctorate of Physical Therapy from Northeastern University. While at Northeastern, Jenn swam on the varsity swim and dive team. Her experience with her own injuries as an athlete spurred her interest in pursuing a physical therapy degree. While in PT school, Jenn found her true passion in working with children. Since graduating, Jenn has worked in a variety of settings, including a school system for children with visual impairments and outpatient pediatrics, treating a wide range of diagnoses including cerebral palsy, developmental delays, genetic disorders, torticollis, and amputees. Outside the clinic Jenn enjoys beach days, learning to ski, and traveling every chance she gets.
Nikki graduated from Ithaca College with her Doctorate of Physical Therapy. While at Ithaca, she played for the women’s varsity soccer team. She has enjoyed both playing and coaching sports since she was a little girl, which eventually helped clinch her decision to pursue a physical therapy degree to helping children. Her physical therapy career has been solely in the pediatric field, and she has experience in both the outpatient and inpatient settings. She has worked for several years as a clinical supervisor, teaching graduate students of different universities. In May 2015, she became an American board pediatric certified specialist. Nikki has experience treating a wide range of pediatric diagnoses, ranging from children with developmental delay to those with neurologic impairments, orthopedic conditions, and rare diseases. Furthermore, she has extensive training in evaluating and treating infants with torticollis as well as recommending orthotics for children. Nikki is a CME level II clinician, and has trained several times under the creator, Ramon Cuevas. Since becoming certified in CME, Nikki truly believes her therapeutic approach has been further polished and more importantly, life-changing.