Toe walking and Torticollis

Toe walking and Torticollis
Carolyn Forsman, MD
April 20, 2012
Pediatric Physical Medicine and Rehabilitation
Why do These 2 Topics go Together?
• Both toe-walking and torticollis are common pediatric
presentations
• The management of each is controversial and there is
much discussion about the natural course and potential
long-term consequences, as well as conservative vs.
aggressive treatment
1
Toe
Walking
Torticollis
2
Objectives
• Define toe walking and formulate a differential diagnosis
of toe walking
• Explain the treatment options of idiopathic toe walking
• Define torticollis and formulate a differential diagnosis of
torticollis
• Explain the treatment options of torticollis
• Provide appropriate referral for evaluation of toe walking
and torticollis
Normal Gait Pattern
3
Normal Gait Pattern
First Rocker
Second Rocker
Normal Gait Cycle
•
http://www.youtube.com/watch?v=occFkFbl3ms
4
Normal Gait Development
• The normal toddler gait is wide-based with excessive
knee and hip flexion
• Toddlers walk with a flat-foot or on their toes
• In typically developing children, consistent heel strike
during initial stance occurs by 18 months of age OR at a
mean time frame of 22.5 weeks (about 5 and a half
months) after the onset of independent ambulation
Burnett, et al; Sutherland, et al.
Normal Gait Development
• Reciprocal arm swing also develops by 18 months
• Idiopathic toe-walking has been described as a normal
variant of early gait by some, but this is not supported by
the literature
• Gait characteristics should be mature by 5 years of age
Burnett, et al; Sutherland, et al.
5
Toe walking is defined as the failure of
the heel to contact the floor at the onset
of stance during gait:
Video of Toe Walking
• http://www.youtube.com/watch?v=IQRkSrmcH5E
6
Differential Diagnosis of Toe-Walking
• Idiopathic Toe Walking
• Cerebral Palsy: secondary to an injury to the brain; spasticity
causes one to walk on their toes; also has abnormal tone in
their hamstrings, hip flexors, adductors; clonus is present
• Congenital triceps surae contracture: present at birth with
foot in equinovarus
• Pervasive Developmental Disorder: autism spectrum, often
behavioral
• Myopathy: weakness causes the patient to compensate their
gait pattern
• Peripheral Neuropathy (i.e. Charcot Marie Tooth): again
causes weakness
• Tethered Spinal Cord: secondary to a spinal dysraphism
Toe Walking in Cerebral Palsy
7
Initial Evaluation of Toe-Walking - History
• Was the child born prematurely? - More concern for
cerebral palsy
• Were there any heel cord contractures at birth?
-Think about a congenital contracture
• Are there any other concerns for developmental
delays? - Could be PDD, CP
• Is there a family history of toe walking? - More likely
to be idiopathic, could also be a myopathy or neuropathy
Initial Evaluation of Toe-Walking - History
• Is the child having any foot or leg pain? - Concern for
spasticity
• Are there balance problems? - Ataxia may lead down
more of a neurologic workup
• Is there any bowel or bladder dysfunction?
- Spinal cord more likely involved
8
Initial Evaluation of Toe-Walking –
Physical Exam
• Gait observation - toe walking is often clinically less
obvious when walking in shoes vs. barefoot
• Neurologic exam –check strength, reflexes, look for
clonus
• Passive and active lower extremity range of motion normal ankle dorsiflexion is 15 to 20 degrees
Ankle Dorsiflexion
9
Idiopathic Toe-Walking (ITW)
• Probably the same condition as congenital short tendo
calcaneus
• Also known as habitual toe walking
• Always bilateral and symmetrical
• Incidence appears to be as high as 5/500 births
• Can be autosomal dominant with a familial incidence of to
32%
• True etiology is not known
• ITW is a diagnosis of exclusion
Sala, et al.
Idiopathic Toe-Walking
• Children with ITW have abnormal muscle firing when
studied by EMG (electromyography)
• There is abnormal co-contraction of the tibialis anterior
muscle (controls dorsiflexion) and the gastrocnemius
muscle (controls plantarflexion)
• Children with ITW can temporarily control their gait to
walk with a normal heel-toe
heel toe pattern when cued, but it is
not lasting
Eastwood, et al.
10
Eastwood, et al.
Gait Deviations Seen in Toe-Walking
• Ankle plantarflexion in stance and swing phase
• Lack of first rocker
• Lack of second rocker
• Decreased push-off
• Premature heel-off
• Out-toeing (to compensate)
• Knee hyperextension
• Increased anterior pelvic tilt
Sutherland, et al.
11
Gait Deviations
Other Implications of Toe Walking
• Positive correlation between language delays and
toe walking
toe-walking
• Positive correlation between learning disabilities and
toe-walking
• Potential correlation with anecdotal evidence between
sensory processing dysfunction and toe-walking, but not
confirmed by the literature
Shulman, et al.
12
Natural History of Toe-Walking
• This is controversial
• The consensus is that true toe-walking persists into
adulthood although may improve without intervention in
up to 50%
• Some studies say that toe-walking resolves on its own as
the patient gets heavier with age
• “Outgrowing” of toe walking is more likely due to other
compensatory changes:
– Foot
F t pronation
ti
– Excessive external tibial torsion
– Out-toeing
•
http://www.youtube.com/watch?v=IQRkSrmcH5E
Shulman, et al.
Consequences of Prolonged walking on
One’s Toes…
• Gastrocnemius, soleus, and Achilles tendon tightness is
acquired after years of toe-walking making treatment much
more difficult
• This can result in a fixed equinus contracture
• Limitation in ankle dorsiflexion passive range of motion is
associated with increased frequency of ankle injuries in
children
• Limitation in ankle dorsiflexion is also associated with
increased
c eased forefoot,
o e oot, midfoot,
d oot, a
and/or
d/o hindfoot
d oot pa
pain in adu
adulthood
t ood
• Older children with a history of toe-walking often demonstrate
excessive external tibial torsion with an increased positive
thigh foot ankle and out toeing to accommodate their plantar
flexion contracture.
Shulman, et al; Tabrizi, P.
13
Consequences of Prolonged Walking on
One’s Toes…
• Type II vs. Type I muscle fibers in the gastrocnemius
(tonic, slow-contracting,
slow contracting, fatigue resistant) thought to be
adaptive (there are actual histological changes!)
• Risk of increased lumbar lordosis with spondylolysis
• Risk of osteochondritis dessicans of the talus and/or
femoral condyles
Shulman, et al; Tabrizi, P.
Treatment Options
• Physical Therapy
• Orthotics
• Serial Casting
• Botox
• Surgery
14
What Happens When You Refer to PT?
• Stretching of ankle plantarflexors
• Strengthening of anterior tibialis muscle
• Strengthening of all other trunk and lower extremity muscles
• Neuromuscular electrical stimulation
• Ankle joint mobilization
• Orthotic intervention
• Treadmill training
• Night splinting
• Home exercise program development
• Stretching alone is often not effective likely because there is
often only a minimal limitation in range of motion
Physical Therapy Outcomes
The efficacy of therapy alone is dependent upon:
1. The amount of contracture present at the time of
evaluation
2. The percentage of time the child spends toe-walking
3. The age of the child at initial evaluation
– Older children
children, over the age of 5 years
years, are not as
likely to be as successful with conservative
treatment
15
Physical Therapy Goals
• To improve ankle dorsiflexion passive range of motion to
greater than or equal to 10 degrees with knee extended
• For the patient to achieve heel-toe ambulation at least
75% of the time in spontaneous gait
• For the patient and family to become independence in
their home-exercise program
• To maximize the patient’s gross motor skills if there are
other delays
Tidwell, et al.
Physical Therapy Setbacks
• Plateaus in range of motion even after successful
treatment may occur with
– Growth spurt
– Anxiety
– Fatigue
– Illness
– Lack of follow through at home
• If these plateaus last longer than 4 weeks, a therapy
reassessment is indicated
Tidwell, et al.
16
Orthotics
• Braces are almost always indicated to help reinforce a
normal gait pattern wtihout consistent verbal reminders
• Night stretching splints can also be helpful
Articulated vs. Solid
17
Serial Casting
• Application of a series of below knee walking casts with
the foot in neutral
– Casts are changed ever 1-2 weeks
– 6-8 weeks total
• These can be very effective in the short term:
– Gain ankle dorsiflexion range of motion
– Improve gait EMG with a reciprocal contraction of
tibialis anterior and gastrocnemius instead of cocontraction
• Children can relapse
Brouwer, et al.
18
Botox
• Botox is a neurotoxin derived from the bacteria
Clostridium botulinum
• It produces a protein that inhibits the release of
acetylocholine and results in temporary localized
reduction in muscle activity
• Effects last for up to 3 months
Botox
• It appears that Botox A treatment can normalize the ankle
EMG pattern during gait and a more normal foot-strike
pattern is obtained
• Botox is often used in association with therapy, casting
and/or orthotics
Brunt, et al; Engstrom, P; Jacks, et al.
19
Botox Video
• http://www.youtube.com/watch?v=l7l0csoCQkM
Surgery
• Toe walking may persist after all conservative treatment
methods, even in the absence of significant Achilles
contracture
• Surgical options include gastroc-soleus lengthening,
tendo Achilles lengthening
• Toe-walking can STILL recur
• There is a risk of over-lengthening and functionally
weakening the gastrocnemius
• Surgeons usually wait until children are 8-10 years of age
20
Other Attempted Treatments
• Supportive shoes
• Auditory biofeedback
• Electrical stimulation
Auditory Biofeedback
• Pressure-sensitive heel switch
• Heel strike makes a sound
• Feedback for at least an hour a day for at least 3 months
• Not good evidence to support
Conrad, et al.
21
When Should You Refer?
• If a child is over the age of 2 and continues to walk on
their toes, they should be treated
• If you are uncomfortable ordering physical therapy
therapy, refer
to pediatric physical medicine and rehabilitation or
pediatric orthopedics
• If you have tried physical therapy and bracing and the
child is still toe walking after 6 months to a year, refer for
further treatment options
• If the child is older than the age of 5 years old, refer
• If there is any concern that there is an underlying
diagnosis other than just idiopathic toe walking, refer
appropriately (ie neurology, PM&R, ortho)
Questions???
22
Definition and History of Torticollis
“Torticollis” literally means “twisted neck”
Latin “torquere” for twisted and “collum” for neck
It is not a diagnosis, but a word used to describe the
twisted posture of the neck
Torticollis be a sign of an underlying pathology or may be
benign
Cheng, et al. 2000
Underlying pathologies can include:
• Muscular
• Skeletal
• Neurologic
• Inflammatory
• Neoplastic
23
Differential Diagnosis of Torticollis
• Congenital muscular torticollis
• Sternocleidomastoid tumor
• Postural torticollis
more of a preference than a muscle problem
• Posterior fossa tumor
• Hemiplegia –causing weakness and spasticity on one
side
• Abnormal vertebral structure
– Klippel-Feil Anomaly (congenital fusion of any 2 cervical
vertebrae)
– Hemivertebrae
Cheng, et al. 2000; Cooperman.
Differential Diagnosis of Torticollis
(continued)
• Fracture or dislocation of vertebrae – acute onset
• Occular abnormalities – head tilt to try to prevent
diplopia
• C1-C2 rotary subluxation – acute onset
• Clavicle fracture – typically a birth injury
• Brachial plexus palsy – again,
again typically a birth injury.
injury
Causes weakness on one side.
Cheng, et al. 2000; Cooperman.
24
Cervical Hemivertebra
Klippel-Feil Anomaly
25
Sternocleidomastoid Tumor
Congenital Muscular Torticollis
26
Can you tell the difference between
each of those pictures?
NOPE!
They all look the same!!!
27
Congenital Muscular Torticollis (CMT)
• Over 80% of all infants presenting with a torticollis
posture have congenital muscular torticollis
• That means about 20% have one of the other underlying
abnormalities!!!
• CMT is observed at birth or early infancy
• CMT results from unilateral fibrosis and shortening of the
sternocleidomastoid muscle and/or upper trapezius
muscle
• This is the 3rd most common musculoskeletal condition in
infants
• The incidence is 0.3%-2%
• The etiology of congenital muscular torticollis appears to
be multifactorial
Cheng, et al. 2000
Initial Evaluation of Torticollis - History
• Was the child born prematurely?
More concern for hemiplegia
• Wh
Whatt was the
th birthweight?
bi th i ht? Was
W the
th child
hild large
l
for
f
gestational age?
Intrauterine positioning plays a large role
• Was the infant a multiple?
Again, less room means malpositioning
• Was there any shoulder dystocia?
Question clavicle fracture or brachial plexus injury
• Is the child using both hands equally?
Think about brachial plexus injury
28
Initial Evaluation of Torticollis – Physical
Exam
• Observation of the infant at rest - look at head
position/preference
• Observe from the front, from above, and from behind
- look for head shape and soft tissue deformity
• Palpate the neck musculature - for presence of a mass
• Passive and active range of motion of the neck –
should be symmetric, should not have a “hard end feel”
Initial Evaluation of Torticollis – Physical
Exam
• Look for symmetry in arm and leg use
• Hip Exam – increased risk for hip dysplasia
• Look at the feet! – check for metatarsus adductus
29
Presentation of Torticollis
• Limitation of active and passive neck motion
• Posturing of the neck in lateral flexion to the ipsilateral
side
• Rotation to the contralateral side causing chin to point
toward the contralateral shoulder
Enter Title Text Here | April 16, 2012 | 59
30
Three Classifications of CMT
1. Sternomastoid tumor group
– A hard mass within the substance of a tight SCM
– Recognized at 1-4 weeks of age
– Size of lesion from 1-3
1 3 cm
– Firm and smooth and movable beneath the skin
– Reaches maximize size and then recedes within the first
year
– Muscle can become fibrotic
2. Muscular torticollis without palpable tumor
3. Postural torticollis
– All the clinical features of torticollis
– No tumor or muscle tightness
•
Has prognostic significance
Cheng, et al. (2000, 2001)
Work-Up - Imaging
• X-ray of cervical spine (AP and lateral) to look for bony
abnormalities
• Ultrasound to look for fibrosis or tumor
– Confirms diagnosis of congenital muscular torticollis
31
Ultrasound
Other Implications of Torticollis
• Can be seen in association with metatarsus adductus
• Can be seen in association with developmental dysplasia
of the hip
• Torticollis, metatarsus, and DDH are all associated with
fetal intrauterine malposition
– There is a high correlation with breech positioning
32
Positional Plagiocephaly
• Over 80% of infants with CMT also present with
craniofacial asymmetry and deformational plagiocephaly
Natural History of Torticollis
• 54-70% of sternocleidomastoid tumors resolve within the
first year of life
• Some patients have persistent residual fibrosis without
clinical problem
• 9-21% have progression to frank muscular torticollis and
clinical deformity
– Similar outcomes in both SCM tumor and muscular
torticollis groups
Do, TT.
33
Treatment Options
• Physical therapy
• Orthoses
• Botox
• Surgery
What happens when you refer to PT?
• Physical Therapy
– Positioning
P iti i
– Environmental adaptations
– Passive stretching of tight SCM
– Active stretching of tight SCM
– Strengthening
g
g of weak neck and trunk muscles
– Movement therapy
– Home program
• Stretching by caregivers
34
Range of Motion
Physical Therapy Outcomes
• Over 90% of children achieve a good to excellent
outcome with conservative treatment
• Outcomes are best when therapy is initiated during the
first 12 months
• Required length of treatment range from 1 to 36 months
(average is 4.7 months)
– Longer treatment if:
•
•
•
•
•
SCM tumor
Right sided involvement
Associated with birth “difficulties”
Initial visit at greater than one month old
Rotation deficit of >15 degrees
Binder, et al; Cheng, et al. (2001); Taylor, et al.
35
Physical Therapy Goals
• Cervical range of motion within 5 degrees of normal in
lateral flexion and rotation
– Active
– Passive
• Symmetric posture in all functional positions
• Head in midline majority of the time when active
• Symmetric gross motor skills
Binder, et al; Cheng, et al. (2001); Taylor, et al.
Physical Therapy setbacks
• Plateaus in range of motion or temporary decrease in
midline control may occur
– During gross motor progression (i.e. starts walking,
etc)
– During a growth spurt
– With fatigue
– With illness, especially an ear infection
• If these plateaus last more than 10-14 days, a therapy
reassessment should occur
36
Complications of manual stretching
• Sudden give-way or snapping of the SCM
– Up to 8% of the time
– Increased risk if:
• Hip dysplasia
• Left sided involvement
• Rotational deficit of >15 degrees
• Less than one month old at presentation
– Followed by bruising and increased range of motion
– Signifies potential tear or rupture of muscle
– Does not seem to result in increased need for
operative treatment
Cheng, et al. (2001); Taylor, et al.
Orthotics – the TOT Collar
• The TOT Collar™ is designed to provide a noxious
stimulus to the lateral aspect of the skull. The user
moves away from this stimulus towards a new, central
corrected position. Adoption of a new, normal head
position provides the ability to reset perception of
horizontal and so maintain the corrected head position.
• The TOT Collar use is added to the conservative
treatment of infants with congenital muscular torticollis if
they are 4 months of age or older and show a consistent
head tilt of 5 degrees or more despite 2-3 months of
treatment.
Cottrill-Mosterman, et al.
37
The TOT Collar
Botox
• Used in combination with therapy
• Goal is to temporarily weaken the affected SCM or upper
trapezius muscle to allow for easier and more successful
stretching and an improved ability to strengthen
opposing neck musculature
• Has been used for years in adults with cervical dystonia
• Low doses used
• Transient adverse affects uncommon (self-limited)
– Dysphagia
– Neck weakness
• Used in hopes of eliminating need for surgery
• One study showed 75% of patients with significant
improvement
Joyce, et al; Oleszek, et al.
– 11% needed repeat injections
– The remainder may still need surgical release
38
Surgery
• Before the mid 1960’s, surgical release of the SCM
during the first few months of life followed by
immobilization was the standard of care
• Is more likely needed in. . .
– Children in the SCM tumor group (8%)
– Children with initial deficit in cervical rotation of >30
degrees
– Children who initiate therapy after 12 months
Cheng, et al. (2001); Do, TT.
Surgery (continued)
• Goal to is achieve a functional and cosmetically
acceptable outcome
• Never indicated in postural torticollis
• Indications:
– Deficits of passive rotation and lateral flexion greater
than 15 degrees
– Presence of a tight band or SCM tumor
– Inadequate response to therapy after
f 6 months
• Best results within 6 months to 2 years age range
• Technically difficult, typically involves an orthopedic
surgeon and ENT
Cheng, et al. (2001); Do, TT.
39
When to think about something other
than congenital muscular torticollis…
• Sudden onset – think about a subluxation or a fracture
• Other associated anomalies – think about a vertebral
anomaly
• Hard-end feel with passive range of motion – more
likely a bony abnormality
• Weakness associated with neck position – consider
brachial plexus injury, hemiplegia
When should you refer?
• If a child is over the age of 1 and continues to have a
head tilt, you should refer.
• If you are uncomfortable ordering physical therapy, refer
to pediatric physical medicine and rehabilitation or
pediatric orthopedics.
• If you have tried physical therapy and the child still has a
neck preference after 6 months, refer for further
treatment options.
• If there is any concern that there is an underlying
diagnosis other than congenital muscular torticollis, refer
appropriately (ie neurology, ortho, neurosurgery).
40
When should you refer?
• Ophthalmology
– Referral if visual dysfunction is observed or suspected
• Check midline visual focus
• Look at ocular alignment, check light reflex
– Referral if residual head tilt with adequate range of
motion and strength
• Orthopedics
– Referral
R f
l if concern ffor non-muscular
l origin
i i
• Bony end feel on cervical range of motion
• Abnormal hip exam
• Abnormal foot exam
Positional Plagiocephaly
• A little bit about posterior plagiocephaly and torticollis
– 1992, the AAP introduced the “Back to Sleep”
campaign
• The following decade showed a dramatic increase
in the diagnosis of CMT and plagiocephaly
• It is now considered an “epidemic”!
– Purely a cosmetic problem, but may effect the child
psychologically later on
Argenta, et al.
41
Argenta, et al.
PT and Positional Plagiocephaly
• Physical therapy intervention for CMT may also improve
positional preference and plagiocephaly
• Craniosacral therapy can be helpful
42
Cranial remolding orthoses
• Ideal period for initiating is 4-6 months
• Treatment lasts 3 months on average
• Needs to be worn 23 ½ hours every day
• Its well tolerated
• Should always be tried before surgery is considered in
patients less than 1 year of age
• Only risks are of pressure spots if not well fitted
43
Questions???
References
•
•
•
•
•
•
•
•
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predisposes
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46