Use of Combined Botulinum Toxin and Physical Therapy for Treatment Resistant Congenital Muscular Torticollis

Abstract

Background: Physical therapy (PT) alone is not always effective for treatment of congenital muscular torticollis (CMT). The adjunctive use of botulinum toxin (BTX) injection into the sternocleidomastoid, followed by PT, could provide correction and avoid more invasive surgery. Aims of the study were to review clinical and caregiver-reported outcomes of children with resistant CMT treated by BTX injection combined with a guided-PT program. Methods: Medical records of consecutive children with resistant CMT treated by our protocol between 2010 and 2015 were reviewed. A minimum 2-year follow-up was required. Demographic parameters, numbers of BTX required and pre-BTX and post-BTX head tilt and range of neck rotation were recorded. A univariate analysis test was conducted to identify variables related to the need of repeated BTX injections. A phone interview with the caregivers was done regarding their satisfaction. Results: A cohort of 39 patients with treatment resistant CMT were identified that had an average age of 14 (range, 6.5 to 27.6) months at initiation of BTX treatment. Multiple BTX injections were utilized in 21/39 (54%) of patients. No patient required tendon lengthening surgery. At the final evaluation, there was improvement in both head tilt (18.7±6.8 degrees vs. 1.7±2.4 degrees, mean difference (95% CI) 16.9 (14.6-19.3); P<0.001) and range of neck motion (56.0°±11.7 degrees vs. 86.0±3.8 degrees, mean difference (95% CI) 30.0 (26.1-33.9), P<0.001). Pre-BTX parameters were not associated with the requirement of repeated BTX injections (P>0.05). Caregivers were satisfied with the treatment protocol. No untoward effect was observed during the study period. Conclusions: The proposed minimally invasive protocol provided correction of resistant CMT and obviated the need for more invasive surgical procedures. Level of Evidence: Level IV.

Ocular abnormal head posture: A literature review

“… Congenital nonocular AHP starts in the first 6 months, and it can even manifest itself in the 1 st week of life, 31 whereas ocular AHP usually develops after 18 months of age 32 It is impossible or difficult to return the head to the normal position in congenital nonocular AHP, 33 34 whereas the head often returns easily to its normal position passively or voluntarily in ocular AHP 32 On neck examination, muscle palpation shows stiffness of the sternocleidomastoid muscle in congenital nonocular AHT while palpation is unremarkable in ocular AHP 35 36 Vision is often normal and is not affected in patients with congenital nonocular AHP, whereas in patients with ocular AHP, the strabismus angle increases when the head is straightened with force or the head is positioned in the opposite direction to the habitual AHP, and moreover, diplopia may also occur in acquired cases 37 Monocular patching does not change the head position in congenital nonocular AHP while patching the paretic eye corrects the head position in ocular AHP (in acquired and recent-onset cases). 38 …”

“…It is impossible or difficult to return the head to the normal position in congenital nonocular AHP, 33 34 whereas the head often returns easily to its normal position passively or voluntarily in ocular AHP 32…”

The effectiveness and safety of conservative interventions for positional plagiocephaly and congenital muscular torticollis: a synthesis of systematic reviews and guidance

“…We were able to ascertain that it met at least 16 of the total AGREE II quality appraisal criteria (See Additional file 3). This guideline [27] was based on the systematic reviews by Klimo et al [22], Baird et al [5] and Tamber et al [21], all published in 2016 as part of the taskforce working group. The guideline recommended both physical therapy and repositioning as first line treatment followed by helmet therapy as a second line of treatment for infants with moderate to severe and persisting asymmetry.…”

“…CMT has been associated with dysfunction in the upper cervical spine and is sometimes referred to as kinetic imbalance due to subocciptal strain (KISS) [2]. Treatment approaches for CMT include manual therapy (including practitioner-led stretching exercises) [4], repositioning therapy (including tummy time) [1] and, in severe nonresolving cases, botulinum and surgery [5]. CMT can lead to secondary changes such as cranial asymmetry, and also to functional problems, including breastfeeding problems [2].…”

The Action of Botulinum Toxin A on the Sternocleidomastoid Muscle: An Experimental Study on Rats

“…Pathologies of the muscle are related to several forms of torticollis and cervical dystonia, with treatment varying from conservative physiotherapy to surgical interventions [1,[4][5][6]. e use of botulinum toxin on the sternocleidomastoid to relieve or assist the treatment of torticollis has been proposed by several researchers and is an area attracting more and more interest [4][5][6][7].…”