One of the most common conditions that I treat in infants is Torticollis. Torticollis literally translates to “twisted neck”. Babies are naturally very flexible meaning they exhibit large ranges of motion in all of their joints, their neck included. When a baby is born with, or develops, Torticollis, they present with limited range of motion in their neck, usually in 1-3 directions (side bending, rotating, and extending). This is due to the muscle that is affected with this condition: Sternocleidomastoid, or SCM for short. The SCM bends your ear to your shoulder, rotates your head in the opposite direction, and brings your chin to your chest. When this muscle is tight, the head is pulled into any or all of these 3 directions at the same time. For example, the baby’s right ear will be close to the right shoulder, the chin will be turned to the left, and there will be less of a gap between the chin and chest.
So how does a baby develop this common condition? Studies suggest that infants who are in position for delivery or low in utero for prolonged periods, were breech, or multiples (twins, triplets, etc), are possible reasons. It has to do with how long the baby’s head is maintained in the same position of side bending and rotation, as opposed to their head being in midline/center. Think about when you’re sitting for long periods. After a while, you have to get up and stretch your legs because your muscles feel tight. Babies in utero don’t have that option, which means their muscles shorten (or tighten) to whatever position they are maintained in. So if the baby’s head is bent to the right for 3 months, when they are delivered, their right side neck muscles are going to be tight and they will hold their head bent to the right. Babies that are a multiple (twin, triplet, etc) have less space to move in utero and may be stuck in the same position for a while causing a tightness in the muscles in their neck from being held in the same position.
While this condition is treatable/correctable with Physical Therapy treatment, it does present some concerns for development, especially if left untreated.
Decreased Range of Motion: Because of the muscle tightness, the baby will hold their head tilted to one direction. It will be hard for them to turn their head to one side and you may see that they favor looking to one side. This can limit their exploration of the environment. This decreased range of motion can also cause difficulty breastfeeding on one side.
Cosmetic Changes:
a. Plagiocephaly: With the constant pressure on only one part of the back of the head when the baby is lying on their back, this can lead to plagiocephaly, or flat head. The baby can develop flattening on one side of the head and protrusion of the other, especially if they do not engage in enough tummy time and are not being encouraged to turn their head to the opposite side. Plagiocephaly sounds very scary, but it is purely cosmetic; it has no effect on cognitive development.
b. Craniofacial Asymmetry: Because of where the SCM attaches behind the ear, the ear on the affected side may be lower than the other side. The eye on the affected side may also be droopy, and the cheek may appear less full. When the muscle returns to its normal length with stretching, these asymmetries will improve.
Favoring One Side: Because of the favoring of one side with the head/neck and looking mostly in one direction, the baby may develop a hand preference earlier than they should because they are only looking at one of their hands. Children do not usually develop a hand dominance until 18-36 months and should be encouraged to use both hands prior to this time, especially in infancy, to allow for full exploration of the environment, learning, and development.
Difficulty with Tummy Time: With Torticollis, the tight SCM muscle pulls the chin closer to the chest. It can lead to difficulty with tummy time and lifting the head up to the ceiling (extending the neck). The babies head will most likely fall into the tilted position as soon as they are put on their belly, especially if prior to 3 months old. At this time, the baby will not have great head control and the muscle tightness will be too strong for the baby to overpower. Also, with favoring one side, it may be challenging for the baby to support themselves equally with both arms while on their belly due to lack of strength from disuse on one side. By practicing tummy time often (one time per hour that baby is awake), it will improve the strength in neck and shoulder muscles which will, in turn, help with achievement of development milestones.
Developmental Delay: Torticollis can, but not always, cause a delay in achieving developmental milestones. With the limitation in neck range of motion, babies may not be able to strengthen their muscles on the back of their neck while in tummy time, causing difficulty with achieving other skills such as rolling and sitting. Favoring one side can lead to asymmetry in rolling, meaning they only roll in one direction both back to bell and belly to back. It may be hard for the baby to roll belly to back as they cannot achieve enough neck extension to start the rolling motion or they may not have enough strength in their arms to push themselves to roll from favoring one side. With that being said, I treated a baby with Torticollis that started taking her first steps at 9 months old! So with early treatment for this condition, delays can be minimized!
Development of Scoliosis: The spine is a column and each part of the column responds to the parts above and below it. If the neck is tilted in one direction, the rest of the spinal column will react and bend in the opposite direction to maintain balance in the spine. If Torticollis is caught and treated early on, midline of the head and neck can be established earlier and future consequences can be minimized.
While everything above might sound really scary, Torticollis is typically not cause for concern. Physical Therapy treatment is highly effective in the treatment of Torticollis and most cases are 100% correctable! Some things that you can do at home to treat this condition are listed below.
Stretching the SCM Muscle: These stretches will be demonstrated to you by a Physical Therapist and should be practiced at home regularly. Do not attempt these stretches without the guidance of a Physical Therapist or Pediatrician. I suggest performing 3-5 stretches at diaper changes and feedings, holding for 5-10 seconds, or up to a minute if the baby will tolerate it.
Tummy Time, Tummy Time, Tummy Time!: I cannot stress this one enough. Tummy time is SO important for a baby’s development, even without Torticollis. As soon as the umbilical cord falls off, the baby can be placed on their belly to engage in some tummy time. Being on the belly allows weight bearing into the shoulders as well as strengthening of the muscles on the back of the neck. These things are needed for achievement of milestones such as rolling, sitting, and crawling. Weight bearing into the hands helps develop the tiny muscles in the hand needed for fine motor skills such as handwriting. Tummy time is also important for preventing plagiocephaly. With less time spent on the back, there is less time for the baby to develop flattening on one part of the head leading to those cosmetic changes mentioned above. *Always put your baby to sleep on their back to reduce the risk of SIDS*
Tracking: Getting your baby to turn their head to both directions, while on their back and on their belly, will help them increase their range of motion and strength in their neck muscles. Objects that are red, black, and white are high contrast colors and will catch your baby’s attention the most. Once your baby hits the 3 month mark, their vision will start to get better and they wll be able to track most toys. Dangle the object in front of your baby’s face and move it to their right and left for them to follow the object with their eyes, head, and neck.
Feeding Changes: If breastfeeding, make sure you are switching breasts and altering your baby’s position while breastfeeding. Try not to feed only into the baby’s favored side. If bottle feeding, try to feed your baby to the side they have difficulty turning towards. For example, if your baby has difficulty turning their head to the left, place the bottle towards your baby’s left side so that they have to look to their left side for feedings.
Noggin Nest: Boppy makes a great insert for baby seats that helps to hold the head in midline.
Implementing these changes, combined with weekly Physical Therapy treatment, will make a huge difference in your baby’s condition. Torticollis is treatable, typically with 100% correction, especially with early intervention of Physical Therapy treatment. We at PMPT begin treating Torticollis as early as 4 weeks old.
As mentioned above, do not perform any stretches on your baby’s neck without proper guidance from a Physical Therapist. If you have any questions related to this condition or if you would like to schedule an appointment, please contact our office at 347-857-6368.
Dr. Amanda