C L I N I C A L P R A C T I C E G U I D E L I N E

Physical Therapy Management of Congenital Muscular Torticollis: A 2024

Evidence-Based Clinical Practice Guideline From the American Physical Therapy
Association Academy of Pediatric Physical Therapy
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Barbara Sargent, PT, PhD, PCS; Colleen Coulter, PT, DPT, PhD, PCS; Jill Cannoy, PT, DPT, PCS; Sandra L. Kaplan, PT, DPT, PhD, FAPTA
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Division of Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry, University of Southern California (Dr Sargent), Los Angeles, California;
Orthotics and Prosthetics Department (Drs Coulter and Cannoy), Children’s Healthcare of Atlanta, Atlanta, Georgia; Department of Rehabilitation and
Movement Sciences, Rutgers (Dr Kaplan), The State University of New Jersey, Newark, New Jersey

0898-5669/110/0000-0001
Pediatric Physical Therapy
Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical
Therapy Association.
Correspondence: Barbara Sargent, PT, PhD, PCS, Division of Biokine-
siology and Physical Therapy, University of Southern California, 1540
E. Alcazar St, CHP 155, Los Angeles, CA 90089 ([email protected]).
The authors declare no conflicts of interest.
The American Physical Therapy Association Academy of Pediatric
Physical Therapy welcomes comments on this guideline. Comments
may be sent to [email protected]. This guideline may be repro-
duced for educational and implementation purposes.
Reviewers: Cynthia Baker, MD, FAAP (American Academy of Pediatrics
representative), Kristen Barnes, BS (parent/caregiver and public represen-
tative), Colin Brady, MD, FACS (pediatric plastic and craniofacial sur-
geon), Anna Öhman, PT, PhD (pediatric physical therapist and
researcher), J. Scott Parrott, PhD (methodologist), Melanie Percy, RN,
PhD, CPNP, FAAN (pediatric nurse practitioner), Amy Pomrantz, PT,
DPT, OCS, ATC (parent/caregiver and public representative), Robyn Scha-
fer, PhD, CNM, IBCLC, FACNM (nurse midwife, lactation consultant),
and members of the Academy of Pediatric Physical Therapy Knowledge
Translation Committee: Tiffeny Atkins, PT, DPT, PCS, Catie Christensen,
PT, DPT, PCS, Caitlin Deville, PT, MPT, DSc, and Allison Heschle, PT,
DPT.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML
and PDF versions of this article on the journal’s Web site (https://
journals.lww.com/pedpt/pages/default.aspx). Additionally, imple-
mentation resources can be downloaded from the Academy of
Pediatric Physical Therapy website (https://pediatricapta.org/clini
cal-practice-guidelines/).
Grant support: None.
DOI: 10.1097/PEP.0000000000001114

370 Sargent et al Pediatric Physical Therapy

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 ABSTRACT

B a c k g r o u n d : Congenital muscular torticollis

(CMT) is a postural condition evident shortly after
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birth. The 2013 CMT Clinical Practice Guideline

(2013 CMT CPG) set standards for the identification,
referral, and physical therapy management of infants
with CMT, and its implementation resulted in im-
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proved clinical outcomes. It was updated in 2018 to

reflect current evidence and 7 resources were devel-
oped to support implementation. Purpose: This
2024 CMT CPG is intended as a reference document
to guide physical therapists, families, health care
professionals, educators, and researchers to improve
clinical outcomes and health services for children
with CMT, as well as to inform the need for continued
research. Results/Conclusions: The 2024 CMT
CPG addresses: education for prevention, screening,
examination and evaluation including recommended
outcome measures, consultation with and referral to
other health care providers, classification and prog-
nosis, first-choice and evidence-informed supple-
mental interventions, discontinuation from direct
intervention, reassessment and discharge, imple-
mentation and compliance recommendations, and
research recommendations. (Pediatr Phys Ther
2024;36:370–421)
Key words: clinical practice guideline, congenital
muscular torticollis, infant, pediatrics, physical therapy

WHAT THIS EVIDENCE ADDS

Current evidence: The physical therapy management of congenital muscular torticollis is informed by a clinical
practice guideline (CMT CPG) that was published in 20131 and updated in 2018.2 Implementing the CMT CPG1
recommendations not only improved outcomes3 but also led to research to align documentation with the best
practice recommendations,4 develop a clinical decision algorithm,5 and provide guidance for intervention and
follow-up.6 To support the implementation of the CMT CPG,2 7 resources were developed by the American Physical
Therapy Association Academy of Pediatric Physical Therapy (APTA Pediatrics)7 and a state-of-the-art review for
pediatricians was published.8
Gap in the evidence: The 2018 CMT CPG2 does not include evidence published after 2018.
How does this study fill this evidence gap? This 2024 CMT CPG was updated based on current evidence on the
physical therapy management of CMT through June 2023, the guideline development group’s clinical and profes-
sional experience, trends in practice changes, the impact of previous versions of the CMT CPG, and external review
both by content experts, including parents/caregivers of infants with CMT, and the general public.
Implications of all the evidence: This 2024 CMT CPG informs the physical therapy management of congenital
muscular torticollis on: education for prevention, screening, examination and evaluation including recommended
outcome measures, consultation with and referral to other health care providers, classification and prognosis, first-
choice and evidence-informed supplemental interventions, discontinuation from direct intervention, reassessment
and discharge, implementation and compliance recommendations, and research recommendations.

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 DOCUMENT ORGANIZATION

This 2024 Congenital Muscular Torticollis Clinical Practice Therapy Examination and Evaluation of Infants with
Guideline (2024 CMT CPG) is an update of the 2013 and 2018 Asymmetries/CMT; Physical Therapy Intervention for Infants
Congenital Muscular Torticollis Clinical Practice Guidelines with CMT; and Physical Therapy Discontinuation, Reassess-
(2013 and 2018 CMT CPG).1,2 It is intended as a reference ment, and Discharge of Infants with CMT. Following the
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document to guide physical therapists (PTs), families, health summary (Table 3), descriptions of the clinical practice guide-
care professionals, and educators to improve clinical outcomes line (CPG) purpose, scope, and methods are followed by an
and health services for children with congenital muscular torti- action statement with a standardized profile of information
collis (CMT), as well as to inform future research. Accepted based on the Institute of Medicine’s (IOM’s) criteria for trans-
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international methods of evidence-based practice were used to parent CPGs.9 Research recommendations are placed within
systematically search peer-reviewed literature, assign levels of the text where the topics arise and are collated at the end of the
evidence (Table 1), summarize the literature, formulate action document. Evidence tables on psychometric properties of
statements, and assign grades for each action statement (Table 2). assessment tools, randomized controlled trials (RCTs) of the
Table 3 (also available as Supplemental Digital Content 3, first-choice intervention, RCTs of evidence-informed supple-
available at: https://links.lww.com/PPT/A548) summarizes mental interventions, and long-term outcomes are available as
the 17 action statements with their 2024 status. They are Supplemental Digital Content 4-7, available at: https://links.
organized with 4 major headings: Education, Identification, lww.com/PPT/A545, and at https://pediatricapta.org/clinical-
and Referral of Infants with Asymmetries/CMT; Physical practice-guidelines/.7

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 TABLE OF CONTENTS

LEVELS OF EVIDENCE AND RECOMMENDATION GRADE CRITERIA

Levels of Evidence (Table 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

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Recommendation Grades for Action Statements (Table 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

Levels of Evidence and Recommendation Grades . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Status Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
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SUMMARY AND STATUS OF ACTION STATEMENTS FOR THE 2024 CONGENITAL MUSCULAR TORTICOLLIS CLINICAL PRACTICE GUIDELINE
(TABLE 3)

INTRODUCTION

Background of the 2024 Congenital Muscular Torticollis Clinical Practice Guideline… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Purpose of the 2024 Congenital Muscular Torticollis Clinical Practice Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Scope of the Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Changes in the 2024 Congenital Muscular Tortiollis Clinical Practice Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Statement of Intent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380

METHODS

Search Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380

Selection Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Study Appraisal and Data Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Recommendation Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
External Review Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Appraisal for Guidelines for Research & Evaluation (AGREE) II Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Plan for Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382

CONGENITAL MUSCULAR TORTICOLLIS

Incidence and Evaluation of Congenital Muscular Torticollis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382

Importance of Early Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382

ACTION STATEMENTS

I. Education, Identification and Referral of Infants with Asymmetries/Congenital Muscular Torticollis (CMT) . . . . . . . . . . . . . 382
II. Physical Therapy Examination and Evaluation of Infants with Asymmetries/CMT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
III. Physical Therapy Intervention for Infants with CMT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
IV. Physical Therapy Discontinuation, Reassessment, and Discharge of Infants with CMT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412

GENERAL GUIDELINE IMPLEMENTATION STRATEGIES

Strategies for Individual Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413

Strategies for Facilitating Clinical Practice Guideline Implementation in Other Clinicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413

SUMMARY OF RESEARCH RECOMMENDATIONS PER ACTION STATEMENT

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415

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 SUPPLEMENTAL DIGITAL CONTENT

All content: https://links.lww.com/PPT/A545

SDC 1: Figure 1 – Referral Flow Diagram, https://links.lww.com/PPT/A546
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SDC 2: Figure 2 – 2024 Classification of Severity and Management of CMT, https://links.lww.com/PPT/A547

SDC 3: Table 3 – Summary and Status of Action Statements for the 2024 Congenital Muscular Torticollis Clinical Practice Guideline,
https://links.lww.com/PPT/A548
SDC 4: Psychometric Properties of Assessment Tools Commonly Used in the Management of Congenital Muscular Torticollis
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SDC 5: Randomized Controlled Trials of the First-Choice Physical Therapy Intervention for Infants with Congenital Muscular
Torticollis
SDC 6: Randomized Controlled Trials of Evidence-Informed Supplemental Interventions for Infants with Congenital Muscular
Torticollis
SDC 7: Studies of Long Term Outcomes of Congential Muscular Torticollis
SDC 8: International Classification of Functioning, Disability and Health (ICF) and International Statistical Classification of Diseases
and Related Health Problems (ICD) 10 Codes
SDC 9: Operational Definitions
SDC 10: Development of the Guideline

374 Sargent et al Pediatric Physical Therapy

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 LEVELS OF EVIDENCE AND RECOMMENDATION GRADE CRITERIA

Levels of evidence are assigned based on a combination of improve examination and intervention efficacy or minimize
a risk of bias assessment and the quality of the outcome unwarranted variation.
measures used in a study (Table 1). Recommendation grades
Status Definitions
A-C are consistent with the levels of evidence in the BRIDGE-
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Wiz software deontics used to structure the recommendation These terms in the Summary of Action Statements table
statements to align with the IOM recommendations for indicate changes from the 2018 CMT CPG recommendations.2
transparency.9,10 Theoretical/Foundational (Grade D) and • New – the action statement was not in the prior version.
Practice Recommendations (Grade P) are not generated with
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• Upgraded – the action statement grade was increased.

BRIDGE-Wiz. Grade D is based on basic science or theory, • Downgraded – the action statement grade was decreased.
and Grade P is determined by the Guideline Development • Revised – the action statement has been reworded for
Group (GDG) to represent current best physical therapy clarity.
practice or exceptional situations for which studies cannot • Reaffirmed – the action statement is unchanged.
be performed (Table 2). Research recommendations identify • Updated – the action statement has new references.
missing or conflicting evidence, for which studies might • Retired – the action statement was withdrawn.

TABLE 1: Levels of Evidence

Level Criteria
I Evidence obtained from high-quality diagnostic studies, prognostic or prospective studies, cohort studies or randomized controlled trials, meta-
analyses, or systematic reviews (critical appraisal score greater than 50% of criteria)
II Evidence obtained from lesser-quality diagnostic studies, prognostic or prospective studies, cohort studies or randomized controlled trials, meta-
analyses, or systematic reviews (eg, weaker diagnostic criteria and reference standards, improper randomization, no blinding, and <80%
follow-up) (critical appraisal score less than 50% of criteria)
III Case-controlled studies or retrospective studies
IV Case studies and case series
V Expert opinion

TABLE 2: Recommendation Grades for Action Statements

Grade Recommendation Quality of Evidence

A Strong A preponderance of level I studies, but at least 1 level I study directly on the topic supports the recommendation

B Moderate A preponderance of level II studies but at least 1 level II study directly on topic supports the recommendation

C Weak A single level II study at less than 25% critical appraisal score or a preponderance of level III and IV studies, including
consensus statements by content experts support the recommendation

D Theoretical/ A preponderance of evidence from animal or cadaver studies, conceptual/theoretical models/principles, basic science/
Foundational bench research, or published expert opinion in peer-reviewed journals supports the recommendation
P Best Practice Recommended practice based on current clinical practice norms, exceptional situations where validating studies have
not or cannot be performed and there is a clear benefit, harm, or cost, and/or the clinical experience of the guideline
development group
R Research There is an absence of research on the topic, or higher-quality studies conducted on the topic disagree with respect to
their conclusions. The recommendation is based on these conflicting or absent studies

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 375

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 SUMMARY AND STATUS OF ACTION STATEMENTS FOR THE 2024
CONGENITAL MUSCULAR TORTICOLLIS CLINICAL PRACTICE GUIDELINE

TABLE 3: Summary and Status of Action Statements for the 2024 Congenital Muscular Torticollis Clinical Practice Guideline
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Action Statement Status Page

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I. EDUCATION, IDENTIFICATION AND REFERRAL OF INFANTS WITH

ASYMMETRIES/CONGENITAL MUSCULAR TORTICOLLIS (CMT) 382
P Action Statement 1: EDUCATE EXPECTANT OR NEW PARENTS/CAREGIVERS OF NEWBORN Revised, Updated 382
INFANTS TO PREVENT ASYMMETRIES/CMT. Health care providers (eg, prenatal educators, physicians,
midwives, obstetrical or other nurses, lactation specialists, or physical therapists) should educate and document
instruction to all expectant or new parents/caregivers of infants before or within the first 2 to 3 days of life on the
importance of supervised prone/tummy play 2 or 3 times daily when the infant is awake, full active movement
throughout the body, prevention of postural preferences, and the role of pediatric physical therapists in the
comprehensive management of postural preference and optimizing motor development if concerns are noted.
(Evidence Quality: V; Recommendation Strength: Best Practice)
A Action Statement 2: ASSESS NEWBORN INFANTS FOR ASYMMETRIES/CMT. Health care providers (eg, Revised, Updated 385
prenatal educators, physicians, midwives, obstetrical or other nurses, lactation specialists, or physical therapists)
and parents/caregivers must assess and document the presence of neck and/or facial or cranial asymmetry within
the first 2 to 3 days of life, using passive cervical range of motion and/or visual observation as their respective
training or experience supports. (Evidence Quality: I, Recommendation Strength: Strong)
A Action Statement 3: REFER INFANTS WITH ASYMMETRIES/CMT TO THEIR PRIMARY CARE Upgraded, Revised, 386
PROVIDER AND A PHYSICAL THERAPIST. Health care providers (eg, physicians, midwives, obstetrical or Updated
other nurses, lactation specialists, or physical therapists) and parents/caregivers should refer infants identified as
having postural preference, reduced cervical range of motion, a sternocleidomastoid (SCM) mass, and/or
craniofacial asymmetry to their primary care providers and a physical therapist with expertise in infants as soon as
the asymmetry is noted. (Evidence Quality: I, Recommendation Strength: Strong)
II. PHYSICAL THERAPY EXAMINATION AND EVALUATION OF INFANTS WITH ASYMMETRIES/CMT 387
B Action Statement 4: DOCUMENT INFANT HISTORY. Prior to initial screening, physical therapists should Revised 387
obtain and document a general medical and developmental history of the infant, including 6 specific health
history factors: chronological and corrected age, age of onset of symptoms, pregnancy and birth history, head
posture/preference, other known or suspected medical conditions, and developmental milestones. (Evidence
Quality: II-IV, Recommendation Strength: Moderate)
B Action Statement 5: SCREEN INFANTS FOR NONMUSCULAR CAUSES OF ASYMMETRY AND Revised, Updated 388
CONDITIONS ASSOCIATED WITH CMT. When infants present with or without a primary care provider
referral, and a professional or parent/caregiver indicates concern about head or neck posture and/or
developmental progression, physical therapists should perform and document a review of the neurological,
musculoskeletal, integumentary, and cardiopulmonary systems, including screens of vision, gastrointestinal
history, postural preference and the structural and movement symmetry of the neck, face and head, trunk, hips,
and upper and lower extremities, consistent with state practice acts. (Evidence Quality: II-IV, Recommendation
Strength: Moderate)
B Action Statement 6: REFER INFANTS FROM PHYSICAL THERAPIST TO THEIR PRIMARY CARE Revised, Updated 389
PROVIDER IF INDICATED BY SYSTEMS REVIEW. Physical therapists should document consultation with or
referral of infants to their primary care providers for additional diagnostic testing when a systems review identifies:
nonmuscular causes of asymmetry (eg, poor visual tracking, spinal conditions, abnormal muscle tone, extra-
muscular masses, and gastroesophageal reflux disorder); associated conditions (eg, craniofacial asymmetry);
asymmetries inconsistent with CMT (eg, head lateral flexion and rotation to the same side or the side of torticollis
changes); changes in the infant’s color during screening of neck passive range of motion (PROM); history of acute
torticollis; history of late-onset torticollis at 6 months or older; a SCM mass at 6 months or older, or an SCM mass
that changes shape and location or increases in size at any age; the infant is older than 12 months and either facial
asymmetry and/or 10°-15° of difference exists in passive or active cervical rotation or lateral flexion ROM.
(Evidence Quality: II, Recommendation Strength: Moderate)
B Action Statement 7. REQUEST IMAGES AND REPORTS. Physical therapists should request, review, and Updated 391
include in the medical record all images and interpretive reports completed for the diagnostic workup of an infant
with suspected or diagnosed CMT to inform prognosis. (Evidence Quality: II, Recommendation Strength:
Moderate)
(continues)

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 TABLE 3: Summary and Status of Action Statements for the 2024 Congenital Muscular Torticollis Clinical Practice Guideline
(Continued )

Action Statement Status Page

B Action Statement 8: EXAMINE BODY STRUCTURES. Physical therapists should perform and document the
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Revised, Updated 391

initial examination and evaluation of infants with suspected or diagnosed CMT for the following 7 body
structures:
• Infant posture and tolerance to positioning in supine, prone, sitting, and standing for body symmetry, with or
without support, as appropriate for age. (Evidence Quality: II; Recommendation Strength: Moderate)
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• Bilateral PROM into cervical rotation and lateral flexion using an arthrodial protractor or goniometry. (Evidence
Quality: II; Recommendation Strength: Moderate)
• Bilateral active range of motion (AROM) into cervical rotation using an arthrodial protractor or goniometry and
cervical lateral flexion functional strength using the Muscle Function Scale. (Evidence Quality: II; Recom-
mendation Strength: Moderate)
• PROM and AROM of the trunk and upper and lower extremities, inclusive of screening for possible develop-
mental dysplasia of the hip. (Evidence Quality: II; Recommendation Strength: Moderate)
• Pain or discomfort at rest, and during passive and active movement using a standard scale, such as the Face, Legs,
Activity, Crying, and Consolability Scale. (Evidence Quality: III; Recommendation Strength: Weak)
• Skin integrity, symmetry of neck and hip skin folds, presence and location of an SCM mass, and size, shape,
and elasticity of the SCM muscle and other cervical muscles. (Evidence Quality: II; Recommendation Strength:
Moderate)
• Craniofacial asymmetries and head/skull shape using a quantitative measurement method or standard
classification, such as the Argenta Classification Scales. (Evidence Quality: II; Recommendation Strength:
Moderate)
B Action Statement 9: CLASSIFY CMT USING THE CMT SEVERITY GRADING SCALE. Physical therapists Revised, Updated 397
should classify and document CMT severity using the CMT Severity Grading Scale, choosing 1 of 8 grades (Figure 2)
based on infant’s age at examination, the presence of an SCM mass, and the difference in cervical rotation PROM
between the left and right sides. (Evidence Quality: II, Recommendation Strength: Moderate)
B Action Statement 10: EXAMINE ACTIVITY AND DEVELOPMENTAL STATUS. During the initial and Revised, Updated 398
subsequent examinations of infants with suspected or diagnosed CMT, physical therapists should examine and
document the types of and tolerance to position changes, and motor development for movement symmetry and
milestones, using an age-appropriate, norm-referenced standardized test, such as the Test of Infant Motor
Performance, Alberta Infant Motor Scale, or gross motor subtests of the Peabody Developmental Motor Scales,
third edition. (Evidence Quality: II; Recommendation Strength: Moderate)
B Action Statement 11. EXAMINE PARTICIPATION STATUS. The physical therapist should obtain and Revised, Updated 399
document the parent/caregiver responses regarding:
• Positioning when awake and asleep. (Evidence Quality: II; Recommendation Strength: Moderate)
• Infant time spent in prone while awake, consistent with Safe Sleep Recommendations. (Evidence Quality: II;
Recommendation Strength: Moderate)
• Whether the parent/caregiver alternates sides when holding the infant for breast or bottle. (Evidence Quality:
II; Recommendation Strength: Moderate)
• Infant time spent in equipment/positioning devices, such as strollers, car seats, or swings. (Evidence Quality: II;
Recommendation Strength: Moderate)
B Action Statement 12: DETERMINE PROGNOSIS. Physical therapists should determine and document the Revised, Updated 401
prognosis for resolution of CMT and the episode of care after completion of the evaluation and communicate it to
the parents/caregivers. Prognoses for the extent of symptom resolution, the episode of care, and/or the need to
refer for more invasive interventions are related to: the age of initiation of treatment, CMT Severity Grade
(Figure 2, SDC 2), intensity of intervention, presence of comorbidities, rate of change, and adherence with home
programming.
(Evidence Quality: II, Recommendation Strength: Moderate)
III. PHYSICAL THERAPY INTERVENTION FOR INFANTS WITH CMT 402
B Action Statement 13: PROVIDE FIVE COMPONENTS AS THE FIRST-CHOICE INTERVENTION. Physical Revised, Updated 403
therapists should provide and document these 5 components as the first-choice intervention for infants with
CMT:
• Neck PROM when PROM is limited. (Evidence Quality: I; Recommendation Strength: Strong)
• Neck and trunk AROM. (Evidence Quality: II; Recommendation Strength: Moderate)
• Symmetrical movement. (Evidence Quality: II; Recommendation Strength: Moderate)
• Environmental adaptations. (Evidence Quality: II; Recommendation Strength: Moderate)
• Parent/caregiver education. (Evidence Quality: II; Recommendation Strength: Moderate)
(continues)

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 377

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 TABLE 3: Summary and Status of Action Statements for the 2024 Congenital Muscular Torticollis Clinical Practice Guideline
(Continued )

Action Statement Status Page

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C Action Statement 14. EVALUATE EVIDENCE-INFORMED SUPPLEMENTAL INTERVENTION(S) FOR Revised, Updated 405
APPROPRIATENESS TO AUGMENT THE FIRST-CHOICE INTERVENTION. Physical therapists may
provide and document evidence-informed supplemental interventions, after evaluating their appropriateness for
managing CMT or postural asymmetries, as adjuncts to the first-choice intervention when the first-choice
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intervention has not adequately improved range or postural alignment, and/or when access to services is limited,
and/or when the infant is unable to tolerate the intensity of the first-choice intervention, and if the physical
therapist has the appropriate training to administer the intervention. (Evidence Quality: I-V, Recommendation
Strength: Weak)
B Action Statement 15: INITIATE CONSULTATION WHEN THE INFANT IS NOT PROGRESSING AS Revised, Updated 407
ANTICIPATED. Physical therapists who are managing infants with CMT or postural asymmetries should initiate
consultation with the infant’s primary care provider and/or specialists about other interventions when the infant is not
progressing as anticipated. These conditions might include when asymmetries of the head, neck, and trunk are not
starting to resolve after 4-6 weeks of comprehensive intervention or after 6 months of intervention with a plateau in
resolution. (Evidence Quality: II, Recommendation Strength: Moderate)
IV. PHYSICAL THERAPY DISCONTINUATION, REASSESSMENT, AND DISCHARGE OF INFANTS WITH CMT 409
B Action Statement 16: DISCONTINUE DIRECT SERVICES WHEN THESE 5 CRITERIA ARE ACHIEVED. Reaffirmed 409
Physical therapists should discontinue direct physical therapy services and document outcomes when these 5
criteria are met: cervical PROM within 5° of the non-affected side, symmetrical active movement patterns, age-
appropriate motor development, no visible head tilt, and the parents/caregivers understand what to monitor as the
child grows. (Evidence Quality: II-III, Recommendation Strength: Moderate)
B Action Statement 17: REASSESS INFANTS 3-12 MONTHS AFTER DISCONTINUATION OF DIRECT Revised, Updated 410
SERVICES, THEN DISCHARGE IF APPROPRIATE. Physical therapists should complete a full evaluation to
assess for reoccurrence of CMT and evidence of atypical development if the parent/caregiver or primary care
provider observes asymmetrical posture OR 3-12 months following discontinuation from direct physical therapy
intervention OR when the child initiates walking. (Evidence Quality: II-III, Recommendation Strength:
Moderate)

378 Sargent et al Pediatric Physical Therapy

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Unauthorized reproduction of this article is prohibited.
 INTRODUCTION

establish policy and funding for physical therapy man-

Background of the 2024 Congenital Muscular Torticollis
agement of CMT; (3) academic programs for all health
Clinical Practice Guideline
care and educational professionals providing services to
CMT is a common postural condition evident shortly after infants and their families; and (4) across health care
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birth. It is typically characterized by cervical lateral flexion to settings, including prenatal classes, community birth
one side and cervical rotation to the opposite side due settings, hospitals, offices of primary care providers, out-
to unilateral shortening or muscle imbalance of the sternoclei- patient pediatric physical therapy practices, and early
domastoid (SCM) muscles. The 2013 Congenital Muscular Tor- intervention programs.
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ticollis Clinical Practice Guideline (2013 CMT CPG)1 from the • Identify areas of research necessary to strengthen the
American Physical Therapy Association Academy of Pediatric evidence for physical therapy management of CMT.
Physical Therapy (APTA Pediatrics) set standards for the
identification, referral, and physical therapy management of in-
The Scope of the Guideline
fants with CMT. Implementing the 2013 CMT CPG1 recommen-
dations not only improved outcomes3 but also led to research to The 2024 CMT CPG is based on the 2018 CMT CPG,2
align documentation with the best practice recommendations,4 a systematic review of literature from January 2017 through
develop a clinical decision algorithm,5 and provide guidance for June 2022,11 and critical appraisals of the literature published
intervention and follow-up.6 from June 2022 through June 2023. It is assumed throughout
Current conventions are to update CPGs every 5 years. The the document that the PT has newborn and early childhood
2013 CMT CPG1 was updated by the 2018 CMT CPG2 to experience.
reflect current evidence. To support implementation of the The CPG addresses these aspects of CMT management for
2013 and 2018 CMT CPG,1,2 implementation resources were infants and toddlers:
developed by APTA Pediatrics7 and a state-of-the-art review for • Parent/Caregiver education to prevent or identify pos-
pediatricians was published.8 tural preference and the role of pediatric physical ther-
apy in its management.
• Diagnostic and referral processes.
Purpose of the 2024 Congenital Muscular Torticollis Clinical
• Importance of early assessment and referral of infants
Practice Guideline
with asymmetries/CMT to primary health care providers
The 2024 CMT CPG is intended as an updated reference and PTs.
document to guide PTs, families, health care professionals, • Reliable, valid, and clinically useful screening, examina-
and educators to improve clinical outcomes and health services tion, and evaluation procedures that should be
for children with CMT, as well as to inform the need for documented.
continued research related to the physical therapy management • Determination of a severity classification and prog-
of CMT. This document replaces the 2018 CMT CPG2 and nosis for physical therapy intervention and duration
2013 CMT CPG.1 of care.
Specifically, for infants (birth to 12 months) and toddlers • First-choice physical therapy intervention and evidence-
with CMT, the purposes of the 2024 CMT CPG are to: informed supplemental interventions.
• Conditions for referral to the infant’s primary care pro-
• Update the evidence and guidance for physical therapy
vider and/or specialist for consideration of additional
management of CMT to improve clinical outcomes and
tests and interventions.
health services for infants with CMT in the areas of:
• Criteria for discontinuation of direct physical therapy
education for prevention, screening, examination and
intervention, the importance of a reassessment, and cri-
evaluation including recommended outcome measures,
teria for discharge.
consultation with and referral to other health care pro-
• Important outcomes of intervention and infant and
viders, severity classification and prognosis, first-choice
family characteristics affecting outcomes.
and evidence-informed supplemental interventions, dis-
continuation from direct intervention, and reassessment
and discharge. Changes in the 2024 Congenital Muscular Torticollis Clinical
• Identify areas of knowledge translation necessary to im- Practice Guideline
plement and maintain compliance with best practices for The following changes to the 2018 CMT CPG were made in
physical therapy management of CMT within 4 groups: this 2024 CMT CPG:
(1) the general community focusing on expectant
parents/caregivers and parents/caregivers of infants; • One action statement was upgraded, revised, and
(2) health care and educational delivery systems that updated with new literature; 13 action statements

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 379

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Unauthorized reproduction of this article is prohibited.
 were revised for clarity and updated with new lit- Statement of Intent
erature; 1 action statement was revised for clarity; 1 This guideline is intended to inform clinicians, family mem-
action statement was updated with new literature; 1 bers, educators, researchers, policy makers, and payers. It is not
action statement was reaffirmed; and no action state- intended to serve as a legal standard of care. As rehabilitation
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ments were retired. knowledge expands, clinical guidelines are promoted as synth-
• Action Statement 3 was upgraded to a Grade
eses of current research and provisional proposals of recom-
A Strong Recommendation based on consistency of mended actions under specific conditions. Standards of care
results: (1) reevaluation of a cohort study that de- are determined based on all clinical data available for an indivi-
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monstrated a dose-response relationship of physical dual child and are subject to change as knowledge and technol-
therapy intervention with earlier intervention result- ogy advance, patterns of care evolve, and child/family values are
ing in improved outcomes and decreased treatment integrated. This CPG is a summary of practice recommendations
duration12; and (2) several cohort studies that con- that are supported with current published literature that has
sistently supported that earlier physical therapy in- been reviewed by parents/caregivers, health care providers, and
tervention for infants with CMT results in better academic program members. These parameters of practice
outcomes, 12-14 shorter episodes of care, 12 , 14 , 15 should be considered guidelines only, not mandates. Adherence
reduced need for surgical interventions,14,16,17 and to them will not ensure a successful outcome in every child, nor
reduced risk of secondary complications, such as should they be construed as including all proper methods of care
cervical spine dysmorphism 18 and mandibular or excluding other acceptable methods of care aimed at the same
asymmetry. 19 Demonstration of a dose-response results. The ultimate decision regarding a particular clinical
relationship is considered strong evidence for procedure or intervention plan must be made using the clinical
a causal relationship between the exposure and the data presented by the child/family, the diagnostic and interven-
outcome because increasing levels of exposure, in tion options available, the child and family’s values, expectations,
this case, earlier physical therapy intervention, is and preferences, and the clinician’s scope of practice and exper-
associated with an increasing chance of improved tise. Significant departures from accepted guidelines should be
outcome.20 documented in the child’s records at the time the relevant clinical
• Within Action Statement 13, the recommendation for
decisions are made; clinicians are strongly encouraged to publish
the use of cervical passive range of motion (PROM) if the clinical reasoning and results of alternative approaches.
PROM is limited was upgraded to Strong with a level
I RCT that supported that passive stretching was
more effective at improving passive cervical rotation METHODS
than thermotherapy or handling for active and active-
assisted movements,21 combined with a previous The GDG was approved by APTA Pediatrics to update the
level I RCT that demonstrated a dose-response rela- 2018 CMT CPG2 in accordance with Academy procedures. APTA
tionship of stretching with higher frequency of Pediatrics did not influence the content of the guideline, and there
stretching resulting in greater improvement in head was no external funding to support this revision of the guideline.
tilt and cervical passive rotation and lateral flexion The purpose, scope, and content outline builds on the 2013 CMT
range of motion (ROM).22 CPG1 survey; its content validity is further supported by evidence
• There are 3 revised and updated evidence tables: of the integration of recommendations into practice.6
Supplemental Digital Content 4 (Psychometric Prop-
erties of Assessment Tools Commonly Used in the
Management of Congenital Muscular Torticollis), Search Strategy
Supplemental Digital Content 5 (Randomized Con- This CPG update is based on a systematic review (Janu-
trolled Trials of the First-Choice Physical Therapy ary 2017-June 2022) of the physical therapy evidence for
Intervention for Infants with Congenital Muscular diagnosis, prognosis, and intervention of CMT to inform the
Torticollis), and Supplemental Digital Content 6 2024 CMT CPG.11 Refer to Castilla et al11 for details of the
(Randomized Controlled Trials of Evidence-In- search strategy, study selection, study appraisal, data extrac-
formed Supplemental Interventions for Infants with tion, and results for the 15 included studies; 4 studies informed
Congenital Muscular Torticollis; all available at: physical therapy assessment for infants with CMT, 5 studies
http://links.lww.com/PPT/A545). One evidence table informed prognosis, and 6 studies informed intervention.
was reaffirmed, Supplemental Digital Content 7 To ensure that the updated CMT CPG used the most
(Studies on Long-Term Outcomes of Congenital current evidence, a comprehensive search of 5 databases (CI-
Muscular Torticollis, available at: http://links.lww. NAHL, Cochrane Library, PsycInfo, PubMed, and Web of
com/PPT/A545). Science) was completed from June 2022 to June 2023 by an

380 Sargent et al Pediatric Physical Therapy

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 information services librarian using the same search as the practice changes, and the reported impact of the 2013 and
Castilla et al, 2023 systematic review.11 The search resulted in 2018 CMT CPGs.1,2
433 studies.
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Selection Criteria External Review Process

Studies meeting the following 2 criteria were added to External review is consistent with the IOM’s recommenda-
those from the 2018 CMT CPG2 and the 2023 systematic tions for trustworthy guidelines.9 The purposes are to ensure
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review11: participants included infants and children diagnosed clarity, quality, and comprehensiveness of the CPG and to iden-
with CMT and studies informed the physical therapy manage- tify potential bias, lapses in logic or alternative perspectives.
ment of CMT. All study designs were included. Studies were A first draft of the 2024 CMT CPG was reviewed by 2 parents/
excluded on 4 criteria: only focused on plagiocephaly, disserta- caregivers of infants with CMT and 10 professionals representing
tions, and abstracts, published in a language other than English CPG methodology, lactation specialists, midwifery, pediatric
when an adequate English translation could not be obtained, medicine, pediatric nursing, pediatric surgery, and physical ther-
and no statistical analysis of results. apy practice, research, and knowledge translation. Both a rating
scale to assess the clarity and implementation feasibility of the 17
action statements and an open-ended invitation for comments
Study Appraisal and Data Extraction and edits were used to gather feedback.
After addressing the first round of suggested edits, the
Of the 433 studies, 1 newer study informed the man-
rating scale of the 17 action statements and a second draft of
agement of CMT. This retrospective study compared
the 2024 CMT CPG was posted for public review on the APTA
stretching and stretching preceded by traditional Chinese
Pediatrics website; invitations to review were distributed to
massage23 and was appraised using the Risk of Bias in
APTA Pediatrics members via its electronic newsletters,
Non-randomized Studies—of Interventions assessment
a social media posting, and direct email notices to volunteers.
tool.24 Two reviewers independently appraised the study,
Non-members could review if notified by APTA Pediatrics
scores were compared for agreement, and discrepancies
members. During the public review, the 2024 CMT CPG
were resolved via discussion. In addition, the study was
was reviewed by 55 PTs, 1 parent, and 1 other health care
assigned a level of evidence using criteria from Table 1.
professional.
Levels of evidence range from level I, as the highest, to
To assess the clarity and implementation feasibility of
level V, as the lowest.
the 17 action statements without the additional information
Data were extracted to maintain consistency with the 2018
provided in the 2024 CMT CPG, both groups of reviewers
CMT CPG2 and the 2023 CMT systematic review.11 Evidence
were asked to rate the action statements on a 3-point scale
tables that were revised and updated with new evidence as
for clarity (clear, somewhat clear, not clear) and feasibility
follows: Supplemental Digital Content 4 (Psychometric Proper-
(feasible, somewhat feasible, not feasible) before reviewing
ties of Assessment Tools Commonly used in the Management of
the entire 2024 CMT CPG. Of the 17 action statements,
CMT), Supplemental Digital Content 5 (Randomized Controlled
94% were rated as clear and 71% as feasible by at least 75%
Trials of the First-Choice Intervention for Infants with CMT),
of reviewers. Suggested edits were addressed, and the final
and Supplemental Digital Content 6 (Randomized Controlled
draft was submitted to Pediatric Physical Therapy for editor-
Trials of Evidence-informed Supplemental Interventions for In-
ial review.
fants with CMT). Supplemental Digital Content 7 (Studies of
Long-Term Outcomes of Congenital Muscular Torticollis) was Appraisal of Guidelines for Research & Evaluation (AGREE) II
reaffirmed. All supplemental content available at: http://links. Review
lww.com/PPT/A545. Strengths and limitations of the evidence
The 2024 CMT CPG was evaluated by 2 external reviewers
are included in the Aggregate Evidence Quality and Supporting
using AGREE II.25 Domain scores for the 2024 CMT CPG
Evidence and Clinical Interpretation section of each action
ranged from 92% to 100%. The reviewers unanimously agreed
statement.
to recommend the guideline for continued use.

Recommendation Formulation
Each 2018 recommendation was evaluated for its currency Plan for Revision
and consistency with the updated literature. The decision to Per current standards, this CPG will be reviewed for po-
develop a new recommendation or reaffirm, revise, upgrade, or tential updates or reaffirmation within 5 years as the body of
retire an existing recommendation was informed by the evi- evidence expands. The guideline revision will be organized by
dence, the GDG’s clinical and professional experience, trends in Barbara Sargent, PT, PhD, PCS.

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 381

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 Language infants achieving good outcomes.12 Infants with CMT and
The 2013 CMT CPG and 2018 CMT CPG are referenced an SCM mass typically are identified earlier but may have
the first time they appear and are used without reference here- longer episodes of care.14,32,33
after. In contrast, this document is referred to as the 2024 CMT Infants diagnosed with CMT are not expected to sponta-
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CPG. Additionally, the generic phrase “primary care provider” neously resolve or resolve with 1-2 sessions of parent/caregiver
is used to reference pediatricians, physicians (MD or DO), training on neck stretching; therefore, immediate referral to
advanced practice nurses, physician assistants, or other primary physical therapy is recommended for optimal outcomes.8 Phy-
health care providers. A list of International Classification of sical therapy management of CMT is comprehensive and
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Functioning, Disability, and Health (ICF) and International addresses these 5 components as the first-choice intervention:
Classification of Diseases, tenth revision, codes and a glossary (1) neck PROM if PROM is limited; (2) neck and trunk active
of terms are provided in Supplemental Digital Content 8 and 9, range of motion (AROM); (3) development of symmetrical
available at: https://links.lww.com/PPT/A545. movement; (4) environmental adaptations; and (5) parent/care-
giver education.
Physical therapy intervention for infants with CMT is
CONGENITAL MUSCULAR TORTICOLLIS highly effective when provided in early infancy, so early re-
ferral and initiation of physical therapy intervention is recom-
mended to improve clinical outcomes, shorten episodes of
Incidence and Evaluation of Congenital Muscular Torticollis care, reduce burden on families, and decrease cost of care
CMT is a condition evident shortly after birth, affecting for infants with CMT.8
3.9%26 to 16%27 of newborns. It is typically characterized
by cervical lateral flexion to one side and cervical rotation to
the opposite side due to unilateral shortening or muscle
ACTION STATEMENTS
imbalance of the SCM muscles, with or without an SCM
mass. An SCM mass is a benign fibrotic mass or enlarge-
ment of the SCM and is synonymous with fibromatosis colli I. EDUCATION, IDENTIFICATION AND REFERRAL OF
or tumor.28 INFANTS WITH ASYMMETRIES/CONGENITAL MUSCULAR
A comprehensive physical therapy examination and eva- TORTICOLLIS (CMT)
luation is essential as CMT may co-occur with other medical
P Action Statement 1: EDUCATE EXPECTANT OR NEW
conditions, such as craniofacial asymmetry,29 and up to 18% of
cases of asymmetrical head and neck posturing may be due to
PARENTS/CAREGIVERS OF NEWBORN INFANTS TO PREVENT
nonmuscular causes, eg, cerebral palsy, visual impairments,
ASYMMETRIES/CMT. Health care providers (eg, prenatal educa-
tors, physicians, midwives, obstetrical or other nurses, lactation
scoliosis, gastroesophageal reflux disorder (GERD), and acute
specialists, or PTs) should educate and document instruction to
respiratory distress that require referrals to other health care
all expectant or new parents/caregivers of infants before or within
professionals.30,31
the first 2 to 3 days of life on the importance of supervised prone/
tummy play 2 or 3 times daily when the infant is awake, full active
movement throughout the body, prevention of postural prefer-
Importance of Early Referral
ences, and the role of pediatric PTs in the comprehensive manage-
The evidence is strong that earlier physical therapy ment of postural preference and optimizing motor development if
intervention results in better outcomes,12-14 shorter epi- concerns are noted.
sodes of care, 12 , 14 , 15 reduced need for surgical (Evidence Quality: V; Recommendation Strength: Best
interventions,14,16,17 and reduced risk of secondary com- Practice)
plications, such as cervical spine dysmorphism18 and man-
dibular asymmetry.19 Petronic et al found that if started Action Statement Profile
before 1 month of age, 98.6% of infants with CMT achieve Aggregate Evidence Quality: Level V based on clinical
good outcomes (no head tilt, >100° passive cervical rota- experience of the GDG.
tion, >65° passive cervical lateral flexion) with an average Benefits:
treatment duration of 1.5 months; waiting until 1 to • Increases parent/caregiver self-efficacy in caring for their
3 months of age prolongs the treatment duration to infant.
5.9 months with 89% of infants achieving good outcomes; • Informs parents/caregivers on the importance of super-
waiting until 3 to 6 months prolongs the treatment dura- vised tummy time to optimize motor development
tion to 7.2 months with 62% of infants achieving good within the first 6 months.
outcomes; and waiting until after 6 months of age prolongs • Informs parents/caregivers about the role of pediatric
the treatment duration to 9.8 months with only 19% of PTs in providing a comprehensive and supportive plan

382 Sargent et al Pediatric Physical Therapy

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Unauthorized reproduction of this article is prohibited.
 of care to manage postural preference associated with Risk, Harm, and Cost:
CMT and cranial deformation (CD). • May increase parent/caregiver anxiety about the potential
• Teaches parents/caregivers to initiate early surveillance for CMT and CD.
for postural preference and to bring concerns to the • May marginally increase the cost of care if perinatal care
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infant’s primary care provider or, in states with direct providers and educators do not incorporate education
access, to a pediatric PT. into usual care and it requires a separate child
• May reduce the episode of care and improve outcomes if encounter.
postural preference is identified and comprehensively • May increase the time needed to spend with a newborn
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managed early. and parents/caregivers during health care encounters.

Fig. 1. Referral flow diagram.

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 383

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 Benefit-Harm Assessment: Preponderance of benefit. development, and (e) ways to access the CMT CPG
Value Judgments: A preponderance of evidence supports implementation resources.7
that early identification of postural preference and CMT results • PTs should collaborate with policymakers, administra-
in shorter episodes of care and more complete resolution of tors, and health care providers in their clinical settings to
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asymmetries. The GDG feels that if parents/caregivers know develop pathways for parent/caregiver education on
how to monitor their newborn during the first months of life, CMT to ensure that education is provided both before
how to encourage tummy time during awake periods, and are and within the first 2 to 3 days of life.
empowered to report their concerns to their primary care provi- • Audits of education provided to expectant parents/care-
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der, that asymmetries could be reduced more quickly or even givers and parents/caregivers of newborns may indicate if
prevented. patterns of education are changing.
Intentional Vagueness: Prone positioning for supervised
play up to 2 to 3 times a day is the recommendation for newborns
because the amount of time awake is limited, though the need to Supporting Evidence and Clinical Interpretation
start prone positioning right away for short periods should be
Early and frequent parent/caregiver education to monitor
reinforced. As time awake increases, infants should be placed for
for asymmetry, the importance of “prone for play” or “tummy
supervised prone play as often as tolerated and practical.
time”, and the recommendation for “supine or back to sleep”
Role of Child/Parent/Caregiver Preferences: Due to the
may help to reduce or prevent asymmetries from developing,
amount of information that parents/caregivers of infants receive
during the first days of parenthood, they may benefit from particularly when postural preferences are apparent. Daily
multiple educational opportunities before and after the infant’s supervised awake prone time is widely recommended starting
arrival. Parents/caregivers may prefer receiving instruction at birth for 2 to 3 times daily for 3 to 5 minutes, gradually
using different modes of delivery (by video or brochure), by working toward 15 to 30 minutes daily by 7 weeks of age, and
different health care providers (with those they already have at least 30 minutes daily by 6 months of age.35,36 Supervised
a relationship with or as part of prenatal care), or at different awake prone time has been positively associated with gross
phases in their pre- to post-natal experience. motor and global development, prevention of brachycephaly,
Exclusions: None. and the ability to move while prone, supine, crawling, and
Quality Improvement: walking.37,38
• Pre- and post-natal education for parents/caregivers on The American Academy of Pediatrics’ policy on surveillance
postural preference and the benefits of early intervention for developmental disorders is to “elicit and attend to parents’
may shorten the episode of care or improve outcomes if an concerns about their child’s development”39 although this does
infant is diagnosed and referred to physical therapy early. not universally happen.40 Thus, parents/caregivers should be
This is especially true for parents/caregivers of multiples, educated on early surveillance of symmetry and positioning.
whose infants may be at greater risk than singletons for A mixed methods study determined that 90% of mothers
CD, which may lead to postural preference.34 are educated about infant supine sleeping positions, but
instruction on awake prone play or rotating prone and
Implementation and Audit: supine was only received by 27% of mothers postpartum,
• PTs need to engage in knowledge-translation outreach, and 2 months later, only 8% of mothers used prone posi-
including distributing the CMT CPG implementation tioning during awake time, with 70% positioning only 1-2
resources,3 to ensure that expectant parents/caregivers, times per day.41 The success of the Back to Sleep/Safe Sleep
parents/caregivers of newborns, and health profes- campaign42 has demonstrably reduced cases of sudden
sionals, including but not limited to primary care and unexpected infant death, including sudden infant
providers, prenatal educators, physicians, midwives, ob- death syndrome; however, many ascribe parent/caregiver
stetrical or other nurses, lactation specialists, nurse adherence to supine positioning, and concomitant avoid-
practitioners, physician assistants, doulas, and early in- ance of prone positioning for infant play, as a contributing
tervention providers, have an accurate understanding of: factor to an increase in CMT.
(a) screening for postural preference in all infants, (b)
Research Recommendation: Studies are needed on the
ways to prevent or minimize postural preference through
impact of education on:
positioning and handling, (c) the importance of early
referral to a primary care provider and pediatric PT if • Health care providers and their knowledge of pediatric
postural preference is noted or CMT is suspected, (d) the PTs’ roles in managing postural preference.
role of physical therapy in the comprehensive manage- • Parents/caregivers about the experience of receiving this
ment of postural preference and optimizing motor education.

384 Sargent et al Pediatric Physical Therapy

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
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 A Action Statement 2: ASSESS NEWBORN INFANTS FOR • Early examination can detect asymmetries and support
ASYMMETRIES/CMT. Health care providers (eg, prenatal educa- earlier referral to PTs who can provide comprehensive
tors, physicians, midwives, obstetrical or other nurses, lactation intervention and follow-up.
specialists, or PTs) and parents/caregivers must assess and docu-
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ment the presence of neck and/or facial or cranial asymmetry Implementation and Audit:
within the first 2 to 3 days of life, using passive cervical ROM • PTs should share the CMT CPG and the APTA Pediatrics
and/or visual observation as their respective training or experi- CMT CPG implementation resources7 with other health
ence supports. care providers in their geographic area, highlighting this
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(Evidence Quality: I, Recommendation Strength: Strong) recommendation and the importance of early cervical
ROM screening.
Action Statement Profile • Develop clinical pathways for health professionals who
Aggregate Evidence Quality: Level I based on the odds see infants at birth ensure that cervical ROM assessment
ratio (OR) for prediction of CMT from facial asymmetry (OR occurs within the first 2 to 3 days of life.
21.75; 95% confidence interval [CI], 6.60-71.70) and plagioce- • Documentation forms or electronic records may need
phaly (OR 23.30; 95% CI, 7.01-70.95)43 and cohort studies that revision to include the documentation of cervical ROM
consistently support that starting intervention before 4-6 weeks and postural symmetry screens.
of age yields greater reductions in SCM thickness, improved • Audits of newborn charts may indicate if patterns of
outcomes, shorter episodes of care, and reduced need for surgical examination are changing.
intervention, compared to starting after 4-6 weeks.12-14
Benefits:
• Early identification of infants at risk for CMT or other Supporting Evidence and Clinical Interpretation
conditions that may cause asymmetries. This action statement intends to increase the early identifica-
• Early onset of intervention for infants with CMT if referred. tion of infants with CMT for early referral to physical therapy. The
• Reduced episode of care to resolve CMT, with conse- American Academy of Pediatrics policy on surveillance states that
quent reduction in costs. primary care providers should provide developmental surveillance
• Reduced risk of needing more invasive interventions for all infants at every well-child preventative care visit from birth
(botulinum neurotoxin therapy or surgery) in the future. and throughout the first 6 months39; thus, infants with identified
postural asymmetries are referred immediately for physical therapy
Risk, Harm, and Cost: intervention.8 During the first neonatal exam,44 infants can be
• Potential of overidentification of infants may increase easily screened by assessing for full neck rotation (chin turns
costs. past shoulder to 100°)27 and lateral cervical flexion (ear approx-
• Potential of increasing parent/caregiver anxiety. imates shoulder)27 while stabilized in supine.45
Newborns are at higher risk for CMT if their birth
Benefit-Harm Assessment: Preponderance of benefit. history includes a combination of longer body length, pri-
Value Judgments: None. miparity, maternal perineal trauma during delivery, facial
Intentional Vagueness: Assessment of neck and/or facial asymmetry, and plagiocephaly.43 Infants with cranial and/or
or cranial asymmetry is recommended within the first 2 to facial asymmetries have a 22-fold increase in abnormal
3 days of life to allow for variations in birth settings, eg, sonogram for CMT; primiparity a 6-fold increase; maternal
hospitals, out-of-hospital birth centers, or homes. perineal trauma during delivery a 4-fold increase; and body
Role of Child/Parent/Caregiver Preferences: While par- length a 2-fold increase.43 Additionally, infants with
ents/caregivers may not be skilled in formal infant assessment, a history of neonatal abstinence syndrome (NAS) who re-
they are keen observers of their own child. Parents/caregivers may quire medication have a higher incidence of CMT than
notice that their infant has greater difficulty eating on one side, or infants without NAS.46 No single characteristic predicts
they may notice asymmetry in photographs. These observations CMT alone but the presence of 2 or more of the above
should trigger ROM screening by a health care professional. risk factors warrants referral for preventative care and par-
Exclusions: None. ent/caregiver education.
Quality Improvement: The diagram shown in Figure 1 (Supplemental Digital Content
• Documentation of an assessment for postural symme- 1, available at: http://links.lww.com/PPT/A546) outlines the possi-
try and cervical ROM, including baseline measure- ble screening, referral, and communication pathways based on
ments, provides uniform data for more effective time of observation, identification of nonmuscular causes of asym-
communication among clinicians and settings, for metry, prior models, and current literature.30,31,47-49
monitoring progress, and for uniform data entry in The referral flow diagram has 2 distinct time frames: Birth
child registries. to 2 to 3 days, representing the newborn period, and

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 385

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 throughout infancy, representing the typical time after dis- Benefits:
charge to home. During the newborn period, many different • Early differential diagnosis to determine that the postural
health care providers may observe the infant because they are asymmetry is due to CMT vs another medical condition,
involved in the birth and/or postnatal care. These health care such as a visual impairment or reflux.
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providers are in the ideal position to observe the symmetry of • Earlier intervention to resolve limited ROM and asym-
the head on the shoulders and screen for passive and active metries more quickly.
movement limitations. After the infant is at home, the most • Early parent/caregiver education to facilitate symmetrical
likely observers will be the primary care provider and parents/ development and self-efficacy with home programs.
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caregivers, who may document persistent asymmetries with • Greater infant tolerance with intervention in the first few
photos. Regardless of who performs the initial screen, infants months of life.
with asymmetry should undergo an evaluation by their primary
care provider to rule out nonmuscular causes of CMT. If CMT Risk, Harm, and Cost:
or a persistent postural preference is diagnosed, the infant • Increased cost of treating asymmetries at later ages when
should be immediately referred to a pediatric PT. CMT is assumed to spontaneously resolve without
Research Recommendation: Studies are needed to intervention.
determine:
Benefit-Harm Assessment: Preponderance of benefit.
• whether routine screening during the first 2 to 3 days of
Value Judgments: Early referral to physical therapy en-
life increases the rate of CMT identification and/or in- sures early onset of intervention, which strongly correlates with
creases false positives. improved outcomes, shorter episodes of care, and, as a result,
• the barriers to early referral of infants with CMT to can lower overall costs of care. A pediatric PT also screens and
physical therapy. monitors the infant for developmental delays, eating issues, and
environmental factors that may be associated with or contribute
A Action Statement 3: REFER INFANTS WITH ASYMMETRIES/ to postural preference or CMT.
CMT TO THEIR PRIMARY CARE PROVIDER AND A PHYSICAL Intentional Vagueness: For infants suspected of other
THERAPIST. Health care providers (eg, physicians, midwives, causes of asymmetries, eg, bony anomalies, fractures, neurolo-
obstetrical or other nurses, lactation specialists, or PTs) and gical conditions, or extra-muscular masses, PTs should colla-
parents/caregivers should refer infants identified as having borate with the infant’s primary care provider and appropriate
postural preference, reduced cervical ROM, an SCM mass, specialists to determine when to initiate physical therapy inter-
and/or craniofacial asymmetry to their primary care provider, vention. The focus and prioritization of interventions may
and a PT with expertise in infants as soon as the asymmetry is change depending on the type of limitations the infant presents
noted. (Evidence Quality: I, Recommendation Strength: with (eg, neurological, musculoskeletal, cardiopulmonary, in-
Strong) tegumentary, and/or gastrointestinal).
Role of Child/Parent/Caregiver Preferences: Infant tol-
erance with stretching is easier in the first 2 months than when
Action Statement Profile started after the infant develops greater head control50,51; thus,
Aggregate Evidence Quality: Recommendation upgraded infant cooperation is greater, and parent/caregiver adherence to
to Strong based on consistency of results: (1) reevaluation of home programs may be optimized. Later referrals put addi-
a cohort study that demonstrated a dose-response relationship tional stress on parents/caregivers to adhere to stretching
of physical therapy intervention with earlier intervention result- recommendations.
ing in improved outcomes and decreased treatment duration12; Exclusions: Infants suspected of having nonmuscular condi-
and (2) several cohort studies that consistently support that ear- tions that might cause asymmetrical or torticollis posturing should
lier intervention results in better outcomes,12-14 shorter episodes be fully examined by the appropriate specialists to rule out con-
of care,12,14,15 reduced need for surgical interventions,14,16,17 founding medical conditions prior to initiating physical therapy.
and reduced risk of secondary complications, such as cervical Quality Improvement:
spine dysmorphism18 and mandibular asymmetry.19 Demonstra- • This recommendation will reduce delays in referrals to
tion of a dose-response relationship is considered strong evidence PTs who can provide a comprehensive plan of interven-
for a causal relationship between the exposure and the outcome20 tion and follow-up to ensure that the primary caregivers
because increasing levels of exposure, in this case, earlier physical can adhere to the recommended interventions.
therapy intervention, is associated with an increasing chance of
Implementation and Audit:
improved outcome. In addition, stretching interventions are ea-
• Training for health professionals and early intervention
sier for parents/caregivers to administer when infants are younger
providers who see infants in early infancy may be needed
and more tolerant of stretching.12,50

386 Sargent et al Pediatric Physical Therapy

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
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 to ensure that infants are appropriately and quickly surgical intervention,14,16,17 and reduced risk of secondary
referred to physical therapy. Health professionals may complications, such as cervical spine dysmorphism18 and
be reluctant to refer right away if they perceive parents/ mandibular asymmetry.19 Petronic et al found that when
caregivers as being overburdened during those early intervention was initiated before 1 month of age, 99% of
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weeks; however, earlier referral translates to better infants with CMT achieved good clinical outcomes (no head
outcomes. tilt, full passive cervical rotation, and lateral flexion ROM)
• Audits of the age at which parents/caregivers first notice with an average treatment duration of 1.5 months, but if
the CMT, the date of referral, and the age of the first initiated between 1 and 3 months of age, only 89% of infants
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physical therapy examination will provide objective achieved good outcomes with an average treatment duration
measures of delays between identification and referral of 6 months.12 When initiated between 3 and 6 months of
to physical therapy and delays between referrals and the age, 62% of infants achieved good outcomes with an average
first scheduled physical therapy examination. treatment duration of 7 months.12 When initiated between 6
• PTs should share the 2024 CMT CPG and/or the APTA and 12 months of age, 19% of infants achieved good out-
Pediatrics CMT CPG implementation resources7 with comes with an average treatment duration of 9 months.12
primary care providers, early intervention providers, This research supports a dose-response relationship 20 of
and other referral sources in their geographic area, physical therapy intervention with earlier intervention re-
highlighting this recommendation and the supporting sulting in improved outcomes and decreased treatment
evidence for early referral. duration.12
• Clinical pathways for examination and referral processes In contrast to recommendations to provide stretching in-
may reduce delays in the onset of physical therapy ser- struction to the parents/caregivers when CMT is identified at
vices by prioritizing infants with asymmetry/CMT for birth, and only refer to physical therapy at 2 months of age if
physical therapy examinations. PTs may need to colla- the condition does not resolve,52 early physical therapy reduces
borate with administrators and nonmedical professionals the time to resolution compared to parent-only stretching,57
infants become more difficult to stretch as they age and develop
to ensure that these infants receive immediate referrals,
neck control,50 and earlier intervention can negate the need for
either internally or through external referrals.
later surgery.14,16,17
PTs address a broad range of developmental and environ-
mental factors that influence outcomes, such as parent/caregiver
Supporting Evidence and Clinical Interpretation ability to perform or adapt the home exercise programs, trans-
Clinicians involved with the delivery and care of infants are portation distance from the clinical setting,58 eating positions,59
in the ideal position to assess the presence of CMT. If screening and the infant’s motor and developmental progression.58,60
for CMT occurs routinely within the first 2 to 3 days of life, Since developmental delays are detectable at 2 months in infants
newborns who are at high risk for CMT, or who have identified with CMT,61 and the delays may be inversely related to time
SCM tightness or masses, can have physical therapy initiated spent in the prone position,61 instruction to parents/caregivers
when the infant is most tolerant of interventions. CMT may not and early modeling of prone play time may help negate potential
appear until several weeks after birth; thus, the 1-month well- developmental delays that can occur with CMT.37,62
child visit with the primary care provider may be the first point Research Recommendations:
of identification. Using multivariate analysis with stepwise lo- • Studies are needed to clarify the predictive baseline
gistic regression, Cheng et al found that infants with CMT older measures and characteristics of infants who benefit
than 1 month of age at presentation to the clinic demonstrated from immediate follow-up and to compare the cost-
longer treatment durations, worse overall outcome scores, and benefit of early physical therapy intervention and educa-
increased need for surgical management.14 tion as compared to parent/caregiver instruction and
Early intervention for infants with CMT, initiated before 3 monitoring by primary care providers.
to 4 months of age, results in excellent outcomes with 92% to • Longitudinal studies of infants with CMT would clarify how
100% achieving full neck rotation PROM and 0 to 1% requiring referral timing and intervention initiation impact body
surgical intervention,12,16,52,53 compared to only 75% achiev- structures and functional outcomes, and overall care costs.
ing full resolution after 3 to 4 months of age. Yet, 3 retro-
spective studies54-56 of infants with CMT managed from 2014 II. PHYSICAL THERAPY EXAMINATION AND EVALUATION
to 2018 found that the average age at initial physical therapy OF INFANTS WITH ASYMMETRIES/CMT
examination ranged from 3.2 (SD 1.6)55 to 3.5 (SD 2.1)54
months of age. B Action Statement 4: DOCUMENT INFANT HISTORY. Prior
Earlier intervention results in better outcomes, 12-14 to initial screening, PTs should obtain and document a general
shorter duration of intervention,12,14,15 reduced need for medical and developmental history of the infant, including

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 387

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 6 specific health history factors: chronological and corrected • Pregnancy and birth history, including obstetric
age, age of onset of symptoms, pregnancy and birth history, and neonatal complications.43,45,63 These may include:
head posture/preference, other known or suspected medical ○ maternal sense of whether the infant was “stuck” in
conditions, and developmental milestones. one position during the final 6 weeks of pregnancy,45
63
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(Evidence Quality: II-IV, Recommendation Strength: ○ breech presentation,

Moderate) ○ operative delivery (ie, forceps or vacuum-assisted
delivery),43
63
○ low birth weight.
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Action Statement Profile • Head posture/preference27,64-66 and asymmetries of the

Aggregate Evidence Quality: Level II-IV based on cohort head or face.27,29
and outcome studies. • Other known or suspected congenital, developmental, or
Benefits: medical conditions.30,31,66-68
• A complete history of the pregnancy, birth, known medical • Developmental milestones.61,69,70
conditions, developmental milestones, and daily manage-
ment of the infant can provide information important to the Research Recommendation: Studies are needed to
physical therapy diagnosis, prognosis, and intervention. clarify how the health history screening influences CMT
identification, physical therapy diagnosis, prognosis, and
Risk, Harm, and Cost: None. intervention.
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments: None. B Action Statement 5: SCREEN INFANTS FOR NONMUSCU-
Intentional Vagueness: None. LAR CAUSES OF ASYMMETRY AND CONDITIONS ASSOCIATED
Role of Child/Parent/Caregiver Preferences: Parents/ WITH CMT. When infants present with or without primary care
caregivers can provide the history through interview and pread- provider referral, and a professional or parent/caregiver indi-
mission information packets. Medical records may also be used. cates concern about head or neck posture and/or developmen-
Exclusions: None. tal progression, PTs should perform and document a review of
Quality Improvement: the neurological, musculoskeletal, integumentary, and cardio-
• Documentation of the 6 specific health history factors pulmonary systems, including screens of vision, gastrointest-
provides uniform data for more effective communication inal history, postural preference, and the structural and
among clinicians and settings and for uniform data entry movement symmetry of the neck, face and head, trunk, hips,
in child registries. upper and lower extremities, consistent with state practice acts.
(Evidence Quality: II-IV, Recommendation Strength:
Implementation and Audit: Moderate)
• Create parent/caregiver intake forms that are completed
prior to the initial examination to assist with collecting
the 6 items. Action Statement Profile
• Documentation forms or electronic records may need
revision to include documentation of the 6 specific Aggregate Evidence Quality: Level II-IV based on cohort
health history factors. and outcome studies and expert clinical consensus.
• Audit the completeness of history documentation. Benefits:
• Comprehensive screening can identify asymmetries and
determine their consistency with CMT.
Supporting Evidence and Clinical Interpretation • Screening for other causes of asymmetry (eg, cerebral
palsy, craniofacial asymmetries, visual impairments, sco-
In addition to documenting the standard intake informa- liosis, GERD, acute respiratory distress) facilitates refer-
tion (eg, date of birth, date of examination, sex, birth rank or ral to specialists.
order, reason for referral, parent/caregiver concerns, general • For infants treated for other conditions associated with
health of the infant, and the infant’s other health care provi- higher risks for developing CMT (ie, brachial plexus
ders), the PT should specifically document the following 6 birth injuries, developmental dysplasia of the hip [DDH],
and health history factors. and GERD), parents/caregivers can receive preventative
• Chronological age (and corrected age if the infant was instruction for CMT.
born preterm) at the initial visit.13,60 • In states where PTs may screen and/or treat without
• Age of onset of symptoms,29,60 which may be aided by primary care provider referral, infants may receive
early photographs. services more quickly.

388 Sargent et al Pediatric Physical Therapy

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 Risk, Harm, and Cost: • History: per parent/caregiver report as described in Ac-
• The cost of a physical therapy screening if the infant is tion Statement 4.
not already being treated for other conditions. • Systems Review: Per the APTA Guide to Physical Thera-
• The risk that PTs without infant experience may miss or pist Practice 4.0,71 a systems review traditionally exam-
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misidentify nonmuscular causes of asymmetry. ines the following 6 domains and for infants with CMT,
a gastrointestinal history should be added as the seventh.
Benefit-Harm Assessment: Preponderance of benefit. • Musculoskeletal System: Screen for the symmetrical
Value Judgments: In some geographic locations or prac- shape of the face, skull, and spine72,73; symmetrical
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tice settings, particularly where direct access to physical alignment of the shoulder and hip girdles74 with parti-
therapy is permitted, PTs may be the first to screen an infant cular attention to cervical vertebral anomalies, rib cage
for postural asymmetries. Infants may present for reasons symmetry,47 and DDH74; symmetrical PROM and
other than head or neck postures, but observing overall AROM of the neck; and palpation for an SCM mass or
symmetry is an element of a thorough physical therapy tight cervical musculature.75
systems review. • Neurological System: Screen for abnormal or asymme-
Intentional Vagueness: None. trical tone or spasticity; cranial nerve integrity; brachial
Role of Child/Parent/Caregiver Preferences: None. plexus injury; temperament (irritability, alertness); sym-
Exclusions: None. metrical movement; and achievement of age-appropriate
Quality Improvement: developmental milestones.30,31,47,66,69,75 Perform
• Documentation of the neurological, musculoskeletal, in- a visual screen composed of symmetrical eye position
tegumentary, cardiopulmonary, and gastrointestinal sys- in midline and symmetrical eye tracking in all directions,
tem reviews provides uniform data for more effective noting visual field defects and nystagmus as potential
communication among clinicians and settings and for ocular causes of asymmetrical postures.76
uniform data entry in child registries. • Integumentary System: Screen for skin fold symmetry of
• Systematic screening ensures that nonmuscular the hips45,66 and cervical regions77; color and condition
causes of asymmetry or associated conditions are of the skin, with special attention to signs of pressure and
ruled out or that timely referral for additional testing trauma that might cause asymmetrical posturing.66
occurs.
• Cardiopulmonary System: Screen for symmetrical
coloration, rib cage expansion, and clavicle movement
Implementation and Audit:
• Documentation forms or electronic records may need to rule out conditions that might cause asymmetrical
posturing (eg, brachial plexus injuries and Grisel’s
revision to reflect the data collected from the screens.
• Clinicians may require training to enhance consistency syndrome)66,68; screen for acute respiratory distress.78,79
and reliability of system reviews. The infant should be alert and appropriately vocal, with-
• Audit the incidences in which system reviews are posi- out wheezing.
• Communication: Screen for facial expressions when
tive for nonmuscular causes of CMT or potential asso-
ciated conditions. vocalizing or crying, general alertness and behavioral
responses, and receptivity to caregiver or clinician
vocalizations.71
• Movement: Observe for symmetrical and full AROM or
Supporting Evidence and Clinical Interpretation preferential patterns in supine, prone, and while held by
It is within the scope of physical therapy practice to perform the caregiver.71
a systems review for nonmuscular causes of CMT in the neuro- • Gastrointestinal System: Interview the parents/care-
muscular, musculoskeletal, cardiopulmonary, and integumen- givers for an infant history of GERD80,81 or difficult or
tary systems, including screening for visual impairments, preferential eating from one side64; both can contribute
GERD, and developmental delay.71 The systems review is to asymmetrical posturing.
performed to rule out nonmuscular causes of asymmetrical Research Recommendation: Studies are needed to iden-
posturing30,31,66 and to determine whether the PT should tify the precision of screening procedures specific to CMT.
refer to or consult with the infant’s primary care provider
immediately or continue with a detailed examination for B Action Statement 6: REFER INFANTS FROM PHYSICAL
CMT. The systems review is conducted through parent’s/care- THERAPIST TO PRIMARY CARE PROVIDER IF INDICATED BY
giver’s report and observation of the infant in different posi- SYSTEMS REVIEW. PTs should document consultation with or
tions. Elements of the systems review to document include the referral of infants to their primary care providers for additional
following: diagnostic testing when a systems review identifies: nonmuscular

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 389

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
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 causes of asymmetry (eg, poor visual tracking, spinal conditions, professional judgment to determine if they should refer to or
abnormal muscle tone, extra-muscular masses, and GERD); asso- consult with the infant’s primary care provider immediately if any
ciated conditions (eg, craniofacial asymmetry); asymmetries incon- of the aforementioned conditions are present or continue with
sistent with CMT (eg, head lateral flexion and rotation to the same a detailed examination for CMT. If the PT continues with the
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side, or the side of torticollis changes); changes in the infant’s color evaluation, the PT should consult with the infant’s primary care
during screening of neck PROM; history of acute torticollis; history provider when any of the conditions are present to assure that the
of late-onset torticollis at 6 months or older; an SCM mass at primary care provider is aware of them and refer the infant to the
6 months or older, or an SCM mass that changes shape and primary care provider for further diagnostic testing when
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location or increases in size at any age; the infant is older than indicated.
12 months and either facial asymmetry and/or 10° to 15° of Role of Child/Parent/Caregiver Preferences: None.
difference exists in passive or active cervical rotation or lateral Exclusions: None.
flexion ROM. Quality Improvement:
(Evidence Quality: II, Recommendation Strength: Moderate) • Documentation of consultation with or referral to the
infant’s primary care provider when the PT suspects
a nonmuscular cause of the asymmetry or associated
Action Statement Profile medical conditions provides uniform data for commu-
Aggregate Evidence Quality: Level II based on cohort and nication across clinicians and settings and ensures an
outcome studies. accurate record of care.
Benefits:
• Infants with positive results from the systems review are Implementation and Audit:
identified and can be co-managed with the infant’s pri- • Consultations with or referrals to the primary care pro-
mary care provider and other specialists, eg, orthotists, vider should include the results of the review of systems
neurologists, or orthopedic surgeons. and a rationale for concerns underlying the consult or
• Early coordination of care may resolve CMT more referral.
quickly and with less cost, as well as initiate appropriate • Documentation forms or electronic records may need
intervention for conditions other than CMT. revision with indicators and rationales for consults and
• Parent/caregiver support starts earlier for effective home referrals.
programming, parent/caregiver education, and the bal- • Audit the incidences in which consults and referrals
ance of intervention with parent/caregiver needs to enjoy helped to identify nonmuscular causes of CMT and
and bond with their infant. associated conditions.

Risk, Harm, and Cost:

• Cost of care is increased in the cases when there is a false Supporting Evidence and Clinical Interpretation
positive from the review of systems. Up to 18% of cases with asymmetrical head posturing may
• Additional family stress due to concerns about the infant
be due to nonmuscular causes.30,31 The following are the basis
having more serious health conditions. for consultation with or referral to the infant’s primary care
provider or other specialists:
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments: Evidence demonstrates that earlier di- • Signs and symptoms consistent with nonmuscular
agnosis of CMT is better, but there is no literature that docu- causes of head preference, such as neurological condi-
ments the risks and consequences of a lack of immediate tions including cerebral palsy, visual impairments and
follow-up for the 18% of infants who have conditions other visual field deficits, spinal conditions including scoliosis,
than CMT.30,31 While the recommendation strength is categor- and GERD.30,31,76,80,81
ized as Moderate based on level II evidence, the GDG believes • Signs and symptoms consistent with conditions asso-
that consultation with or referral to the infant’s primary care ciated with CMT, such as CD and/or facial asymmetry,
provider should be categorized as a MUST when any nonmus- brachial plexus injury, and DDH.66,82
cular causes of asymmetry or other parental concerns are iden- • Presentations atypical of CMT, such as head lateral flexion
tified. This promotes collaboration in the co-management of and rotation to the same side, plagiocephaly and head lateral
care of the infant who may have both CMT and other medical flexion to the same side, or torticollis that alternates
conditions. sides.31,55
Intentional Vagueness: An infant with postural asymme- • Signs and symptoms consistent with medical conditions
try may present to the physical therapy evaluation with or in which neck stretching may be contraindicated or
without a primary care provider referral. The PT should use their require precautions, such as skeletal dysplasia,

390 Sargent et al Pediatric Physical Therapy

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 osteogenesis imperfecta, or conditions associated with infant’s suspected or diagnosed condition is appropriate
atlantoaxial instability, eg, Trisomy 21.83 medical history gathering.
• Changes in the infant’s color during screening of neck Intentional Vagueness: None.
PROM. Role of Child/Parent/Caregiver Preferences: Parents/
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• History of acute onset torticollis, which is usually asso- caregivers need to formally request release of reports to
ciated with trauma or acute illness.30,84 the PT or bring copies to their first physical therapy
• Late onset torticollis at 6 months or older, which can be appointment.
the result of neurological conditions, tissue mass, inflam- Exclusions: None.
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mation, or acquired asymmetry.66,78 Quality Improvement:

• The presence of an SCM mass at 6 months or older, or an • Document the request for and receipt of reports and images.
SCM mass that changes shape and location or increases
in size at any age.85 Implementation and Audit:
• The infant is older than 12 months on initial screening, • Documentation forms or electronic records may need
and either facial asymmetry and/or 10° to 15° of revision with indicators of requests for and receipt of
difference exists in active or passive cervical rotation or images and reports.
lateral flexion ROM.1 • Audits the incidences in which a report or image helped
to inform the prognosis or intervention choices.
Research Recommendations: Studies are needed to clarify
the incidence of nonmuscular causes of CMT and associated
conditions and how early referral impacts ultimate outcome. Supporting Evidence and Clinical Interpretation
The current standard of care does not include routine ima-
B Action Statement 7. REQUEST IMAGES AND REPORTS. PTs ging of infants with suspected or diagnosed CMT younger than
should request, review, and include in the medical record all
1 year of age.86 Rather, infants are typically referred for imaging
images and interpretive reports completed for the diagnostic
when there is a specific sign or symptom that raises concern, eg,
workup of an infant with suspected or diagnosed CMT to
skeletal dysplasia or atlantoaxial instability for Trisomy 21, or
inform prognosis.
there is a lack of progress despite close adherence to the inter-
(Evidence Quality: II, Recommendation Strength:
vention program.83 Reports and images from specialized exams
Moderate).
or laboratory tests can rule out ocular, neurological, skeletal, and
oncological reasons for asymmetrical posturing.30,84 A growing
Action Statement Profile body of research uses sonoelastography or ultrasound imaging to
quantify the size, shape, organization, and location of fibrous
Aggregate Evidence Quality: Level II based on cohort and
bands or SCM masses, to inform treatment duration and quantify
outcome studies.
change with intervention.21,29,33,87-93 Evidence suggests that in-
Benefits:
fants with masses or abnormal fiber organization of the SCM are
• Imaging may prevent injury to the spine in infants diag-
typically identified earlier but require longer episodes of care.32,33
nosed with skeletal dysplasia, osteogenesis imperfecta, or
Research Recommendations: Studies are needed to deter-
Trisomy 21.83
mine infants who would benefit from imaging, at what time in
• Available images and imaging reports provide
the management of CMT images are useful, and how images
a comprehensive picture of the infant’s medical status,
affect the plan of care.
including comorbidities.
• Images provide visualization of the SCM muscle fiber
B Action Statement 8: EXAMINE BODY STRUCTURES. PTs
organization, and the location and size of fibrotic tissue.
should perform and document the initial examination and
• Parents/caregivers appreciate care that is coordinated
evaluation of infants with suspected or diagnosed CMT for
and shared across disciplines.
the following 7 body structures:
Risk, Harm, and Cost: • Infant posture and tolerance to positioning in supine,
• Requesting reports may require additional time for the prone, sitting, and standing for body symmetry, with or
parents/caregivers and/or the PTs. without support, as appropriate for age. (Evidence
• Imaging may incur additional costs.
Quality: II; Recommendation Strength: Moderate)
• Bilateral PROM into cervical rotation and lateral flexion
Benefit-Harm Assessment: Preponderance of benefit.
Value Judgments: Per the APTA Guide to Physical Thera- using an arthrodial protractor or goniometry. (Evidence
pist Practice 4.0,71 requesting relevant clinical reports on an Quality: II; Recommendation Strength: Moderate)

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 391

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 • Bilateral AROM into cervical rotation using an arthrodial restricted movement, discomfort with PROM tests, or
protractor or goniometry and cervical lateral flexion intolerance of general handling.
• In infants with undiagnosed orthopedic conditions
functional strength using the Muscle Function Scale.
(eg, osteogenesis imperfecta, hemivertebrae, or cervical
(Evidence Quality: II; Recommendation Strength:
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instability), there is a risk that overly aggressive testing of

Moderate) PROM could cause secondary injury, although this has not
• PROM and AROM of the trunk and upper and lower been reported.
extremities, inclusive of screening for DDH. (Evidence Value Judgments: The evidence for selected measurement
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Quality: II; Recommendation Strength: Moderate) approaches varies in strength; however, measures of passive
• Pain or discomfort at rest, and during passive and active and active ROM, strength, and posture must be documented as
part of any physical therapy exam and are consistent with
movement using a standard scale, such as the Face,
current standards of practice.71 For ROM measurement, the
Legs, Activity, Crying, and Consolability (FLACC) GDG recognizes that clinical practicality has to be weighed
Scale. (Evidence Quality: III; Recommendation against the desire for the most reliable measures. Use of photo-
Strength: Weak) graphy, head markers, and other devices to increase measure-
• Skin integrity, symmetry of neck and hip skin folds, ment reliability may create undue burdens for the infant, the
presence and location of an SCM mass, and size, shape, family, and the PT in clinical practice even while they are
necessary for research protocols. While there is only moderate
and elasticity of the SCM muscle and other cervical
to weak evidence to justify the measurement of cervical spine
muscles. (Evidence Quality: II; Recommendation AROM, AROM of the upper and lower extremities, pain or
Strength: Moderate) discomfort, condition of the skin folds, condition of the SCM
• Craniofacial asymmetries and head/skull shape using and cervical muscles, and head shape, a lack of evidence is not
a quantitative measurement method or standard equated with a lack of clinical relevance. Documenting these
classification, such as the Argenta Classification Scales. initial examination results sets the baseline for regularly sched-
uled objective reassessment and outcome measurement.
(Evidence Quality: II; Recommendation Strength:
Intentional Vagueness: There is no vagueness as to what
Moderate) should be documented. There is variability as to how selected
body structures should be measured, due to the limited number
of valid tools or methods.
Action Statement Profile Role of Child/Parent/Caregiver Preferences: During test-
ing, parents/caregivers may perceive that the infant experiences
Aggregate Evidence Quality: Level II-III based on cohort
discomfort or that testing positions could potentially harm the
studies, reviewed by Seager et al94 (refer to Supplemental
infant, resulting in requests to stop testing if the infant is crying.
Digital Content 4, Psychometric Properties of Assessment
The clinician must be aware and responsive to the parent/care-
Tools Commonly Used in the Management of Congenital
givers’ perceptions; it is incumbent on the clinician to fully
Muscular Torticollis, available at: http://links.lww.com/PPT/
explain the importance of the measures and the safety precau-
A545). tions used, so that parents/caregivers and infants can comfortably
Benefits: and accurately complete the testing procedures. Clinicians may
• Confirms the diagnosis of CMT and identifies other
need to provide the infant breaks during testing to obtain the
medical conditions such as craniosynostosis, DDH, pla- infant’s best performance and most reliable measures. Including
giocephaly, brachycephaly, or scoliosis. the parent/caregiver in the test procedures may help elicit the
• Standardizes baseline measurement and documentation
infant’s best performance, calm the infant if under stress, and
of body structure and function to inform prognosis, generally assist with building trust between the PT and the infant.
evaluate individual progress and outcomes, and evaluate Exclusions: None.
group outcomes within or across clinical settings. Quality Improvement:
• Documentation of the 7 body structures and functions
Risk, Harm, and Cost: provides uniform data for more effective communication
• Examination of passive cervical rotation PROM may among clinicians and settings, as well as uniform data
result in SCM snapping or a sense of “giving way” in entry in child registries.
approximately 8% of young infants with CMT and an
SCM mass.95 Implementation and Audit:
• During the physical therapy examination, infants may • Documentation forms or electronic records may need
feel some discomfort or pain, and/or may cry79 due to revision to reflect the 7 body structure elements.

392 Sargent et al Pediatric Physical Therapy

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Unauthorized reproduction of this article is prohibited.
 • Additional equipment may be needed, such as an arthro- Still photography for measuring preferred head tilt in supine
dial protractor or goniometer. has sufficient reliability (intraclass correlation coefficient
• Clinicians may require training to enhance examination [ICC] ≥ 0.7) for clinical use100,101; however, setting up for
consistency and reliability, specifically for cervical photo consistency and adding photos to the medical record
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PROM and AROM using an arthrodial protractor or may not be feasible in some clinical settings. To quantify the
goniometer, cervical lateral flexion functional strength head tilt on the photo, a line is drawn through the acromial
using the Muscle Function Scale, pain assessment using processes and another is drawn through the midpoints of both
the FLACC scale, and craniofacial asymmetries using eyes. The intersection angle of the eye line with the shoulder line
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a quantitative measurement method or a standard classi- provides an objective measure of preferred head tilt. Care needs
fication, such as the Argenta Classification Scales. to be taken not to record artifacts of the placement of the infant
• Use of photos may require consent and storage proce- on the surface; photos should represent the typical posture that
dures for Health Insurance Portability and Accountabil- the infant repeatedly reverts to during the examination session.
ity Act of 1996 compliance. The Functional Symmetry Observation Scale, version 2
• Audit the incidences in which body structure elements (FSOS-2) is a standardized method for assessing spontaneous
informed intervention. movement and posture in infants with CMT.102 The FSOS-2
has evidence of content validity,102 but further research on
reliability and other psychometric properties are needed before
Supporting Evidence and Clinical Interpretation
recommending it for clinical use.
Following a thorough history and screening to rule out
asymmetries inconsistent with CMT, the PT conducts a more • PROM: Document the infant’s bilateral PROM into
detailed examination of the infant. The following items appear cervical rotation and lateral flexion using an arthrodial
as a checklist, but in practice, the PT simultaneously observes protractor or goniometry. (Evidence Quality: II, Recom-
for asymmetries throughout all exam positions to reduce infant mendation Strength: Moderate)
repositioning and increase infant cooperation. The arthrodial protractor has sufficient intra-rater reliabil-
• General Posture: Document infant’s posture and toler- ity (ICC ≥ 0.7) to measure cervical lateral flexion PROM, and
ance to positioning in supine, prone, sitting, and stand- a standard goniometer has sufficient intra-rater reliability to
ing for body symmetry, with or without support, as measure cervical rotation PROM.101,103 An accurate measure-
appropriate for age. (Evidence Quality: II, Recommen- ment of cervical rotation PROM establishes a baseline and
dation Strength: Moderate) informs the CMT severity grade. For all PROM measures,
cervical neutral104 needs to be maintained but is easily com-
Observe the infant in all positions, documenting promised when the infant compensates with cervical rotation
symmetrical alignment and preferred positioning or or extension movements at the end ranges. The PT should
posturing. 27 , 60 , 64 , 70 In supine, document the side of visually check the cervical neutral position, assuring that the
torticollis, 27 , 45 , 64 , 70 asymmetrical hip positions, 45 , 64 , 96 infant’s nose, chin, and visual gaze are directed forward
facial and skull asymmetries, restricted AROM, and asymme- (neutral rotation), with the nose, mouth, and chin vertically
trical use of the trunk and extremities,27,45,64,70,97 as these aligned (neutral lateral flexion) and the ear lobes and base of
are all typical of CMT. the nares are horizontally level (neutral flexion-extension).104
In prone, document asymmetry of the head relative to the Normal infant passive cervical rotation PROM is 110 ± 6.2°
trunk, the spine and/or the presence of scoliosis, asymmetrical and should be measured with the infant in supine, head in
use of the extremities, and the infant’s tolerance to the position cervical neutral, and the nose aligned with the 90° vertical re-
and ability to clear the face from side to side and lift their head ference using an arthrodial protractor or a goniometer.101,105,106
upright against gravity. In infants with typical development, It is important to remove the table surface as a possible
greater time spent in prone while awake is positively corre- barrier to full PROM by either elevating the infant’s body above
lated with higher Alberta Infant Motor Scale (AIMS) scores the table with a supporting mat or supporting the infant’s head
and fewer delays in achieving prone extension, rolling, un- beyond the edge of the supporting table.
supported sitting, and fine motor control.98,99 In infants with Normal infant passive cervical lateral flexion is 70 ± 2.4°
CMT, positioning in prone at least 3 times per day is corre- with the limiting factor being cheek size106 and should be
lated with higher AIMS scores.61 measured in supine with the infant’s shoulders stabilized,
In sitting, supported sitting, and supported upright positions using an arthrodial protractor or a goniometer.101,103 The PT
(eg, holding the infant vertically in the air or supported standing as can either place their hands on the side of the head if the
age appropriate), document asymmetrical preferential postures parent/caregiver stabilizes the trunk and shoulders, or place
and compensations in the shoulders, trunk, and hips.47,60,61 one hand under the occiput and another diagonally across the

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 393

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
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 infant’s chest to palpate for trunk movement and to stabilize The clinical challenge of using either an arthrodial
the shoulder on the side of the stretch. The head should start in protractor or goniometer is that they minimally require 2
cervical neutral, avoiding neck extension or flexion. The head adults: one to stabilize the infant’s trunk on the support
is laterally flexed until the ear approaches or contacts the surface (and this can be the parent/caregiver) and another
stabilized shoulder103 while the opposite shoulder is
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to rotate the head/neck while measuring PROM. A third

stabilized. person may be needed to hold the arthrodial protractor or
When testing cervical PROM, infants with orthopedic con- goniometer in place unless it can be attached to the sup-
ditions associated with cervical instability may require modifi- port surface or stabilized in a stand and calibrated to be
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cation or avoidance of tests, eg, osteogenesis imperfecta, level. Practice surveys in New Zealand and Canada suggest
congenital hemivertebrae, or infants with Trisomy 21. In that PTs often visually estimate, rather than measure ROM
these cases, the GDG recommends that testing PROM can be with an instrument; the greatest barrier being the absence
avoided or the PT may modify testing cervical PROM by using of a time efficient and reliable tool.58,60 The GDG strongly
very gentle guidance through the range, ending at the first values the objective measurement of cervical rotation and
palpable sign of resistance. lateral flexion PROM as a means of establishing a baseline

Fig. 2. 2024 Classification of Severity and Management of CMT

394 Sargent et al Pediatric Physical Therapy

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 for future comparison and determining the CMT severity extend into the poor range.94 Therefore, quantification
grade. of active cervical rotation using an arthrodial protractor
Research Recommendation: Develop reliable, valid, and or goniometry is recommended by the GDG.
time-efficient methods of measuring infant cervical PROM, • For infants 2 months and older, the Muscle Function Scale
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including lateral flexion, and large-scale normative data of provides an objective categorization of active lateral flex-
PROM established by age in months. ion functional strength in developmentally appropriate
positions.106,111 By holding the infant vertically in front
• AROM: Document the infant’s bilateral AROM into cervi-
of a mirror and tipping the infant horizontally for 5 sec-
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cal rotation using an arthrodial protractor or goniometry onds, the PT classifies the head righting position accord-
and cervical lateral flexion functional strength using the ing to a 6-point scale.111 Infants with typical development
Muscle Function Scale. (Evidence Quality: II, Recom- do not differ between sides by more than 1 point, and
mendation Strength: Moderate). infants with CMT frequently have a difference of 2 to 3
points.111 Clinicians should refer to the study by Öhman
Cervical AROM is considered an important indicator of sym- et al111 for specific reference values and procedures.
metrical development and neck strength51,106,107 and the infant’s
integration of PROM for functional activities. Intervention to im- Research Recommendations:
prove AROM is consistent with the goals of early intervention.108 • Determine the sensitivity and specificity of the Muscle
Asymmetrical movements and movement compensations can in- Function Scale to differentiate infants with clinically sig-
dicate muscle tightness, restrictions, or weakness.50,109 nificant limitations from infants with typical development.
Active range is challenging to measure in infants due to • Establish a clinically practical, objective method of measur-
behavior and movement variability, difficulty with isolating ing cervical rotation AROM in infants 0 to 3 months and
cervical movements, and a paucity of practical measurement infants ≥3 months to assess baselines and changes over
tools that capture infant movements in the clinical setting in time.
a timely manner.58,60,101 Studies may list “active movement” as • Determine what, if any, correlation between active and
an outcome but do not describe how it is measured, and many passive ROM should be used for discontinuation and/or
PTs rely on visual estimation.60 discharge criteria.
PTs should measure active cervical movement, looking for
active and full range in all planes, including diagonals, while • Trunk and Extremity ROM: Document the infant’s
the infant is enticed to follow toys, sounds, or other forms of PROM and AROM of the trunk and upper and lower
stimulation to elicit full range. extremities, inclusive of screening for DDH. (Evidence
• For infants <3 to 4 months old, it is recommended for Quality: II; Recommendation Strength: Moderate)
active cervical rotation to be tested in supine using an
arthrodial protractor or goniometer, similar to passive The PT should examine passive and active ROM of the
cervical rotation, but with visual tracking of a toy to spine, shoulder and hip girdle, and arms and legs by ob-
obtain available AROM.101,110 Although the ROM Lim- serving the natural straight plane and rotational movements
itation Scale that classifies active cervical rotation as full, of the infant and by passively moving the arms and legs
moderate limitation, or severe limitation has sufficient through all available range at each joint to rule out concern
intra- and inter-rater reliability for infants with positional for brachial plexus injuries, clavicle fractures, neurological
plagiocephaly to screen for CMT,110 it does not have the impairments, hypermobility, or central nervous system
precision needed to measure active cervical rotation for lesions.30,31,47
infants with CMT.101 Therefore, quantification of active DDH has been associated with CMT, so screening for DDH
cervical rotation using an arthrodial protractor or gonio- is recommended with referral to primary care provider if
metry is recommended by the GDG. indicated.112,113 For infants with CMT under 3 months of
• For infants ≥3 to 4 months old who can hold their head age, the Ortolani maneuver, in which a subluxed or dislocated
upright, it is recommended for active cervical rotation to femoral head is reduced into the acetabulum with gentle hip
be tested using an arthrodial protractor or goniometer abduction by the examiner, is considered the most important
with the parent/caregiver holding the infant in the sup- clinical test for detecting newborn hip dysplasia.112 For the
ported sitting position with visual tracking of a toy to infant with CMT over 3 months of age, observations of asym-
obtain available AROM.94 Although visual estimation of metric limited hip abduction, thigh-fold asymmetry, and un-
cervical rotation AROM has good average intra-rater equal knee heights also known as the Galeazzi sign, can be
(ICC = 0.85; 95% CI, 0.23-0.97) and inter-rater relia- performed, but the most sensitive examination for unilateral
bility (ICC = 0.79; 95% CI, 0.15-0.99), the 95% CIs hip dislocation is asymmetric limited hip abduction.113

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 395

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 • Pain: Document the infant’s pain or discomfort at rest Skin: PTs should observe the symmetry and condition of
and during passive and active movement using the skin folds around the neck and hips. Typically, the neck
a standard scale, such as the FLACC scale. (Evidence skin folds on the anterior affected side are deeper and
Quality: III, Recommendation Strength: Weak) reddened.75 Infants with brachycephaly and limited cervical
ROM in all directions may have deeper posterior folds.77 Ob-
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PTs should document any behaviors that may indicate dis- serve for symmetry of the hip skin folds in the inguinal and
comfort or pain.77,114 Pain is not typically associated with the upper thigh area as an indicator of DDH.66,96
initial presentation of CMT48 but may be associated with passive Muscle: PTs should visually inspect and palpate both
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stretching.115 The infant may cry in response to stretching115 or SCM muscles and document the side of tightness, the presence
in response to handling from the therapist, anxiety, or the stress or absence of a fibrous band and/or mass, and if a mass is
of an unusual environment. One method to differentiate pain present, note its size and location along the SCM muscle
from behavioral distress is to hand the inconsolable infant back to (inferior, middle, superior, or entire length).90 The presence
their parent/caregiver, observing how quickly the infant quiets. of a fibrous band and/or mass, particularly a mass that involves
Another option is to have the parent/caregiver do the handling more than the distal 1/3 of the muscle, is correlated with
with the PT instructing and observing the infant’s reactions to greater severity of the condition and is used to determine the
differentiate pain from behavioral reactions. CMT severity grade.56,90
The Therapy Behavior Scale, version 2.2 (TBS-2), is cur- PTs should document the presence of secondary asymme-
rently under development as a tool to assess infant and toddler tries, compensations, or atypical tone in the shoulders, trunk,
behavior during the physical therapy management of infants hips, and distal extremities while the infant moves through
with CMT.116 The TBS-2 had sufficient reliability to measure positions during the examination. Typical compensations in-
behavior of infants with CMT, but the scale contains 11 items clude tightness of the upper trapezius muscle, imbalance of
that are rated on a 4-point ordinal scale taking approximately neck muscle strength,106 shoulder hiking on the same side of
5 minutes, which may not be feasible in some clinical settings.116 the involved muscle, asymmetrical preference for limb use,122
The FLACC is a clinically practical means to document the asymmetrical and delayed protective and righting reactions of
infant’s pain or discomfort for several reasons: (1) it was origin- the head, neck, and trunk,69 Trendelenburg’s sign in children
ally developed for children from 2 months to 7 years of who are walking,96 and scoliosis.85 Secondary compensations
age,117,118 but its reliability and validity have been investigated and asymmetries of movement need to be continually moni-
for children from 0 to 10 years119,120; (2) the scale ranges from tored across the episode of care as they can develop and/or
0 to 10, similar to the Numeric Pain Rating Scale that is worsen over time.73
common in PT practice with lower scores indicating fewer
• Craniofacial: Document the infant’s craniofacial asym-
pain-related behaviors and higher scores indicating more beha-
metries and head/skull shape using a quantitative mea-
viors; (3) the 5 behaviors that are assessed using the 3-point
surement method or standard classification, such as the
scale of “0” = no expression or a quiet state, “1” = occasional
Argenta Classification Scales. (Evidence Quality: II,
expression or movements, and “2” = inconsolable relate to the
Recommendation Strength: Moderate)
FLACC acronym (Face, Legs, Activity, Crying, Consolability)
making it easy to remember. FLACC training is required to
achieve adequate reliability.121 Facial asymmetries involve the relative alignment of
each side of the jaw, the cheekbones, eye orbits, and ear
Research Recommendation: Studies are needed to:
positions.19,123 Cranial asymmetries or CD refers to asymmetries
• Describe and differentiate signs of discomfort and pain of the skull, including the frontal, temporal, parietal, and occi-
observed in infants with CMT during examination and pital bones, presenting with posterior unilateral flatness (plagio-
intervention. cephaly), bilateral posterior flattening (brachycephaly),
• Determine the validity of the FLACC in rating pain in asymmetrical brachycephaly, or flattening on both sides of the
infants with CMT. skull (scaphocephaly).47,124
• Determine whether pain tools need to be specific to The incidence of localized cranial flattening is 13% in typical
CMT. singleton infants and 55.6% in twins.34 Cheng et al reported
a 90.1% prevalence of craniofacial asymmetry in children with
• Skin and Muscle: Document the infant’s skin integrity, CMT at initial evaluation.29 Untreated CMT may result in cra-
symmetry of neck and hip skin folds, presence and niofacial asymmetries on the side of the CMT, including: reduced
location of an SCM mass, and size, shape, and elasticity jaw or ramal height, a smaller and elevated eye with changes in
of the SCM muscle and other cervical muscles. the orbit (recession of the ipsilateral zygoma), recession of the ear
(Evidence Quality: II, Recommendation Strength: on the affected side, a flat appearance of the jaw, malocclusion,
Moderate) and possible gum line asymmetry.27,73,125

396 Sargent et al Pediatric Physical Therapy

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 Although CMT is associated with CD, it is unclear how or • The 8 grades integrate 3 of the strongest factors related to
whether they are causally related. Limited AROM from CMT outcome: the infant’s age at initiation of physical therapy
may cause CD as asymmetrical muscle tensions lead to an intervention, the presence of an SCM mass, and the
asymmetrical postural head preference and subsequent difference in cervical rotation PROM between sides.
CD.34,48,64,65,72,126,127 Conversely, for infants with CD, an
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• Use of the CMT Severity Grading Scale may more fully

asymmetrical resting position of the skull may cause persistent describe research samples; however, an even more pre-
neck rotation that may lead to SCM tightness.25,48,65,126-128 cise classification system may be needed to compare
PTs should document asymmetries of the skull and face. One outcomes across research samples, eg, classifying infants
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of the most clinically feasible tools is the Argenta Classification by age in 1-month increments and more precise severity,
Scales.124 The method is clinically practical, does not require such as separating infants with PROM restrictions from
equipment other than a copy of the scale, includes pictures to infants with an SCM mass.
assist with rating, and has moderate inter-rater (mean weighted κ
score = 0.54) and substantial intra-rater reliability (weighted κ Risk, Harm, and Cost:
scores ranged from 0.6 to 0.85).129 Other methods to quantify • Minimal costs to update electronic health records to add
head shape asymmetries exist, and when more reliable or accurate the CMT Severity Grading Scale.
methods for quantifying head shape are available and feasible,
PTs should use them. Examples include: anthropometric mea- Benefit-Harm Assessment: Preponderance of benefit.
surements using a caliper,130 plagiocephalometry,131,132 the Value Judgments: The GDG recommends the use of the
modified Severity Scale for Assessment of Plagiocephaly,133 CMT Severity Grading Scale as it may inform episode of care.56
a craniometer with a headband,134 molding a flexible ruler Intentional Vagueness: There is no evidence as to whether
to the infant’s head shape and tracing the shape,135 3-dimen- the chronological or corrected age should be used for infants
sional computerized scanning,136 and the Children’s Health- born preterm to determine the severity grade. Clinicians
care of Atlanta Plagiocephaly Severity Scale.137 These should document both ages in their practice setting. The GDG
alternative methods may not be available in physical therapy recommends using corrected age when determining the severity
clinics or tolerated well by the infant. grade.
PTs should consult with the infant’s primary care
Role of Child/Parent/Caregiver Preferences: None.
provider regarding assessment for craniosynostosis when
Exclusions: None.
craniofacial asymmetry is inconsistent with deformational
Quality Improvement:
plagiocephaly or brachycephaly138 or to assess if a cranial • Documentation of a severity grade provides a common
molding orthosis (ie, helmet or band) is indicated when
taxonomy for clinical and research communication and
cranial asymmetry is moderate or severe or when facial
for uniform data entry in child registries.
asymmetry is noted.139 • The severity grades are a tool for communicating with
parents/caregivers about the estimated episode of care.
B Action Statement 9: CLASSIFY CMT USING THE CMT
SEVERITY GRADING SCALE. PTs should classify and docu- Implementation and Audit:
ment CMT severity using the CMT Severity Grading Scale, • Documentation forms or electronic records may need
choosing 1 of 8 grades (Figure 2, Supplemental Digital
revision to reflect the CMT Severity Grading Scale.
Content 2, available at: http://links.lww.com/PPT/A547) • Clinicians may require training to enhance CMT Severity
based on infant’s age at examination, the presence of an SCM
Grading Scale consistency and reliability.
mass, and the difference in cervical rotation PROM between • Audit the documentation frequency of the CMT Severity
the left and right sides. (Evidence Quality: II, Recommenda-
Grading Scale and the accuracy of prognoses with re-
tion Strength: Moderate)
spect to episode of care and functional outcomes.
• While there are no studies that correlate the severity of
Action Statement Profile cervical lateral flexion to the severity of CMT or the
episode of care, PTs should document objective mea-
Aggregate Evidence Quality: Level II based on cohort
studies of the psychometric properties of the CMT Severity sures of lateral flexion as a type of asymmetry.
Grading Scale.56,140 • For infants who change service providers to treat CMT,
Benefits: CMT severity should be classified based on the infant’s
• Classifying levels of severity may assist with prognosis current age and initial examination findings by the new
and parent/caregiver education. provider.

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 397

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 Supporting Evidence and Clinical Interpretation Grade 8—Very Late: Infants and children older than
The 2013 CMT CPG proposed a 7-grade CMT Severity 12 months of age with any asymmetry, including postural
Grading Scale that combined 3 factors (ie, age at initial preference, any difference between sides in passive cervical
physical therapy evaluation, cervical rotation PROM difference rotation, or an SCM mass.
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between sides, and presence of an SCM mass) to add clarity to The classification process begins at the top of the diagram.
research, aid communication among health providers, and in- Document the age that asymmetry is first noted by a parent/
form prognosis. Prior to the 2013 CMT CPG, only 3% of PTs caregiver or health professional; this may be informed by early
classified CMT severity, but this increased to 57% once the infant photos. This age provides a history of the condition and
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7-grade CMT Severity Grading Scale was introduced.6 Reliabil- may impact the prognosis for the episode of care; however, it
ity of the 7-grade CMT Severity Grading Scale was strong does not directly factor into the choice of severity grades. The
(ICC ≥ 0.81 for inter- and intra-rater reliability).140 The 2018 age of referral for a physical therapy evaluation is documented
CMT CPG updated the original 7 grades to 8, based on clinician to understand the timeliness between referral and the initial
confusion as to how to grade toddlers >12 months old,140 evaluation. The age of initial physical therapy evaluation is
because the majority of evidence is based on infants younger documented and used in combination with the difference in
than 12 months of age. The CMT Severity Grading Scale can in- cervical rotation PROM and/or presence of an SCM mass to
form prognosis because units billed, episode of care duration, determine the CMT Severity Grade. Classifications are first
and total visits increase across CMT Severity Grades 1 to 3.56 grouped as “early,” “later,” or “very late.” “Early” and “later”
Figure 2 graphs the CMT Severity Grading Scale and Deci- have a range of severity within the categories. For example,
sion Tree for 0 to 12 months. The diagram is best viewed in CMT Severity Grade 2, Early Moderate, is assigned to an infant
color; however, to aid clarity with noncolor copies, the lines between 0 and 3 months or between 4 and 6 months of age,
from conditions to grades are patterned. The left edge, vertically with a difference between sides in cervical rotation PROM of
aligned ovals of the diagram, list factors that are most relevant 15° to 30°. van Vlimmeren et al141 illustrate how the grades
to the classification process, ie, age asymmetry noted, age of can describe study samples more accurately.
referral, physical therapy evaluation, and type of CMT. The Research Recommendation: Studies are needed to
combinations of characteristics in the box to the right are linked determine a reliable, valid, and clinically practical method of
to the 8 CMT Severity Grades with recommended actions ex- measuring cervical lateral flexion and then to determine if lateral
plained in the following section. flexion measures relate to the CMT Severity Grading Scale.

B Action Statement 10: EXAMINE ACTIVITY AND DEVELOP-

CONGENITAL MUSCULAR TORTICOLLIS SEVERITY GRADING MENTAL STATUS. During the initial and subsequent examina-
SCALE DEFINITIONS tions of infants with suspected or diagnosed CMT, PTs should
Grade 1—Early Mild: Infants between 0 and 6 months of examine and document the types of and tolerance to position
age with only postural preference or a difference between sides changes, and motor development for movement symmetry and
in passive cervical rotation of <15°. milestones, using an age-appropriate, norm-referenced standar-
Grade 2—Early Moderate: Infants between 0 and 6 months dized test, such as the Test of Infant Motor Performance (TIMP),
of age, with a difference between sides in passive cervical AIMS, or gross motor subtests of the Peabody Developmental
rotation of 15° to 30°. Motor Scales, third edition (PDMS-3). (Evidence Quality: II;
Grade 3—Early Severe: Infants between 0 and 6 months of Recommendation Strength: Moderate)
age, with a difference between sides in passive cervical rotation
of >30° or an SCM mass.
Grade 4—Later Mild: Infants between 7 and 9 months of Action Statement Profile
age with only postural preference or a difference between sides Aggregate Evidence Quality: Level II based on cohort and
in passive cervical rotation of <15°. outcome studies.
Grade 5—Later Moderate: Infants between 10 and Benefits:
12 months of age with only postural preference or a difference • Early detection of developmental delays, neurological
between sides in passive cervical rotation of <15°. impairments, movement capabilities, muscle function/
Grade 6—Later Severe: Infants between 7 and 9 months of age strength in developmental positions, and infant prefer-
with a difference between sides in passive cervical rotation of >15°, ences helps to direct the plan of care.
or between 10 and 12 months with a difference of 15° to 30°. • Provides opportunities for parent/caregiver education on
Grade 7—Later Extreme: Infants between 7 and 12 months typical development, the importance of prone playtime,
with an SCM mass, or between 10 and -12 months of age with alternative positioning, and reinforcement of parent/
a difference between sides in passive cervical rotation of >30°. caregiver adherence to home programs.

398 Sargent et al Pediatric Physical Therapy

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 • Standardizes measurement and documentation of motor to monitor infants with CMT for potential developmental de-
activity to evaluate group outcomes across clinical lays and, if identified, should address remediation of those
settings for infants with CMT. delays in their plans of care. The GDG recommends using
age-appropriate, reliable, and valid standardized tests, such as
the TIMP through 4 months corrected age,107 the AIMS from 1
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Risk, Harm, and Cost:

• No risks or harms. to 18 months corrected age or until walking,142 or the gross
• Norm-referenced developmental standardized tests are motor subtests of the PDMS-3 from 0 to 5 years corrected
proprietary and thus have associated costs for the forms, age,143 during the initial evaluation and reassessments. While
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test manuals, and test items. Proficiency in administering certification is not required to administer these tests, the valid-
the tests may require training. ity of the scores and test-retest reliability may be improved
following formal training. Additionally, the PT should observe
Benefit-Harm Assessment: Preponderance of benefit. and document asymmetries of age-appropriate developmental
Value Judgments: Measures of the infant’s activity, sym- activity, movement, and upper and lower limb use throughout
metry of movements, and developmental progression must be all exam positions.
documented as part of any physical therapy exam. These are Research Recommendation: Studies are needed to iden-
consistent with professional standards of practice71 and clinical tify the best developmental tests to use for infants with CMT,
practice specific to CMT.58,60 from birth through 12 months, so that the same measures can
Intentional Vagueness: None. be documented on all infants, enabling comparison of out-
Role of Child/Parent/Caregiver Preferences: Parents/ comes across studies.
caregivers may perceive that the infant experiences discom-
fort from the testing positions or that the prone position B Action Statement 11: EXAMINE PARTICIPATION STATUS.
is harmful and may request that testing not continue if The PT should obtain and document the parent/caregiver
the infant is crying. The clinician should fully explain the responses regarding:
importance of varying the infant’s positions, including • Positioning when awake and asleep. (Evidence Quality:
the use of prone positioning, which may be avoided by II; Recommendation Strength: Moderate)
parents/caregivers due to misinterpretation of Safe Sleep • Infant time spent in prone while awake, consistent with
Recommendations.61 Safe Sleep Recommendations. (Evidence Quality: II;
Exclusions: None. Recommendation Strength: Moderate)
Quality Improvement: • Whether the parent/caregiver alternates sides when hold-
• Routine assessment of development ensures that ing the infant for breast or bottle feeding. (Evidence
infants with CMT are achieving age-appropriate milestones Quality: II; Recommendation Strength: Moderate)
and, if not, that delays are addressed as they are identified. • Infant time spent in equipment/positioning devices, such
as strollers, car seats, or swings. (Evidence Quality: II;
Implementation and Audit: Recommendation Strength: Moderate)
• Documentation forms and electronic records may need
revision to include the recommended standardized de-
velopmental tests and documentation of asymmetries
Action Statement Profile
during developmental activities.
• Clinicians may require training to enhance consistency Aggregate Evidence Quality: Level II based on cohort and
and reliability to administer standardized developmental outcome studies.
tests. Benefits:
• Audit the incidences in which the standardized develop- • Identifies routine passive positioning that facilitates
mental tests are completed and inform intervention. asymmetrical positions of the head, neck, and trunk.
• Provides information about the general developmental
activities and position preferences of the infant.
Supporting Evidence and Clinical Interpretation • Provides opportunities for parent/caregiver education
Infants with CMT have a higher prevalence of gross motor and counseling about positioning and activities that
delay at 2 and 6 months of age.61,70 The motor delay of most facilitate symmetrical development, including eating.
infants undergoing physical therapy for CMT resolves by 8 to
15 months,61,70 but similar to the general population, some Risk, Harm, and Cost: None.
will continue to demonstrate a gross motor delay.70 PTs should Benefit-Harm Assessment: Preponderance of benefit.
use a standardized norm-referenced developmental assessment Value Judgments: None.

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 399

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 Intentional Vagueness: None. per opportunity, appears to offset the transient effects of supine
Role of Parent/Caregiver or Child Preferences: Parents/ sleep positions on motor skill acquisition.145,146 Supine posi-
caregivers must accurately describe the infant’s daily care rou- tioning is associated with postural preference and consequently
tines so positioning and home exercise programs can be tai- may facilitate asymmetrical neck ROM and secondary develop-
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lored to maximize implementation opportunities and enhance ment of plagiocephaly.64,128 Infants who spend more time in
the success of early parent/caregiver roles. Fear of blame for the prone and side lying positions reduce the impact of preferred
infant’s condition may lead parents/caregivers to provide inac- positioning64 and achieve motor milestones sooner.61,147
curate descriptions. Clinicians should be sensitive to this and The conscientious use of positioning during wakeful activities
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may need to build a level of trust with the parents/caregivers (eg, play, eating, and dressing) facilitates symmetrical development
before an accurate description can be obtained. of head shape,49,148 active and passive neck motion,49 tolerance of
Exclusions: None prone positioning,146 and achievement of motor milestones.51,149
Quality Improvement: Conscientious positioning means that parents/caregivers actively
• Routine examination of participation ensures that par- place infants in positions during play, on changing tables, in cribs,
ent/caregiver-infant dyads are appropriately and success- or carry their infant in ways that require head righting, rotation
fully interacting during daily routines to optimize motor toward the restricted side, neck and upper body extension,51 or
development. visual attraction toward the affected side. Active movement toward
the affected side52 and alternation of trunk and limb movements150
Implementation and Audit: help to counteract asymmetries and prevent potential ones. For the
• Documentation forms and electronic records may need infant with postural preference, these activities may reduce the
revision to document the 4 participation elements. preference and avoid consequential tightness.
• Clinicians may require training to enhance consistency Parents/caregivers are reported to avoid prone positioning
and reliability in assessing participation. with typically developing infants if the infant does not tolerate
• Audit the incidences in which the participation elements the position or if the infant has achieved independent sitting.146
are documented and inform intervention. Education about the importance of prone playtime is critical for
infants with CMT, as they have multiple risks for asymmetrical
development and delayed motor milestones. PTs should assess
Supporting Evidence and Clinical Interpretation each parent’s/caregiver’s ability to implement exercises and
There is consensus about the need to assess across all the home program positioning.
domains of the ICF, including infant participation in daily Eating: PTs should document the infant’s eating positions and
routines, to develop a comprehensive plan of care.58,60,69 Mod- difficulties as reported by the parent/caregiver during the initial
erately strong evidence suggests that specific activities are either and periodic evaluations. Eating issues have been identified in
preludes for possible asymmetrical development or are the infants with CMT and/or plagiocephaly as asymmetrical jaw
consequences of existing asymmetries. positioning,151 preference for side of breastfeeding,65,128 and/or
Positioning When Awake and Asleep, Including Time side of bottle feeding.128,152 As many as 44% of infants with CMT
Spent in Prone: Documentation should address positioning may have an eating preference to one side,152 and as many as
when awake and asleep, while eating, and while using position- 2.4% are described as having additional eating issues.153 In con-
ing devices (eg, car seats, changing tables, and cribs). The pur- junction with infant preference, the parent/caregiver’s preferred
pose of asking parents/caregivers about positioning is to prevent side or hand dominance may also bias positioning to bottle feed
deformational plagiocephaly that may be associated with CMT,49 from the same side.64 Conversely, infants who breastfeed from
to correct postural preference that can lead to CMT and both sides have a lower incidence of CD and CMT, possibly due to
plagiocephaly,27,47,65,144 and to manage CMT and CD if present. frequent position changes as compared to infants who are consis-
Three aspects of positioning support an interaction effect with tently bottle-fed on the same side.154 Alternating sides and alter-
CMT resolution: use of prone positioning when awake, asymme- native positions59 for eating can effectively increase symmetrical
trical handling to activate weak neck musculature and AROM positioning, reduce preferred positioning by the infant, and im-
toward the limited side, and eating from alternate sides. prove parent/caregiver self-efficacy. Interviewing parents/care-
The American Academy of Pediatrics Safe Sleep Recommen- givers about their comfort with alternating eating positions is
dations include consistently placing infants on their back to sleep common practice,58,60 is consistent with family-centered care,108
and encouraging prone positioning while awake and supervised and provides an opportunity to suggest positioning strategies.
for short periods of time beginning soon after birth, increasing Equipment/Positioning Devices: PTs should document
incrementally to at least 15 to 30 minutes daily by 7 weeks of the amount of time the infant spends in positioning equipment
age.42 Prone positioning while awake for greater than 1 as reported by the parents/caregivers (eg, positioning/seating
cumulative hour per day, with no minimum amount of time devices, strollers, car seats, cribs, or swings).126 Persistent use

400 Sargent et al Pediatric Physical Therapy

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 of supportive equipment, in lieu of time spent playing in prone Benefit-Harm Assessment: Preponderance of benefit.
or side lying, may facilitate the deformation of the developing Value Judgments: The GDG supports the need to docu-
skull due to gravitational forces, which increases the risk of CMT ment the potential for improvement of CMT prior to initiating
and other asymmetrical developmental movement patterns. The intervention. The physical therapy prognosis is the bridge be-
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PT should discuss practical strategies with the parents/caregivers tween the evaluation of initial examination results and the clas-
regarding positioning and movement facilitation, including alter- sification of severity with the associated interventions within an
nating positioning of toys and placement in cribs,154 and ensur- expected time frame. It should include both objective outcomes
ing frequent opportunities to play in prone from an early to achieve and time frames in which to achieve them. Articulat-
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age.37,38 Parent/caregiver avoidance of prone placement when ing the prognosis for physical therapy management ensures clear
the infant does not tolerate it well offers an opportunity to assess communication of expectations for the parents/caregivers and
parent/caregiver comfort and provide graded strategies for prone sets objective milestones as a basis for referral back to the
positioning that build on the infant’s tolerance. primary care provider if outcomes are not met. Prognosis is
Research Recommendations: Studies are needed to quan- a continual process that occurs throughout the episode of care.
tify changes in participation and clarify how the participation Intentional Vagueness: None.
elements inform the plan of care. Role of Child/Parent/Caregiver Preferences: The prog-
nosis for improvement, or the time to achieve change, may need
B Action Statement 12: DETERMINE PROGNOSIS. PTs should to be modified based on the parent’s/caregiver’s ability to
determine and document the prognosis for resolution of CMT perform the exercises and adhere to the home program.
and the episode of care after completion of the evaluation and Parents/caregivers and the PT should participate in shared deci-
communicate it to the parents/caregivers. Prognoses for the sion-making to design a home program that addresses both the
extent of symptom resolution, the episode of care, and/or the infant’s limitations and other parent’s/caregiver’s responsibilities.
need to refer for more invasive interventions are related to: the Exclusions: None.
age of initiation of physical therapy intervention, CMT Severity Quality Improvement:
Grade (Figure 2, Supplemental Digital Content 2, available at: • Determining a prognosis provides the family and care-
http://links.lww.com/PPT/A547), intensity of intervention, pre- givers, health care providers, and payors an estimate of
sence of comorbidities, rate of change, and adherence with the episode of care and expected outcomes.
home programming. (Evidence Quality: II, Recommendation
Strength: Moderate) Implementation and Audit:
• Educate parents/caregivers about the estimated episode
of care and the importance of consistently implementing
Action Statement Profile
the home program to maximize outcomes.
Aggregate Evidence Quality: Level II based on cohort and • Update documentation forms or electronic records to
outcome studies. include prognosis based on a uniform collection of age
Benefits: at initiation of intervention, CMT Severity Grade, inter-
• Links the exam results and CMT Severity Grade to inter- vention intensity, presence of comorbidities, change rate,
ventions and/or referrals. and home program adherence.
• Allows parents/caregivers to prepare for what to expect • Include the prognosis and episode of care estimate on the
from physical therapy and the range of possible out- initial evaluation document and in all professional
comes for their infant. communications.
• Assists parents/caregivers with understanding and im- • Audit the documentation frequency of prognoses and
plementing the plan of care. their accuracy with respect to episode of care and func-
• Articulates the relationship of exam results to expected tional outcomes.
outcomes for documentation, including letters of medi-
cal necessity.
Supporting Evidence and Clinical Interpretation
Risk, Harm, and Cost: Figure 2 graphs the CMT Severity Grading Scale and
• Lack of a prognosis by either the primary care provider or Decision Tree for 0 to 12 months. The vertically aligned
the PT may lead to underestimation of the CMT severity, diamonds at the left most edge of the diagram describe the
resulting in inadequate or untimely delivery of care and/or cycle of physical therapy examination, intervention, and re-
parent/caregiver confusion about what to expect. assessment. Following the evaluation, the PT determines
• Parents/caregivers of infants with SCM masses can better a prognosis that includes the expected outcomes in objective
prepare for a longer episode of care and slower resolution. measurable terms, the content, frequency, and duration of

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 401

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 intervention to achieve the outcomes, and appropriate refer- Grade 2, and 6 months for Grade 3.56 However, the average
rals to other health care providers. Decisions regarding ex- number of visits was just over once a month in each
pected outcomes and intervention frequency and duration severity group; therefore, a different frequency may affect
take into consideration each of the factors within the large the intervention duration.56 In addition, longer treatment
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central oval: CMT Severity Grade, Access to Services & Clin- durations have been associated with birth history, including
ician Knowledge and Skill, Child/Caregiver CMT Knowledge lower birth weight63 and breech, compared to cephalic,
and Program Adherence, Muscle Tissue Characteristics, presentation.63
Infant’s Developmental Stage, and Comorbidities. The GDG Intervention frequency. There is no consensus on interven-
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recommends performing the first-choice intervention de- tion frequency. An algorithm based on infant age and CMT
scribed in Action Statement 13 frequently throughout severity was developed to guide therapists on therapy frequency
each day with responses to intervention regularly reassessed with weekly to biweekly therapy recommended for infants
for effectiveness. ≤3 months with CMT Grade 1 severity and 1 to 3 times per
Evidence supports that for infants with CMT, the earlier week for older infants or those with more severe CMT.161
and more intense the intervention, the shorter the episode Intervention delivery. There is no consensus on who
of care12,14,15 and the more complete the resolution should deliver intervention. Ohman et al57 provided preli-
of symptoms.12-14 If an infant diagnosed with CMT begins minary evidence of better outcomes when infants were trea-
physical therapy intervention before 1 month of age, the prognosis ted by a PT vs parents/caregivers, but the combination of
for good clinical outcomes (no head tilt, full passive cervical physical therapy and parent/caregiver home program is the
rotation) is 99% with 1.5 months of physical therapy.12,13 Begin- more frequent intervention plan.14,92 Individual intervention
ning between 1 and 3 months of age, the prognosis for good is the most common model, but a single observational pilot
outcomes declines to 89% with 6 months of physical therapy.12 study of 6 infant-parent dyads and 2 PTs suggests that
Beginning between 3 and 6 months of age, the prognosis for good a group model may be an effective alternative to individual
outcomes declines to 63% with 7 months of physical therapy, and intervention.162
beginning between 6 and 12 months of age, the prognosis for good Research Recommendations: Studies are needed to:
outcomes declines to 19% with 9 months of physical therapy.12
Factors associated with full resolution. These 5 factors • Clarify the interaction between the factors associated
include: (1) participation in physical therapy intervention,155 with full symptom resolution and episode of care.
(2) younger age at initiation of intervention,12-14 (3) CMT • Clarify the prognostic accuracy for full symptom resolu-
severity including less difference between sides of cervical rota- tion and the episode of care.
• Compare the efficacy of different delivery models, eg, in-
tion PROM156 or SCM muscle thickness,157 (4) the caregiver’s
ability to frequently implement a home program of active dividual vs group or clinic vs home vs telerehabilitation.
positioning and passive stretching,57 and (5) infants insured
by private insurance vs Medicaid (91.3% vs 65.2% had no
residual head tilt at discharge).56 III. PHYSICAL THERAPY INTERVENTION FOR INFANTS
Factors associated with treatment duration. Treatment WITH CMT
duration has been associated with age, CMT severity, and birth
The literature continues to support the following 5
history. Although strong evidence supports that younger age at
components as the first-choice intervention for CMT: neck
initiation of physical therapy intervention results in shorter
PROM, neck and trunk AROM, development of symmetrical
treatment durations,12,14,15 some studies support the
movement, environmental adaptations, and parent/caregiver
opposite.63,93 Severity may be a confounding factor since in-
education. The provision of interventions allows for contin-
fants with more severe CMT, including the presence of an SCM uous evaluation of progress along all ICF domains, includ-
mass, may be referred for physical therapy evaluations at ing body structure and function, activity, and participation.
a younger age than infants with less severe CMT.14,32,33 Mea- Repeated objective progress measurements can focus inter-
sures of CMT severity associated with longer treatment dura- vention choices to achieve goals more quickly.3 The PT
tion include: (1) decreased cervical rotation PROM,50 (2) must educate parents/caregivers on the importance of the
increased severity of head tilt,93,158 (3) motor asymmetry,97 home program163 and partner with them to incorporate
(4) increased thickness63,93 or stiffness159 of the involved SCM a reasonable and effective program into the home and
or higher thickness ratio between the involved and uninvolved family schedule. Care should be taken to balance the full
SCM,63,158 and (5) the presence of an SCM mass or scope of the family demands and resources on a case-by-
lesion.14,32,33,160 Knudsen et al found that treatment duration case basis.
increased across CMT Severity Grades 1 to 3, with average Look beyond the infant’s body structure limitations to include
treatment durations of 3 months for Grade 1, 5 months for perceptual-motor experiences within the context of the infant’s

402 Sargent et al Pediatric Physical Therapy

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 social environment and gross and fine motor exploration as con- • Reduces use of environmental supports/equipment that
tributing to cognitive development.108 Infants with limited or may increase asymmetry.
asymmetrical exploration, as seen in CMT and CD,69,70,149 have
demonstrated delays in early motor development that may affect Benefits to the Parents/Caregivers
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the development of early perceptual-motor skills and, by infer- • Education empowers parents/caregivers to be active and
ence, cognition.108 Thus, PTs should treat beyond the body effective caregivers, assures them that they did not cause
structure level to design and provide interventions that incorpo- the CMT, and supports them in implementing interven-
rate the infant’s available functional range into activities that tions between physical therapy appointments.
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promote age-appropriate participation for current and future de- • Education provides parents/caregivers with information
velopment and learning across domains.108 about typical developmental milestones and the factors
Although craniofacial asymmetry is a common condition that contribute to asymmetry.
associated with CMT, the management of positional plagioce- • Reduces potential overall cost of care for CMT with early,
phaly is beyond the scope of the 2024 CMT CPG. Please refer to intense intervention.
the Congress of Neurological Surgeons systematic review and
evidence-based guidelines for the management of children with Risk, Harm, and Cost:
positional plagiocephaly.139,144,164-166 • Stretching of the SCM of younger infants with CMT and
an SCM mass can result in manual myotomy, defined as
B Action Statement 13: PROVIDE 5 COMPONENTS AS THE partial or complete rupture of the SCM. Manual myot-
FIRST-CHOICE INTERVENTION. PTs should provide and docu- omy may or may not cause momentary infant discom-
ment these 5 components as the first-choice intervention for fort, bruising, and an increase in cervical ROM;
infants with CMT: documented long-term outcomes are similar in infants
with CMT with and without manual myotomy.95,167
• Neck PROM when PROM is limited. (Evidence Quality: • Cost of care may be a burden for families.
I; Recommendation Strength: Strong) • Parents/caregivers may apply interventions incorrectly.
• Neck and trunk AROM. (Evidence Quality: II; Recom- • Parents/caregivers may decrease the intensity of home ex-
mendation Strength: Moderate) ercises if they perceive that the PT is implementing the
• Symmetrical movement. (Evidence Quality: II; Recom- intervention.51
mendation Strength: Moderate)
• Environmental adaptations. (Evidence Quality: II; Value Judgments: None.
Recommendation Strength: Moderate) Intentional Vagueness: The GDG supports that stretching
• Parent/caregiver education. (Evidence Quality: II; should be frequent through the day, every day; however, there
Recommendation Strength: Moderate) is no dosage standard linking technique and duration of
stretches, repetitions within each intervention session, fre-
quency of intervention sessions per day, overall duration of
Action Statement Profile care, and frequency of clinic visits, including tapering sche-
Aggregate Evidence Quality: Level I for Neck PROM dules, to specific CMT severity grades.
when PROM is limited based on 2 RCTs.21,22 Level II for other Role of Parent/caregiver or Child Preferences:
components of the first-choice intervention based on cohort and Parent/caregiver perceptions of the impact of CMT on their infant’s
outcome studies. (Refer to Supplemental Digital Content 5, function and the importance of the intervention program on their
Randomized Controlled Trials of the First-Choice Physical Ther- infant’s future function are strong factors related to adherence to
apy Intervention for Infants with Congenital Muscular Torticol- appointments and home exercises.163 Parent/caregiver adherence
lis, available at: http://links.lww.com/PPT/A545.) to the plan of care under a PT’s guidance22,57 is optimal for
Benefits to the Infant achieving early intense intervention dosages.
• Providing evidence-based interventions for CMT im- Exclusions: None.
proves infant outcomes (ie, resolves or minimizes CMT) Quality Improvement:
with shorter durations of care, minimizes or prevents • This recommendation may reduce unwarranted varia-
secondary complications (eg, craniofacial asymmetry and tion in practice and provides consumers with guidance
movement asymmetry), promotes age-appropriate skills for evidence-based interventions.
in all areas of development, and reduces the need for more
invasive procedures. Implementation and Audit:
• Balances the use of supine as a frequent infant position • Develop home exercise program materials, including
with activities in prone, side lying, and sitting during videos that parents/caregivers can access online, of the
supervised, wakeful activities. 5 components of the first-choice intervention.

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 403

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 • Update documentation forms and electronic records may depend on parent/caregiver preference and the size and
to include the education provided to parents/care- age of the infant when stretching is initiated. Younger, smaller
givers and their understanding and adherence to the infants may be more easily managed by a single person, while
exercises. larger or more active infants may require 2 people: 1 to stabilize
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• PTs should consider the corrected age of infants born the infant and 1 to guide the head to obtain an adequate stretch
preterm when designing a plan of care. of the restricted cervical musculature.
• Audit PTs’ adherence to providing the 5 components of Neck and Trunk AROM: Active ROM continues to be the
the first-choice intervention or reasons for deviating standard of care in combination with other interventions.168,169
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from the recommendation. Strengthening cervical and trunk muscles can be achieved
through AROM during positioning, handling,51,79 carrying the
infant,51,79,128 while eating,59,128,154 and through exercises iso-
Supporting Evidence and Clinical Interpretation lating the weaker muscles.51 Incorporating righting reactions in
Neck PROM when PROM is limited: Manual stretching upright postures, rolling, side lying, or sitting has been used
remains the most commonly reported form of intervention for effectively during intervention and daily care routines to
CMT.16,52,92 It is best supported by 2 randomized control trials strengthen muscles opposite of the affected muscles. The affected
(RCT) of infants with CMT. Song et al found that passive side of CMT is placed downward, elongating the tighter muscles
stretching was more effective than thermotherapy or AROM and encouraging activity of the weaker, non-affected side.51
for improving passive cervical rotation.21 He et al documented Positioning the infant in prone encourages bilateral neck flexor
a stretching dose-response relationship with higher doses of elongation and strengthens neck and spine extensors.75 Visual
daily stretching by parents/caregivers leading to greater changes and auditory tracking can elicit head turning toward the affected
in passive cervical lateral flexion and rotation ROM.22 There is SCM52 to strengthen cervical rotation musculature.
no consensus on the techniques to perform the stretches, the Development of Symmetrical Movement: Observational
number of repetitions, the duration of stretches and rest peri- data (n = 173) suggest that up to 25% (n = 44) of infants
ods, and the number of individuals required for the stretches. with postural CMT may have transient motor asymmetry;
Stretching interventions should not be painful; stretches 2/3 of the 33 infants with follow-up data had no asymme-
should be stopped if the infant resists48 or there are perceived tries by age 2 years.97 Developmental exercises should be
changes in breathing or circulation.22 Low-intensity, sus- incorporated into physical therapy interventions and home
tained, pain-free stretches are recommended to promote ac- programs to promote symmetrical movement in weight-
ceptance of stretching by the infant and avoid micro trauma of bearing postures and to prevent the development of asym-
the muscle tissue.48 Manual myotomy, defined as a partial or metrical movement patterns in prone, sitting, crawling,
complete rupture of the SCM during manual stretching, has and walking.97,128
a reported incidence of 9.2% in infants with CMT and an SCM Environmental Adaptations: Adaptations to the infant’s
mass.95 In one study, the only risk factor for the occurrence of environment can be incorporated into the home manage-
manual myotomy during physical therapy was a young age at ment program. Alternating the infant’s position in the crib
the initial physical therapy session, with manual myotomy and on changing tables encourages head turning in the
occurring at approximately 31 days and 90% of events occur- desired direction.34,45,128 Strategic placement of the car
ring during the first physical therapy session.167 Infants with seat and toys in the car can also encourage head turning
and without manual myotomy have similar outcomes and in the desired direction; however, placing towel rolls or
prognoses.167 other positioning devices in the car seat is not recom-
Stretching can be done in many different positions such as mended since they can become a suffocation hazard or
in supine, side lying, sitting, lying prone on the parent/care- decrease the safety of the car seat.147,154 Minimizing the
giver’s chest with the infant’s face turned toward the shortened amount of time in infant equipment that places the child’s
SCM,52,168 with the child held laterally against the adult’s body head against a surface, such as infant swings and strollers,
known as the football hold,48,52 and during eating by encoura- has been recommended as part of a home program,126,127
ging turning toward the shortened SCM while bottle feeding or but not studied.
breastfeeding.59,128,154 The most important features are that Parent/Caregiver Education: Qualitative data on parents’
the child’s head and shoulders are stabilized to prevent com- experiences with infants with mild or severe CMT informs the
pensations and the cervical spine is gently guided through the content of parent/caregiver education on physical therapy man-
available PROM into the cervical rotation, lateral flexion, or agement of CMT.170 Eight themes were identified among all
the combination of rotation with lateral flexion that is parents: unfamiliarity with CMT diagnosis, varying approaches
restricted.45,52 The choice of a 1-person or 2-person technique of pediatricians, worrying about diagnoses of CMT and

404 Sargent et al Pediatric Physical Therapy

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 plagiocephaly, needing the PT’s support and reassurance, CMT or postural asymmetries, as adjuncts to the first-
managing the home program, appreciating family mem- choice intervention when the first-choice intervention has
ber’s support, dealing with more than CMT, and experien- not adequately improved range or postural alignment, and/
cing additional benefits.170 Two themes were unique to the or when access to services is limited, and/or when the
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parents of infants with severe CMT: reflecting on preg- infant is unable to tolerate the intensity of the first-choice
nancy to look for cause and experiencing anxiety after intervention, and if the PT has the appropriate training
finding an SCM mass.170 This study highlights the impor- to administer the intervention. (Evidence Quality: I-V,
tance of parent/caregiver education to build a strong par- Recommendation Strength: Weak)
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ent/caregiver-PT relationship over the episode of care,

educating the family on CMT, tailoring the home program
intensity to meet infant needs and family capacities, and Action Statement Profile
providing strong support and reassurance to parents/care-
Aggregate Evidence Quality: Level I-V studies, with
givers, especially to those with infants with severe CMT
a preponderance of studies with high risk of bias (refer to
who may be experiencing additional guilt and anxiety
associated with the SCM mass. Supplemental Digital Content 6, Randomized Controlled Trials
Parents/caregivers should be educated on the importance of Evidence-informed Supplemental Interventions for Infants
of “tummy time” or prone play while awake consistent with with Congenital Muscular Torticollis, available at: http://links.
Safe Sleep Recommendations,41,61,171 positioning and hand- lww.com/PPT/A545).
ling to encourage symmetry,97,128 minimizing the time spent Benefits: On an individual basis, combining evidence-in-
in car seats and carriers to avoid CD,64,126 and alternating formed supplemental interventions with the first-choice inter-
eating to each side.59,154 These strategies should be inte- vention may:
grated into daily routines and home programs to enhance • be effective in improving outcomes or shortening epi-
adherence. sode of care.
Parents/caregivers may be inclined to seek advice from • accommodate an infant’s temperament or tolerance to
social media, internet sites, and support groups. These intervention.
sources can provide an array of information, but the in- • avoid or minimize the need for future, more invasive
formation veracity varies, and the sites cannot tailor inter- procedures.
ventions to an individual child’s body structures and • increase parent/caregiver ability to implement home
activity limitations. Information on prone positioning for program.
play varies widely on when to start, how often, and for
how long a session.41 Parents/caregivers should be encour- Risk, Harm, and Cost:
aged to review internet information with their infant’s • Evidence-informed supplemental interventions should
primary care provider and/or PT regarding exercises or only be applied by clinicians skilled in that specific
interventions they are considering. Identification of evi- technique or modality, and who understand the poten-
dence-based, reputable internet resources would assist tial risks or side effects.
both clinicians and families in keeping up with current • There may be added parent/caregiver burdens to learn
and valid management approaches. The APTA Pediatrics additional intervention techniques.
has developed several free CMT CPG implementation • Some interventions may not be covered by insurance.
resources7 specifically for parents/caregivers. • Some approaches may increase the cost of care.
Research Recommendation: Studies are needed to:

• Identify intervention techniques and dosages, including Benefit-Harm Assessment: Preponderance of benefit for
accurate descriptions of active exercises, with links to the microcurrent (MC), soft tissue mobilization (STMo), and tradi-
CMT Severity Grades. tional Chinese medicine (TCM) massage if the clinician has
• Identify the components of optimal home programs. received specialized training. Undetermined benefits and
• Evaluate the benefits of individual vs group therapy harms/costs for other evidence-informed supplemental
conditions. interventions.
Value Judgments: Clinicians who are seeking to augment
C Action Statement 14. EVALUATE EVIDENCE-INFORMED their first-choice interventions should choose evidence-in-
SUPPLEMENTAL INTERVENTION(S) FOR APPROPRIATENESS formed supplemental interventions with the strongest evidence
TO AUGMENT THE FIRST-CHOICE INTERVENTION. PTs may first and for which they have appropriate training.
provide and document evidence-informed supplemental inter- Intentional Vagueness: While the evidence supporting
ventions, after evaluating their appropriateness for managing MC and TCM massage is consistent across studies, it is not

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 405

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
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 known when it is best to add it to a plan of care or which 5 minutes of ultrasound, and 30 minutes with the MC unit
approach is most effective. set up, but only 10 infants received active MC. Treatment
Role of Parent/Caregiver or Child Preferences: Parents/ sessions were 3 times per week until PROM resolved or there
caregivers may inquire about different interventions for the were no improvements after 6 months of ongoing care. Those
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management of CMT. receiving the active MC had significantly shorter treatment

Exclusions: None. durations (2.6 months) than those who did not (6.3 months).
Quality Improvement: The results are consistent with a prior clinical trial115 when
• Providing evidence-informed supplemental interven- 30 minutes of MC was applied to the involved SCM of infants
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tions may accelerate the resolution of CMT in infants with CMT, 3 times per week for 2 weeks, resulting in improved
whose progress has slowed. head tilt angle, neck rotation toward the affected side, and less
crying during therapy when compared to a control group of
Implementation and Audit: infants with CMT who received traditional stretching and ex-
• Document the application and dosage of supplemental ercises. The sample size was small (n = 7 experimental vs 8
interventions to accurately measure their impact on in- control), and there was no long-term follow-up. The average
fants with CMT. infant age was 7 months, and many had already been managed
• Audit the types and documentation of supplemental with stretching programs. A case study of a 19-month-old child
interventions to determine their overall benefit to with CMT and fibrotic nodules reported full passive cervical
children. rotation and lateral flexion, improved lateral cervical flexion
strength, and improved head tilt after 10 weeks of stretching,
strengthening, massage, and parent/caregiver education, in-
Supporting Evidence and Clinical Interpretation cluding 7 weeks of MC.172
A retrospective study of supplemental intervention use in Soft tissue mobilization (STMo) as described by Keklicek
infants with CMT54 found that infants who received first-choice and Uygur173 was applied in 3 phases: a passive mobilization
plus supplemental interventions were older with more severe CMT phase, mobilization with stretching, and mobilization with active
at the initiation of physical therapy compared to those who re- cervical rotation. For infants with CMT, a home program with
ceived only the first-choice intervention. The CMT resolution was STMo 3 days a week for 12 weeks, compared to only a home
similar in both groups of infants; however, the treatment duration program, resulted in improved cervical rotation PROM and head
of infants who received supplemental interventions was substan- tilt after 6 weeks of intervention, but not after 12 weeks of
tially longer.54 An anecdotal finding supported that manual tech- intervention or 18 weeks after the start of the study.173 Between
niques, defined as myofascial release and massage, were added to groups, there was no difference in lateral flexion PROM or AROM
the first-choice intervention early in the episode of care, in contrast throughout the study.173 It is not clear if the improvements at
to other supplemental interventions that were used later when the 6 weeks are due to the treatment technique or intensity of treat-
first-choice intervention did not result in the expected outcome.54 ment since the intervention for the control group was not dose
The following interventions are described as supplements equivalent and parents/caregivers performed an unspecified home
to the first-choice intervention described in Action Statement program of stretching and handling.
13 and are presented in descending order of evidence strength. Traditional Chinese Medicine Massage. A systematic re-
Some interventions in the common press, social media, or the view with meta-analysis, an RCT, and a retrospective compara-
internet have no peer-reviewed publications to describe their tive study support the efficacy of TCM massage.23,174,175 The SR
approach or effect on CMT, including some interventions cur- included 6 RCTs and 1 quasi-RCT. Pooled analysis of 2 RCTs
rently taught in physical therapy continuing education courses. supported that TCM massage had similar effects to stretching
Departures from this guideline should be documented in the based on effective rate, the percentage of infants with CMT that
child’s record at the time the relevant clinical decisions are improved (risk ratio 1.00; 95% CI, 0.94-1.06); however, both
made; clinicians are strongly encouraged to publish the clinical RCTs in the meta-analysis had a high risk of bias.174 Cui et al’s
reasoning and results of these alternative approaches. 2019 RCT compared 2 types of TCM massage and found that
infants in the modified tuina group had a greater effective rate
Level I and II Evidence from Small Controlled Clinical Trials than infants in the textbook tuina group; the study had a high
Microcurrent (MC) is a low-intensity single-channel alter- risk of bias.175 A retrospective study comparing stretching alone
nating current applied superficially at a level that is not per- to stretching preceded by 6 minutes of TCM massage to the SCM
ceived by the child. Two studies demonstrate reduced found an effective rate of 87.5% for both groups with improved
treatment duration and improved ROM with the addition of passive cervical rotation and lateral flexion in the TCM massage
MC to physical therapy intervention. In a 2014 RCT,168 all 20 group, but no difference in the surgical rate or the Muscle
infants received a home program, 20 minutes of exercises, Function Scale (MFS) between groups; the study had a high

406 Sargent et al Pediatric Physical Therapy

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 risk of bias.23 These studies support the feasibility of TCM been compared to physical therapy alone in a small RCT of
massage, but further high-quality research is needed to support infants with CMT.181 Results indicated no differences between
its efficacy. the groups, and the technique used for cervical manipulation
was not well described.181 The use of cervical manipulation in
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infants has no sufficient evidence of benefits and may be asso-

Level II Evidence From Cohort Studies ciated with higher risks of apnea and possible death.182-184 In
The following interventions for CMT documented improve- weighing the potential risks against the benefits of other ap-
ments in cohorts of infants with CMT before and after interven- proaches, the GDG does not recommend cervical manipulation
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tion, but intervention efficacies have not been established as an intervention for infants with CMT.
through controlled clinical trials: myokinetic stretching92 and
neural and visceral manipulation.176 Refer to the 2018 CMT
CPG, Castilla et al11 or direct references for greater details. Interventions without Published Evidence of Efficacy
The following approaches have either not been studied sys-
Level IV Evidence From Case Studies and Case Reports
tematically or shown not to provide any additional benefit. Addi-
The following interventions for CMT are described in case tional approaches were found on social media and the internet, as
studies and case reports but efficacy has not been established well as in the common press for which no peer-reviewed litera-
through controlled clinical trials: Tscharnuter Akademie for ture was found.
Motor Organization,79 the Tubular Orthosis for Torticollis Some interventions appear in print, online, on social
(TOT collar),177 soft foam collars, and custom fabricated cervi- media, in continuing education brochures, and at parent/
cal orthosis.178,179 Refer to the 2018 CMT CPG or direct caregiver support groups for infants with CMT and plagioce-
references for greater details. phaly, but no peer-reviewed studies have been found that
describe the approaches or their effectiveness for resolving
Indeterminant Evidence CMT, including craniosacral therapy, Total Motion Release,
Kinesiological taping (KT) refers to the use of stretchable and Feldenkrais. Clinicians and parents/caregivers should be
tape to support muscles and to provide sensory feedback. In aware that these approaches have no peer-reviewed studies
contrast to the 2013 CMT CPG recommendation that KT could that describe their clinical application, efficacy, risks, and
be a supplemental intervention, current evidence is indetermi- anticipated outcomes. Without studies, per guideline devel-
nant. Öhman reported an immediate effect of KT on MFS scores opment criteria, the GDG cannot review these approaches for
while the tape is on180; however, a 2016 RCT suggests that their efficacy. Clinicians who choose to use these approaches
there is no added value to KT when provided for 3 weeks in should document departures from the recommended ap-
conjunction with other conservative methods.169 This small proaches in children’s records at the time the relevant clinical
RCT had 3 infant groups who had KT applied 6 days/week decisions are made, obtain consent to treat from parents/
for 3 weeks; all groups received a home exercise program and caregivers that acknowledges the lack of published evidence,
physical therapy intervention. Group 1 had exercise only, carefully document objective measures of change, and publish
group 2 had KT applied to the involved SCM for inhibition their outcomes.
and the uninvolved SCM for facilitation, and group 3 had KT Research Recommendation: Studies are needed to de-
applied only to the involved SCM for inhibition. While there scribe and clarify the efficacy of all supplementary interven-
were within-group changes in neck PROM, MFS scores, and tions, including determinants for their choice, principles of
head shape symmetry from their baselines, there were no sig- application, dosages, and outcome measures.
nificant differences among intervention groups immediately
B Action Statement 15: INITIATE CONSULTATION WHEN THE
after intervention, at 1 month or 3 months postintervention.
This suggests that there is no added value of KT beyond ex- INFANT IS NOT PROGRESSING AS ANTICIPATED. PTs who are
ercise even over a 3-week intervention period. Since there is managing infants with CMT or postural asymmetries should
conflicting evidence of an immediate effect of KT, but not initiate consultation with the infant’s primary care provider
a sustained effect, additional studies of KT are needed to clarify and/or specialists about other interventions when the infant is
when and if this approach is useful with CMT. not progressing as anticipated. These conditions may include
when asymmetries of the head, neck, and trunk are not start-
ing to resolve after 4 to 6 weeks of comprehensive
Not Recommended intervention, or after 6 months of intervention with a plateau
Cervical manipulation and physical therapy focused on in resolution. (Evidence Quality: II, Recommendation
the encouragement of symmetrical motor performance has Strength: Moderate)

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 407

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Unauthorized reproduction of this article is prohibited.
 Action Statement Profile • Audit the number of infants that are fully resolved as
Aggregate Evidence Quality: Level II based on cohort and compared to those who require referral for interventions
outcome studies. other than physical therapy.
Benefits:
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• Other interventions (eg, botulinum neurotoxin therapy

Supporting Evidence and Clinical Interpretation
or surgery) can be considered to resolve the current
asymmetries and prevent further progression of defor- The literature supports a wide range of intervention dura-
mities and compensations. tions for conservative care, so the question of when to refer an
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• Provides the family/caregivers with alternative manage- infant who is not progressing as anticipated has no clear
ment strategies to help resolve asymmetries. answer. The duration of intervention will vary depending on
• Rules out an underlying condition that has not been the age of initiation of physical therapy intervention and the
identified during initial examination or follow-up physi- CMT severity grade. Infants younger than 3 months with
cal therapy sessions. a CMT severity grade of 1 to 3 (Figure 2) will most likely
NOT require 6 months of conservative intervention if the
Risk, Harm, and Cost: interventions appropriately address the impairments and
• The consultations and possible subsequent interventions there is adherence with home programming. Older infants
may require additional time of the parents/caregivers and who present with severity grades of 4 to 7 will more likely
add to the cost of care. require the full 6 months of care, or more, depending on the
number of comorbidities. Per Action Statement 12, factors
Benefit-Harm Assessment: Preponderance of benefit. associated with longer treatment durations include older age
Value Judgments: Collaborative and coordinated care is in at the initiation of physical therapy intervention, increased
the best interest of the infant and family-centered care. CMT severity, and birth history. Other factors that may in-
Intentional Vagueness: The GDG is intentionally vague crease treatment duration include insufficient frequency, in-
about the range of 4 to 6 weeks as the amount of time that tensity, and content of direct physical therapy intervention,
a PT should treat an infant who is not responding to intervention. inconsistent home program adherence by parents/caregivers,
Since younger infants typically change more quickly than and infant tolerance or medical conditions that may interfere
older infants, the GDG recommends that infants younger than with CMT interventions. Throughout the episode of care, the
2 months who are not responding to intervention should be PT should collaborate with the infant’s primary care provider
referred to their primary care provider sooner than infants older and the parents/caregivers to make a judgment on when to
than 2 months, who may require more time to respond to increase the frequency and intensity of direct physical therapy
intervention. intervention or consider alternative approaches. This decision
Role of Child/Parent/Caregiver Preferences: The infant’s should be based on the rate of change, the persisting impair-
age, CMT severity, change rate, family needs, infant coopera- ments, the age of the infant, and the needs and values of the
tion and developmental needs, and available family/caregiver family. The literature supports that if intervention is initiated
resources should help to determine the episode of care before before 3 months of age, 98% to 100% of infants will respond
an infant is referred to the infant’s primary care provider for to physical therapy intervention within a 6-month period of
consideration of alternative interventions. time,16,17,50,52 though full resolution may require longer dura-
Exclusions: None. tions. The determining factors should be documented mea-
Quality Improvement: sures of progressive improvement, with referral triggered by
• Referral to the primary care provider when the infant is plateaus at or after 6 months of consistent and intensive
not progressing as anticipated enhances coordinated intervention.
communication about the infant, enables the infant to Invasive Interventions: There are 2 conditions for which
receive additional or specialized interventions, and pro- a child may be referred for consideration of more invasive
motes stronger professional relationships. interventions: (1) if after 6 months of physical therapy inter-
vention, there is a lack of progress, or (2) if the child first begins
Implementation and Audit: intervention after 1 year of age and presents with significant
• Documentation should include information supporting restrictions and/or an SCM mass. Under these conditions, the
the reason for referral, the PT’s hypotheses about other PT should consult with the infant’s primary care provider or
factors that might need attention, and the intervention referring provider about other approaches; the 2 most reported
content, frequency, intensity, and duration. are botulinum toxin (BTX) injections and surgical management.
• Survey referral sources for how they would like to re- The following brief descriptions are provided for information
ceive communication about the children they referred but are not exhaustive reviews of these approaches. Clinicians
(ie, digital vs hard copy reports or letters). and families should discuss these options with their infants’

408 Sargent et al Pediatric Physical Therapy

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
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 primary care providers when physical therapy intervention has Action Statement Profile
not been successful. Aggregate Evidence Quality: Level II-III based on cohort
BTX is a neurotoxin that is postulated to act on the tight and outcome studies.
SCM in 2 ways: as a neuromuscular block that inhibits acet- Benefits:
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ylcholine release, thus reducing stimulation of an already tight Use of these criteria for discontinuation from direct PT
muscle, and as a neurotoxin causing muscle atrophy and weak- reasonably ensures that:
ening that allows for easier stretching.185 The use of BTX is
considered off-label for infants; however, there is a growing • The CMT has resolved within accepted ranges of mea-
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body of support for its use with recalcitrant CMT to reduce the surement error.
need for surgical management for infants who have not re- • There are no lingering secondary compensations or de-
sponded to at least 3 months of physical therapy.186-188 velopmental delays.
A meta-analysis of BTX for CMT found an effective rate of • The parents/caregivers know how to assess for regression
84% when BTX was used in combination with physical therapy as the infant grows and when to contact their infant’s
intervention.186 After BTX, the conversion rate to surgical primary care provider and/or the PT for reassessment.
management was 9%, and the adverse reaction rate was • Discontinuation documentation reflects the expected
1%.186 The most common adverse reactions included bruising, outcomes for the episode of care, relative to the baseline
neck pain, transient dysphagia, neck weakness, and fever of measures taken at the initial examination.
unknown origin.186 Other more severe reactions, including
death, have not been reported in the CMT literature.186,189 Risk, Harm, and Cost:
Surgical management of the SCM is the more traditional There is an unknown amount of risk that discontinuation
alternative for managing recalcitrant CMT.190-192 Surgical from physical therapy services with 5° residual asymmetry will
approaches generally fall into 3 categories: unipolar release progress to other anatomical areas (cervical scoliosis, craniofa-
of the distal SCM attachment, bipolar release of both SCM cial) or return as the infant grows.
muscle attachments, or tendon lengthening.193,194 Criteria Benefit-Harm Assessment: Preponderance of benefit.
that have been used to determine the timing for surgery Value Judgments: The GDG defines cervical rotation and
include: persistent limitations in cervical ROM >15°,14,195 cervical lateral flexion motions as included in PROM. Further, it
progressing limitations,48 persistent residual tight band or includes full active cervical rotation and lateral flexion in the
SCM mass,14 persistent visible head tilt,14,29,195 not respond- phrase symmetrical active movement.
ing to physical therapy intervention after 6 months,14,29 and Intentional Vagueness: None.
reaching the age of 1 year without resolution195; surgery Role of Child/Parent/Caregiver Preferences: Parents/
before 8 years of age appears to yield better outcomes than caregivers need to be educated about the importance of screen-
after age 8.196 The postoperative management of CMT is ing for asymmetries as the child grows and becomes more active
similar to preoperative management and can range from 4 to against gravity, eg, when the infant is first learning to walk.
6 weeks197 up to 11 months198 to work on scar management, They should also be advised that preferential positioning is
muscle strength, and ROM. often observed during times of fatigue or illness. Reevaluation
Research Recommendations: Studies are needed to de- is only warranted if the head tilt or asymmetry persists.
scribe the incidence of infants that require invasive care, their Exclusions: None.
history of interventions, the best time for referral, and any Quality Improvement:
associated physical therapy outcomes. • Complete documentation of baseline and discontinua-
tion measures will support more accurate physical
therapy outcomes.
• Measurements taken at each intervention session provide
IV. PHYSICAL THERAPY DISCONTINUATION,
feedback to parents/caregivers about the child’s progress
REASSESSMENT, AND DISCHARGE OF INFANTS WITH CMT
and support fine-tuning of the interventions, which can
B Action Statement 16: DISCONTINUE DIRECT SERVICES shorten the duration of care.3
WHEN THESE 5 CRITERIA ARE ACHIEVED. PTs should discon-
tinue direct physical therapy services and document outcomes Implementation and Audit:
when these 5 criteria are met: cervical PROM within 5° of the • PTs should follow up with families that discontinue
non-affected side, symmetrical active movement patterns, age- direct physical therapy services prior to achieving reso-
appropriate motor development, no visible head tilt, and the lution of asymmetries or formal discharge, to determine
parents/caregivers understand what to monitor as the child the reason for discontinuation.
grows. (Evidence Quality: II-III, Recommendation Strength: • PTs should educate parents/caregivers on signs of recur-
Moderate) ring CMT when changing from direct physical therapy to

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 409

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 monitoring with a reassessment at 3 to 12 months of age discontinuation from direct physical therapy intervention OR
or when the infant starts walking. when the child initiates walking. (Evidence Quality: II-III,
• PTs should send discontinuation and discharge reports Recommendation Strength: Moderate)
to the infant’s primary care provider to inform them
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about the infant’s progress.

• PTs should educate the infant’s primary care provider on Action Statement Profile
signs of recurring CMT when changing from direct phy- Aggregate Evidence Quality: Level II-III based on cohort
sical therapy to monitoring with a reassessment at 3 to and outcome studies (refer to Supplemental Digital Content 7,
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12 months of age or when the infant starts walking and Studies of Long-Term Outcomes, available at: http://links.lww.
to refer to physical therapy with any concerns. com/PPT/A545).
Benefits:
• Detection of postures and movement consistent with
Supporting Evidence and Clinical Interpretation relapsing CMT, particularly as infants initiate walking
and move against gravity.
An implementation study of the 2013 CMT CPG attrib- • Detection of developmental delays.
uted taking cervical ROM measurements at each visit to • Ability to restart home exercise programs if asymmetry is
reducing the episode of care for infants with CMT.3 Fre- identified.
quent, routine measurements may reduce treatment duration • Screening identifies other causes of asymmetry, other
by enhancing progress tracking and intervention adjustments, than CMT, if asymmetries reappear.
such as working more closely with parents/caregivers to im-
prove their skills and confidence in administering interven- Risk, Harm, and Cost:
tions at home. • A single follow-up reassessment will require additional
Discontinuation of direct services occurs when the infant has time of the parents/caregivers and minimally add to the
achieved the 5 criteria and direct intervention is no longer cost of care.
warranted. Discharge is defined as occurring 3 to 12 months • A single follow-up reassessment will require monitoring
after the discontinuation of direct services when physical ther- when to schedule an infant for reassessment and may be
apy reassessment for residual CMT or other developmental easily missed.
concerns are negative. Benefit-Harm Assessment: Preponderance of benefit.
While the duration of intervention for the individual infant Value Judgments: A single follow-up physical therapy
will vary depending on the constellation of factors identified in reassessment for infants with a history of CMT is consistent
Figure 2, the criteria for discontinuing direct physical therapy with the APTA Guide to Physical Therapist Practice 4.0, which
services are based on norms for infant growth and describes the roles of a PT as including prevention of recidivism
development,106 known risks of early delays,61,70,199 and evi- and preservation of optimal function.71
dence of possible long-term sequelae.200 Functionally, it is Intentional Vagueness: The time at which the follow-up
critical that the infant who has achieved full PROM can actively reassessment is scheduled (3-12 months) is varied because an
use the available range, so physical therapy criteria for discon- infant’s age at discontinuation from direct physical therapy inter-
tinuation should address developmental activity rather than vention will vary. Reassessment of younger infants, discontinued
focus solely on biomechanical measures of change.69 Persistent from direct intervention between 4 and 6 months, may need to
functional limitations or developmental delays, after achieve- occur sooner when the infants are initiating standing and walk-
ment of full PROM, are reasons to extend or initiate a new ing. It is not known how far out into early childhood that
episode of care. Finally, these criteria are common across the reassessment should occur. Literature suggests that by 8 to
literature and thus are in keeping with current practice norms. 15 months, infants with delays at 2 to 6 months catch up with
Research Recommendation: Longitudinal studies are their peers,70,201 and they continue to demonstrate age-appro-
needed to understand the best criteria and/or timing for dis- priate motor development at preschool age.199 However, a single
continuing infants from direct physical therapy intervention follow-up study suggests that some infants are at greater risk
and the final discharge from the episode of care. for persistent neurodevelopmental conditions, such as devel-
opmental coordination disorder and attention deficit hyper-
B Action Statement 17: REASSESS INFANTS 3 TO 12 MONTHS activity, which may not become evident until the early school
AFTER DISCONTINUATION OF DIRECT SERVICES, THEN DIS- years.200
CHARGE IF APPROPRIATE. PTs should complete a full evalua- Role of Child/Parent/Caregiver Preferences: Parents/
tion to assess for reoccurrence of CMT and evidence of atypical caregivers may choose to forego a physical therapy reassessment
development if the parent/caregiver or primary care provider if it places undue burden on the family for travel, time, or
observes asymmetrical posture OR 3 to 12 months following finances. Parents/caregivers should be advised at discontinuation

410 Sargent et al Pediatric Physical Therapy

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 of direct physical therapy intervention of the small chance that direct evidence of the long-term effectiveness of early physical
developmental conditions may evidence themselves when the therapy intervention, nor the rate of recidivism following early
child enters school. Parents/caregivers should be counseled to intervention. Studies report an “excellent” resolution of CMT as
express concerns to their infant’s primary care provider and seek having less than 5° of passive cervical rotation asymmetry with
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a physical therapy reevaluation if they observe persistent asym- the opposite side,29,160,203 and a “good” resolution with as
metry or developmental delays. much as 10° residual.203 It is not known whether the last 5°
Exclusions: None. to 10° spontaneously resolves or in whom a mild limitation will
Quality Improvement: remain, whether achieving cervical rotation PROM equates to
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• Long-term follow-up reassessments will provide data full active use of the available range, or whether residual asym-
to understand the incidence of residual asymmetries metry influences normal development.
or functional deficits, as well as parent/caregiver Öhman and Beckung199 found that infants with a history of
satisfaction. CMT did not exhibit motor delays at preschool age, but 7%
exhibited a head tilt and 26% had some degree of PROM
Implementation and Audit: asymmetry. The clinical significance of asymmetric neck
• Provide education to clinicians and families about this PROM is uncertain because only children with CMT were
recommendation to improve adherence to reassessment. followed. All had ≥85° of rotation PROM to each side, and 7
• Determine a method, based on location and health care children had a cervical lateral flexion PROM difference between
coverage processes, to facilitate a cost-effective physical sides of only 5° to 10°; it is not clear if age-matched children
therapy reassessment. This may require PTs to educate without CMT would present with similar results. In this study,
administrators, service coordinators, and non-medical pro- asymmetric cervical PROM at preschool age was associated with
fessionals about the importance of a comprehensive reas- the degree of asymmetric cervical rotation PROM as an
sessment for infants with CMT. PTs should collaborate infant.204
with their administrative and health care providers to The documented potential for increasing muscle fibrosis,91
develop pathways for parents/caregivers to obtain this re-
developmental delays,200 and hemi-syndrome support that
assessment, either internally or by referral to other services.
a single physical therapy reassessment is prudent to determine
• Provide clear instructions to parents/caregivers and the
if the resolution of CMT achieved at an earlier age is maintained
infant’s primary care provider about the signs of unre-
as the infant continues to develop and to assess for potential
solved or returning CMT.
developmental delays or biased limb use. Primary care provi-
• After reassessment, document on a report sent to the
ders should be cognizant of the risk for asymmetries and/or
infant’s primary care provider:
motor delays during routine physical exams as infants with
○ That parents/caregivers were instructed to notify the
a history of CMT are followed through to their teen years.
PT if there is a persistent return of head tilt or asym-
The length of time after discontinuation that a physical
metry in active rotation or lateral flexion ROM.
therapy reassessment should be conducted is supported by
○ The physical therapy recommendation to the primary
level IV evidence. Wei et al153 proposed following infants
care provider to check the infant’s cervical ROM and
until complete resolution or a minimum of 12 months. Ultra-
presence of head tilt in well-child visits.
sound images suggest that while clinical indicators of ROM may
○ The physical therapy recommendation for a physical
improve, they are not correlated with SCM fibrous changes, and
therapy reassessment to check the condition of the
these fibrous changes can continue until at least age 3 years.91
infant’s CMT and general development at 12 months
Finally, the potential for developmental delays may not become
or when walking begins.
• Send reminder texts, emails, and/or postcards to the evident until early school age,200 so a reassessment when the
parents/caregivers for the physical therapy reassessment. child enters elementary school may be warranted if a parent/
• Audit the number of reassessments completed vs the caregiver or teacher reports, or the child presents with, residual
reasons for no reassessment, or premature discontinua- asymmetries, developmental delays, or preferential positioning.
tion of services. Regional differences as to when a child is seen for their final
direct service appointment may differ from the criteria for dis-
charge, when the episode of care for CMT is considered closed.
Supporting Evidence and Clinical Interpretation Research Recommendations: Studies are needed to:
The long-term consequences of CMT are implied from • Determine the most reasonable physical therapy reas-
studies of older children and adults who require surgeries for sessment times after discontinuation of direct physical
correction of unresolved asymmetry193,202 and from long-term therapy intervention based on initial presentations.
outcome studies.52,199 While the short-term outcomes of phy- • Establish the level of risk of developing asymmetries
sical therapy management are well documented, there is little following an episode of intervention.

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 411

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
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 • Determine the validity and reliability of using telemedicine
or virtual meetings as compared to in-person physical
therapy reassessment for the 3- to 12-month reassessment.
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SUMMARY
A review of the literature, including a focused systematic
review, reaffirms and updates 17 graded action statements that
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address education, referral, screening, examination and evalua-

tion, classification, prognosis, first-choice and evidence-in-
formed supplemental physical therapy interventions, inter-
professional consultations, discontinuation, reassessment, and
discharge, with recommendations for quality improvement,
implementation, and audits. Flow sheets for referral paths and
classification of CMT severity have been reaffirmed and up-
dated. Evidence tables are available as supplemental digital
content. Research recommendations made for 17 practice is-
sues are summarized at the end of the document.

412 Sargent et al Pediatric Physical Therapy

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
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 GENERAL GUIDELINE IMPLEMENTATION STRATEGIES

Suggestions are provided as general strategies for clinicians

selected changes in practice to determine their efficacy,
to implement the action statements of this CPG but are not an
and finally, routine integration of the tested changes.206
exhaustive review. Clinicians will need to assess their own • Identify early adopting clinicians as opinion leaders to
practice structures, cultures, and clinical skills to determine
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introduce the guideline via journal clubs or staff

how to best implement the action statements.
presentations.206
The GDG recommends that: • Identify gaps in knowledge and skills following content
• Education about the 2024 CMT CPG be included in presentations to determine staff needs to implement
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physical therapy curricula. recommendations.208

• Continuing education programs are provided to PTs on • Use documentation templates to facilitate standardized
the updates in the 2024 CMT CPG. collection and implementation of the recommended
• PTs distribute implementation resources developed by measures and actions.4,209,210
APTA Pediatrics7 to parents/caregivers, primary care • Institute quality assurance processes to monitor the rou-
providers, and other health care providers who summar- tine collection of recommended data and implementa-
ize the applicable key points of the 2024 CMT CPG. tion of recommendations and to identify barriers to
complete collection.206,211
Strategies for Individual Implementation • Measure structural outcomes (eg, dates of referral and
equipment availability), process outcomes (eg, use of
• Seek training in the use of the recommended standar-
tests and measures, as well as breadth of plan of care),
dized measures and/or intervention approaches.205
and service outcomes (eg, child impact across the ICF
• Build relationships with referral sources to encourage
domains, costs, and parent/caregiver satisfaction)206,207
early referral of infants.
to describe service delivery patterns and publish results.
• Measure individual service outcomes of care (eg, child
impact across the ICF domains, costs, and parent/care-
giver satisfaction).206,207

Strategies for Facilitating Clinical Practice Guideline

Implementation in Other Clinicians
• Recognize that adoption of the recommendations by
others may require time for learning about the 2024
CMT CPG content, developing a positive attitude toward
adopting the action statements, comparing what is al-
ready done with the recommended actions, trialing

Pediatric Physical Therapy Physical Therapy Management of Congenital Muscular Torticollis 413

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 SUMMARY OF RESEARCH RECOMMENDATIONS PER ACTION STATEMENT

Action Statement 1: Educate Expectant or New Parents/

CMT images are useful, and how images affect the
Caregivers of Newborn Infants to Prevent Asymmetries/CMT.
plan of care.
Studies are needed on the impact of education of:
• Health care providers and their knowledge of pediatric
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Action Statement 8: Examine Body Structures.

PTs’ roles in managing postural preference. Studies are needed to:
• Parents/caregivers about their experience of receiving
this education. • Develop reliable, valid, and time-efficient methods of
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measuring infant cervical PROM, including lateral flex-

Action Statement 2: Assess Newborn Infants for ion, and large-scale normative data of PROM established
Asymmetries/CMT. by age in months.
Studies are needed to determine: • Determine the sensitivity and specificity of the Muscle
• Whether routine screening within the first 2 to 3 days of Function Scale to differentiate infants with clinically sig-
life increases the rate of CMT identification and/or in- nificant limitations from infants with typical development.
creases false positives. • Establish a clinically practical, objective method of measur-
• The barriers to early referral of infants with CMT to ing cervical rotation AROM in infants 0 to 3 months and
physical therapy. infants ≥3 months to assess baseline and change over time.
• Determine what, if any, correlation between active and
Action Statement 3: Refer Infants with Asymmetries/CMT passive ROM should be used for discontinuation and/or
to their Primary Care Provider and a Physical Therapist. discharge criteria.
• Describe and differentiate signs of discomfort and pain
• Studies are needed to clarify the predictive baseline observed in infants with CMT during examinations and
measures and characteristics of infants who benefit intervention.
from immediate follow-up and to compare the cost- • Determine the validity of the FLACC in rating pain in
benefit of early physical therapy intervention and educa- infants with CMT.
tion as compared to parent/caregiver instruction and • Determine whether pain tools need to be specific to
monitoring by primary care providers. CMT.
• Longitudinal studies of infants with CMT would clarify how
referral timing and intervention initiation impact body
Action Statement 9: Classify CMT using the CMT Severity
structure and functional outcomes and overall care costs.
Grading Scale.
Action Statement 4: Document Infant History. • Studies are needed to determine a reliable, valid, and
clinically practical method of measuring cervical lateral
• Studies are needed to clarify how the health history
flexion and then to determine if lateral flexion measures
screening influences CMT identification, physical ther-
relate to the CMT Severity Grading Scale.
apy diagnosis, prognosis, and intervention.
Action Statement 10: Examine Activity and Developmen-
Action Statement 5: Screen Infants for Nonmuscular
tal Status.
Causes of Asymmetry and Conditions Associated with CMT.
• Studies are needed to identify the best developmental
• Studies are needed to identify the precision of screening
tests to use for infants with CMT, from birth through
procedures specific to CMT.
12 months, so that the same measures can be documen-
ted on all infants, enabling comparison of outcomes
Action Statement 6: Refer Infants from Physical Therapist
across studies.
to Primary Care Provider if Indicated by Systems Review.

• Studies are needed to clarify the incidence of nonmus- Action Statement 11: Examine Participation Status.
cular causes of CMT and associated conditions, and how
• Studies are needed to quantify changes in participation
early referral impacts ultimate outcome.
and clarify how the participation elements inform the
plan of care.
Action Statement 7: Request Images and Reports.

• Studies are needed to determine who would benefit Action Statement 12: Determine Prognosis.
from imaging, at what time in the management of Studies are needed to:

414 Sargent et al Pediatric Physical Therapy

Copyright © 2024 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 • Clarify the interaction between the factors associated physical therapy reassessment for the 3- to 12-month
with full symptom resolution and episode of care. reassessment.
• Clarify the prognostic accuracy for full symptom resolu-
tion and the episode of care. Development of the guideline details are shown in Supple-
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• Compare the efficacy of different delivery models, mental Digital Content 10, available at: http://links.lww.com/
eg, individual versus group or clinic vs home vs PPT/A545.
telerehabilitation.
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