CONGENITAL MUSCULAR TORTICOLLIS

This study discussed the management of congenital muscular torticollis and deformational plagiocephaly. A fibrotic and shortened SCM muscle ist the most typical finding in CMT along with a head tilt toward the involved SCM muscle.The etiology and pathogenesis of CMT is not completely understood but may be related to breech presentation, birth trauma, nuchal cord, or use of suction and forceps at birth. Sonography and physical examination can confirm the pathology of CMT. Most cases of infants with CMT can be succesfully managed with conservative treatment utilizing passive and active neck stretching exercices, active repositioning, postural control exercices to encourage the head to turn toward the involved SCM muscle side. The severity  of the neck rotation restriction, the amount and distribution of fibrosis in the SCM muscle, and the age of the infant at initiation of physical therapy intervention will influence the succes rate of coservative management. A cranial remodeling  band may be necessary to correct deformational plagiocephaly associated with CMT. Motor control and postural development as well as prevention and treatment of facial asymmetry and deformational plagiocephaly should be emphasized along with intervention of CMT.

Torticollis (tortum collum) is characterized by unilateral retraction of sternocleidomastoid muscle (SCM), resulting in an asymmetric position of the head and neck. It belongs to non-paroxysmal types of cervical dystonia.

A. Torticollis:

The head is: flexed forward, leaning toward the shoulder on the side of the retraction, chin turned towards the shoulder opposite the retraction.

Main muscles involved: splenius capitis ipsilateral the chin, SCM controlateral the chin posture, levator scapulae, oblique longus capitis ipsilateral the chin , semispinal

Secondary muscles involved: longissimus ipsilateral the chin, longus capitis and trapezius controlateral chin posture.

B. Laterocollis:

The head tilts from side to side.

Muscles involved: unilateral splenius capitis, ipsilateral scalene complex, levator scapulae, longissimus, splenius cervicis.

C. Retrocollis:

The head tilts backward.

Muscles involved: splenius capitis bilateral, semispinal capitis, longissimus, splenius cervicis.

D. Anterocollis:

The head tilts forward.

Muscles involved: bilateral sternocleidomastoid, scalene complex.

Classification of Torticollis

Non – paroxymal Torticollis:

1. congenital muscular torticollis;
2. bone torticollis: Klippel-Feil, L. Down, syndrome, vertebral fractures, inflammatory causes, atlantoaxial subluxation;
3. damage to the CNS or PNS: tumours, hypoxic-ischemic lesions, peripheral lesions – brachial plexus;
4. eye level: superior oblique palsy, paralytic horizontal strabismus, spasmus nutans;
5. non-muscular conditions – retropharyngeal infections.

Paroxymal Torticollis (Dynamic)

1. benign Paroxymal Torticollis;
2. primary or Secondary Spasmodic Torticollis (Huntington, Wilson);
3. sandifer syndrome (gastroesophageal reflux);
4. torticollis induced by drugs (neuroleptics);
5. torticollis induced by increased intracranial pressure (cerebral pseudo tumours);
6. torticollis as conversion syndrome.

Congenital muscular torticollis (CMT) may originate:

1. during the intrauterine life, as a result of prolonged posture that shortens the SCM muscle; these modifications are due to the compression of the front area of the child’s chest and shoulder area on the child’s face (2.6);
2. during birth, by the trauma of SCM, including cranio-facial skeletal deformities on the same side with affected SCM, perinatal vascular or neurogenic obstructions.

During labour, the position of the head and neck in forward, lateral and rotational flexion may damage the SCM and the brachial plexus, resulting in ischemia, oedema, and neurological impairment. (6, 13)

Therapeutic intervention should start early to restore the normal movement of the neck and to stop the process of skull deformation, the facial asymmetry and asymmetric motor development.

The etiology of congenital torticollis includes (2,4,5): SCM poor vascularization, muscle tears, myositis, hereditary factors, intrauterine malposition

Torticollis may also associate with (6, 11, 12, 16, 21): homolateral mandibular asymmetry, deformation of the ear, plagiocephaly, scoliosis, asymmetry of the pelvis, coxofemoral luxation (1 in 5 children with the CMT has hip subluxation or dislocation), foot deformities.

It has been shown in a study that 16% of healthy infants showed a slight degree of torticollis with moderate craniofacial asymmetry. (23) Torticollis is defined from 15° difference between the lateral, left to right flexion of the neck, in supine position (SP). Children born with torticollis are at risk of plagiocephaly in 80-90% of cases (10). If cranial deformation begins in utero, it will continue after birth, thus aggravating if the baby sleeps and it is maintained in SP all day.

Factors that favour the emergence of CMT (2, 5, 6, 23): weight at birth, male sex, breech presentation, multiple pregnancy, first pregnancy, prolonged labour, use forceps or vacuum.

In the case of congenital torticollis, when touching the SCM a spindle shaped tumour swelling (olive) may be felt, with a diameter of 1-3 cm, which occurs 14 to 21 days after birth, sometimes even after 3 months.

Generally, it disappears after 4-8 months. Its biopsy reveals a fibroid and it is characterized by deposition of collagen and fibroblasts around the muscle fibre, with the absence of normal striated muscle. The nature of that tissue suggests the damage has started during prenatal period and is due to the position in the womb. (6)

Four subtypes of congenital Torticollis have been identified:

1. Sternocleidomastoid tumour with a discrete palpable mass in the body of the SCM. Normal radiological examination.
2. Muscular torticollis with existing retraction, but without a palpable tumour mass inside the muscle tissue. Radiologically normal.
3. Postural torticollis, without retraction, without palpable tumour mass. Radiologically normal. Causes: Benign paroxysmal torticollis, congenital absence of one or more cervical muscles or retraction of other muscles of the neck. (Cheng)
4. Postnatal torticollis (14): environmental, induced by plagiocephaly, induced by preferred positions, in case of cerebral palsy, Down syndrome, myelodysplasia, dysfunction of the occiput area – C1.

Anatomic elements of SCM:

It consists of four distinct portions:

• a deep cleido-mastoid portion starting from the medial third of the clavicle to the mastoid apophysis;
• three superficial portions: cleido-occipital, sterno-occipital and sterno-mastoid.

The last 2 superficial portions have a common tendon attached to the top of the sternum. The sterno-occipital portion together with the cleido-occipital one are inserted in the superior nuchal line, while the sterno-mastoid portion is inserted on the upper and front part of the mastoid process.

SCM is innervated by the cervical nerve II and the spinal portion of the accessory nerve (which also innervates the upper portion of the trapezius). Children with torticollis resulted from intrauterine malposition also suffer from impairment of the upper trapezius on the same side.

Differential diagnosis: (1, 7)

It should be noted that 1 in 5 children with postural torticollis, does not have a muscular aetiology:

1. Malformative torticollis (abnormalities of the skull base, cranial-spinal joints or cervical vertebrae). It appears later in life than congenital torticollis. It is diagnosed radiologically.
2. Neurological torticollis: pain in the posterior fossa or bulbar region. It is associated with intracranial hypertension.
3. Disorders in constitutional bones: achondroplasia, Morquio’s syndrome, Hurler’s syndrome, Klippel-Feil syndrome.
4. Infectious torticollis (Grisel’s syndrome caused by acute upper respiratory tract infections, retropharyngeal abscess, otomastoiditis, etc). It is not present at birth.
5. KISS syndrome (Kinematic Imbalances due to Suboccipital Strain) – 8% of the population.(1)

Described as a functional disturbance of the cranio-cervical symmetry, characterized by: head tilt, asymmetry of the face and skull, asymmetrical limb movements, unilateral posture of trunk, lateral or medial flattening of occiput, portions of alopecia in the back of the head, sleep disturbances, stereotyped movements of the head, the infant cries frequently, especially when put in the perambulator or car seat.

In untreated children or adults, the following symptoms are described: difficulty in concentrating and learning, hyperkinesia, headache, tinnitus, vertigo, growth retardation, motor deficit, balace disorders, herniated disc.

Factors favouring the syndrome- the same as those for torticollis.

Structural and functional changes: (2, 5, 11, 12, 25)

• the child cannot maintain alignment on the midline of the head, given the retraction and heterolateral neck muscle imbalance;
• the child has diminished homolateral neck rotation, flexion and heterolateral extension;
• craniofacial changes appear: asymmetry of craniofacial skeletal structure; asymmetry of masticatory and lingual muscles; lack of development of homolateral jaw; mandibular hypoplasia (early sign of CMT); ascent of temporomandibular joints; dental occlusion problems; posterior inferior orientation of the homolateral ear; asymmetry of the eyes, the homolateral eye being smaller; deviation of the chin and nose; deformation of the skull base.

The relationship between congenital torticollis, cranio-facial asymmetry and subluxation of the cervical spine has been demonstrated. 26 out of 30 patients had C1-C2 subluxations. This would explain the remainder asymmetry of the head and neck in children who have still made kinesiotherapy intensively. Apart from SCM, in muscular torticollis retractions of other muscle can occur, too: platysma, scalene, hyoid, muscles of the tongue, facial muscles, contributing to impaired motility of mouth and lack of head control in ventral decubitus (VD).

Other characteristics:

• curvatures of the thoracic spine in the sagittal plane, with the concavity towards CMT;
• persistence of the aymmetrical tonic neck reflex (ATNR);
• asymmetric positioning of the pelvis: when the facial side of the hip is in abduction, the occipital side is adducted.

When the infant will aquire the sitting posture, there will be a double curvature of the spine to compensate for the tilt of the head and the pelvis.

Limitation of the movements (11, 12):

The child with CMT has: permanent asymmetry of head movements; asymmetry of primitive reflexes; it uses homolateral hand less; homolateral visual field shrinks; there are asymmetries in rolling, crawling, walking; incomplete development of automatic postural reactions; persistence of postural asymmetry leads to structural deformations such as: pelvic obliquity and scoliosis.

The infant will behave like a paralyzed person, having difficulty in: keeping a weight in the homolateral upper limb (UL); midline extension and supination of the forearm; using the UL in defence and balance reactions.

Besides limited the cervical movements other affections manifest themselves, too: sensory systems (vision and the vestibular function), postural organization, orientation and body schema. The motor development stages evolve atypically, since the subsystems (visual, vestibular, somatosensory and musculoskeletal) develop asymmetrically.

Anamnesis and examination in the rehabilitation centre: (12, 13)

• the prenatal development, gender, birth development must be assessed, other possible congenital abnormalities need to be studied, and other investigations should be carried out;
• we shall find out how much time the infant spends in the perambulator, or any in any type of swing or infant seat; how long he is positioned in DD or VD while he sleeps, in what preferred direction he has his head rotated, how is he fed, any medication, what other rehabilitation interventions he had undergone;
• the musculoskeletal system should be examined in detail to assess the restriction of the articular mobility, the retraction of the SCM and upper trapezius, the asymmetry of the extension and flexion of the cervical contralateral area, the existence of skin folds;
• passive motion of the head allows the determination of the amplitude of the rotation left- right movement;
• slight traction of the cervical spine allows the assessment of the infants ‘s ability to align his spine and to eliminate the tendency of the position induced by the retraction of SCM;
• pulling slightly at the area between the shoulder and the occipital zone will permit the assessment of the retraction of the upper trapezius, scalene and of the posterior homolateral muscles of the neck;
• passive movements of the neck will be evaluated in VD, with head and neck off the exam table;
• the movements of the shoulder girdle will be observed and of the arm on the same side, targeting the movements of adduction and flexion of the arm, and those of supination for the forearm;
• the position the trunk when moving the body weight from one leg to another will be followed as well as the position of the homolateral lower limb (LL) and of the pelvis at their loading (in the older infant);
• the movements of the spine will be assessed in case of a decrease in extension, anterior and lateral flexion, and rotation;
• head posture, passive and active movements will be assessed in VD and sitting position, the child following an object or a person. It is a useful idea to measure the angles;
• examination of the affected muscles includes muscle palpation to assess the quality of tone or possible existence of tumours. The affected muscle will be examined from the perspective of its extensibility in various positions;
• request for voluntary movements will be answered against gravity, or by eliminating it;
• a possible asymmetry of the hips might be noted, too; The length of the LL will be assessed as well as the hip abduction. The incidence of hip dysplasia associated with torticollis is of 8-20 %, often on the same side of the body.

Plagiocephaly and facial asymmetry (9, 14, 15, 23, 25):

• to assess asymmetries accurately, front, profile and rear photos of the vertex, and of the submental triangles are required;
• asymmetries and their location areas will be described (either occipito-parietal or temporal, etc.), as well as the asymmetry of facial muscles, narrowing of the temporomandibular joint space, alignment of the tongue and of the jaw and their movement;
• in plagiocephaly, occiput and frontal bone are deformed due to compression between the mother’s pelvic bones and lumbar-sacral region during the last trimester of pregnancy;
• the most common skull presentation is left occipital anterior (in conjunction with left SCM) with flattening of the right occipital area and the left frontal one;
• plagiocephaly may be on the same side or the opposite side of torticollis.

Risk factors predisposing to plagiocephaly: oligoamnios, uterine malformation, cephalhematoma, complications at birth, postnatal positioning, first pregnancy, male sex, muscular torticollis.

Progression of plagiocephaly stops around the age of 6 months, when the baby begins to sit independently. However, some studies indicate that craniofacial asymmetry still present at 6 months, will persist in adolescence and adulthood. (Mullliken)

The child with plagiocephaly will have his eyes examined, his hearing with vocalization, as well as from the perspective of automatic reactions, posture, and motor development.

Physical therapy: ( 2, 4, 8, 9, 20, 24, 25)

• immediately after birth, the neck being hypotonic, a soft cervical orthosis made of felt is recommended to limit body lateral bend. Eventually gentle passive movements for neck mobility;
• baby’s bed will be oriented so as to look at his mother in the direction of the correction of torticollis;
• toys, as well as the light source will be also placed in the direction that induces correction.
• during sleep, the child will not be positioned in VD, which will fix the incorrect posture, keeping the head of the child on the painless side;
• the age at which the actual rehabilitation starts is about 1 month for the Vojta method, or 2-3 months for conventional methods, when the child sees better at near and control of head appears;
• the goal of therapy is to elongate SCM, to restore elasticity and strengthen the antagonist muscles;
• stretching executed 3 times weekly by the kinesiotherapist consisting in 3 repetitions of 15 elongations of SCM of 1 second with 10 seconds break;
• during the rest of the time, the family will be instructed to execute elongations and rotations of the neck by 2 persons, 4-5 times daily (about 40 exercises per set) together with rotation, flexion, lateral extensions (10 sets for each exercise for a duration 10 seconds);
• exercises are done by two people, with the child in DD, head off the table. One person stabilizes the sternum, shoulders, scapula, the other will run the stretching.

Example for left torticollis:

1. Asymmetric extension of the neck to the right to elongate left SCM and anterior muscles of the neck;
2. Asymmetric flexion of the neck to the right to elongate the upper left trapeze and the posterior cervical muscles;
3. Asymmetrical lateral right flexion of the neck to elongate the left SCM;
4. Rotation of the neck to elongate the left SCM.

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During the exercises the following vital signs will be tracked: changing the face colouring, respiratory rate, any nose wings beats, leading to cessation of therapy. Passive movements will be executed slowly and stretching will not be run against the active resistance of the infant. It expresses discomfort through tense postures of the body, arching, grimacing, crying. The infant’s stress is countered by local warm compresses, effleurage, stretching performed after bathing.

In our clinic, the treatment consists of Vojta therapy, and in stretching described above.

In case of KISS syndrome it is recommended:

• Either Vojta therapy,
• Or Arlen therapy, which consists of short percussion with therapist’s medius finger in the atlas area, which will change the disturbance of muscle tone and of the vegetative system.

Several sessions are needed. At first, cervical spine radiography is done.

Contraindications for passive mobilizations: bone abnormalities, fractures, Down-syndrome, myelomeningocele, cardio-respiratory problems, TBC, osteomyelitis, malignancy, ventriculo-peritoneal shunt, important ligamentous laxity, Arnold-Chiari malformation.

Biomechanics of stretching (13):

Taking into account the origin and insertion of SCM, which are stabilized, we can determine the type of elongation that should be used:

• ipsilateral rotation;
• controlateral lateral flexion;
• controlateral asymmetric extension, with the starting point in the neutral alignment of the cervical spine;
• the exercises are done exclusively by two people, one needs to ensure the stability of the shoulder and their parallelism with the pelvis;
• to maintain the results achieved by stretching, the infant will be trained to tone his SCM antagonist muscles, developing his controlling toward the midline.

For example, to place his ear on the controlateral shoulder, to achieve flexion and extension to the controlateral part and the rotation of the head and neck towards the torticollis part.

At 15 months the child is able to perform these movements by verbal command or imitation, if it has been treated correctly by this age.

Orthotics (2, 13, 22 ):

Soft neck brace is recommended for reverse positioning with that produced by torticollis. It is suitable for 3-4 month infants with a constant inclination of the head at minimum 5°, maintained for about 80% of the waking period.

The child must achieve passive lateral flexion of the neck at least 10° on the unaffected side, or, from lateral decubitus, achieve alignment of the head on the affected side.

Orthosis will not be used as a permanent passive support because it may generate depression of the shoulder area from the healthy part and bending of the cervical spine.

Orthosis will be worn in the perambulator or during sleep.

Vital signs, as well as skin integrity will be monitored continuously.

Medical management ( 6, 17, 20, 25)

• every 3 months, movement normalization in the neck and lack of regression will be tracked;
• the paediatrician will track any possible plagiocephaly and if there are changes in the position of the spine;
• any eventual deviations in the development of the mandibula, any occlusion disharmonies or difficulties in chewing will be noted.

Surgery (2, 3, 17, 19)

• it occurs only after 6 months of intensive physiotherapy treatment, during which there is no improvement;
• indication for surgery includes maintaining head tilt, passive rotation deficit, a lateral neck flexion greater than 15°, a fibrosis of the SCM, lack the correction of plagiocephaly.

Surgical procedures:

• sectioning of the SCM in one or more point;
• total excision of SCM;
• SCM functional myoplasty;
• endoscopic surgery – it preserves neuro-vascular structures;
• surgery is indicated between 10 months-5 years of age. It was found that infants who suffered a surgical intervention at 10-12 months are the most likely to correct facial and cranial asymmetry;
• for the untreated cases, discovered at 5-7 years of age, the practice is to perform tenotomy with the lengthening of the SCM or plastic surgery for muscle lengthening.

Plagiocephaly (14, 16, 19, 22):

The key to success of the treatment of plagiocephaly associated with congenital torticollis, is represented by early diagnosis and treatment. About 80% of the skull growth occurs before the age of 12 months.

Cranial deformations:

• fronto-temporal area of the torticollis and occipito-parietal area of the opposite side are flattened;
• the areas on the opposite side are prominent.

The result is facial asymmetry by reducing the height of the face on the side of torticollis, developing with time hemi-hypoplazia.

Clinical examination takes into account: age; response to conservative treatment of torticollis.

According to these factors the specialist will determine further medical conduct.

The recommendation is that any newborn with cranial vault asymmetry higher than 4mm should be put to direct observed therapy and be recommend a special program for positioning during sleep.

The family will be trained to prevent child placement in the LD on the flattened skull.

The ideal time to get results is in the first 3 months of life, when bones of the skull are malleable.

If torticollis persists after this age, if the child maintains incorrect posture and plagiocephaly becomes obvious, the recommendation is to proceed to cranial remodelling with dynamic orthosis for cranioplasty (DOC).

Anthropometric measurements will be made beforehand as well as scans from different positions and angles.

The orthosis is used with infants over 4 months of age and puts pressure on the anterior and posterior cranial projections. The child will be checked twice weekly for corrections.

Areas of scalp redness persisting more than 30 ‘ from the removal of orthoses are not allowed.

The orthosis is used 23hours out of 24, one hour being necessary for hygiene and mobilization.

The duration of treatment depends on the severity of plagiocephalyi and the age when treatment began. Results obtained in the USA are presented as excellent.

Intervention of physical therapy: (2, 10, 13, 14, 18)

• passive mobilization of the neck, trunk and extremities;
• symmetrical rotations of the head from the midline to 80° to the right and left, from DD, VD, sitting and in orthostatic position (depending on age);
• alignment active play on the midline of the head and trunk to the affected side;
• exercises of anti-gravity strengthening of the trunk and neck, with symmetry to the affected part and to the unaffected one;
• symmetrical left-right exercises, and exercises of recovery and balance;
• exercises of active tilting of the head toward the unaffected side, with or without rotation toward the affected side.

There are a number of factors that contribute to the persistence of asymmetry in children with torticollis and retardation in motor development:

• lack of balancing the head during sleep in DD;
• improper positioning in the perambulator, on the seat or in the swing;

Children who are never positioned in VD, too and are kept in the perambulator for a long time do not have the possibility either to acquire control of head or to develop the strength of the neck extensor muscles. Thus, the following problems may appear: ear infections; difficulty in the emergence of dentition; baby cries frequently, is tired and upset.

It is mandatory to instruct the mother how to position the infant during the day, not leave it permanently in DD. (Timming Time):

• the child will be taken into the arms with head resting on mother’s shoulder;
• the will be put in VD on a blanket on the floor with toys around, possibly mother will sit in front of him in the VD position, trying to stimulate the extension of his paravertebral muscles for the control of the head (after 3 months);
• the infant will be positioned in VD on mother’s thigh, encouraging him to lift his head;
• the infant will be placed on a Bobath ball in VD and rocked back and forth;
• from DD, the infant will be slowly pulled by hand to facilitate the control of the head, an exercise which can be done either as anterior flexion of the trunk or from the side of the body;
• mother sitting “cross-legged” on the ground, will position the infant sitting in between her thighs and will make sideways movements as recovery and balance exercises.

These exercises will be done 2 times a day and will contribute to the child’s motor development and prevent postural plagiocephaly.

When torticollis is not corrected, because SCM retraction is not corrected , a rebound of the antagonists occurs by excessive elongation, thus weakening them. Children with congenital torticollis have an atypical neurological development plan due to musculoskeletal disorders occurring in the womb or in the first months of life.

The anatomical and physiological bases needed to develop in the first year of life are limited due to the development of certain asymmetric models that will be the cause of motor delay. This creates and an additional argument for the treatment of congenital muscular torticollis as early and sustained as possible.

THE 4 ELONGATION POSTURES: head extension, with flexion of the head, in rotation to the right, in rotation to the left. (infant with left torticollis)

BIBLIOGRAPHY

1. Biedermann H. 2007. KISS Kinder. Thieme,Stuttgart.
2. Burger A.- Wagner. 1991. Rééducation en orthopédie pédiatrique. Ed. Masson, p. 112-120.
3. Burstein FD. 2004. Long term experience with endoscopic treatment for congenital muscular torticollis in infants and children. A review of 85 cases. Plastic and Reconstructive Surgery. 114, 491-93.
4. Celayr AC. 2000. Congenital  muscular torticollis: Early and intensive treatment is critical, a prospective study. Pediatric Radiology, 22, 356-60.
5. Chang YI, Tan CK, Huang YF, Sheu JC, Wang NL, Yen ML, Chen CC. 1996. Torticollis: A long term follow up study. Acta Paediatrica Taiwanica, 37, 173-77.
6. Cheng JCY, Tang SP, Chen TMK. 1999. Sternomastoid  pseudotumor and congenital muscular torticollis in infants. A prospective study of 510 cases. Journal of Pediatrics 134, 712-16.
7. Cooperman D. 1997. Differential diagnostic of torticollis in children. Phisical and Occupational Therapy in Pediatrics, 17, 1-11.
8. Emery C. 1994. The determinants of treatment duration for congenital muscular torticollis. Physical Therapy, 74, 921-99.
9. Graham JM, Gomez M, Halberg A,  Earl D, Kreuzman L, Cui J, Guo X. 2005. Management of deformational  plagiocephaly. Repositioning versus orthotic therapy.  Journal of Pediatrics  146, 258-62.
10. Habal MB,  Leimkuehler TL, Chambers C. Scheurle J. Guilford AM.  2003. Avoiding the sequela associated with deformational plagiocephaly. Journ of Craniofacial Surgery 14, 430-37.
11. Hollier L., Kim J., Grayson BH., Mc Carthy JG. 2000. Congenital musc. Torticollis and associated cranio-facial charges. Plastic and Reconstructive Surgery 105, 827-35.
12. Hsieh YY, Tsai FJ., Lin CC.,Chang FCC., Tsai CH. 2000. Breech deformation complex in neonates. Journal of Reproductive Medicine  45, 933-35.
13. Karmel-Ross  K., Lepp M. 1997. Assessment and treatment of children with congenital muscular torticollis. Physical and Occupational Therapy in Pediatrics. 17, 21-67.
14. Littlefield TR., Reiff JL., Rekate HL. 2001. Diagnosis and management of deformational plagiocephaly. BNI Quaterly 17, 18-25.
15. Littlefield TR., Kelly KM., Reiff JL., Pomatto JK. 2003. Car seats, infant carriers and awings. Their role in deformational plagiocephaly. Journal of Prostetics and Orthosis  15, 102-106.
16. Loveday BPT., de Chalain TB. 2001. Active counterpositioning orthotic device to treat positional  plagiocephaly. Journal of Craniofacial Surgery,  12, 308-13.
17. Minamitani K., Inoue A., Okuno T. 1990. Results of surgical treatment of muscular torticollis for pacients 6 years of age. Journal of Pediatrics Orthopaedics.  10, 754-59.
18. Monson RM., Deitz  J.,  Kartin D. 2003. The relation ship between awake slept supine.  Pediatric Physical Therapy,  15, 196-203.
19. Mulliken JB.,Vander Woude DL., Hansen M.,La Brie RA., Scott RM. 1999.  Analysis  of posterior plagiocephaly. Deformational  versus  synostotic. Plastic and Reconstructive Surgery. 103,371-80.
20. Persing J., James H., Swanson J., Kattwinkel J.  2003. Prevention and management of positional skull  deformities in infants.  Pediatrics 112, 199-202.
21. Raco A., Raimondi AJ., De Ponte FS et al. 1999. Congenital torticollis in association with craniosynostosis. Child’s Nervous System 15, 163-68.
22. Ripley LE., Pomatto J., Beals SP. 1994. Treatment of positional plagiocephaly  with dynamic orthotic cranioplasty. Journal of Craniofacial Surgery,  5, 150-59.
23. Steelwagon L., Hubbard E., Chambers C., Lyons KJ. 2008. Torticollis facial asymmetry  and plagiocephaly in normal newborns.  Arch Dis Child. 93, 827-31.
24. Vojta V, Peters A. 1992. Das Vojta Prinzip. Springer Verlag, Berlin, Heidelberg.
25. Yu CC, Wong FH, Lo L J, Chen YR. 2003. Craniofacial deformity in patients with uncorrected congenital muscular torticollis. An assessment from three-dimensional  computed tomography imaging. Plastic and Reconstructive Surgery, 113, 24-33.