CONGENITAL MUSCULAR TORTICOLLIS – A CASE REPORT

This material present the therapeutic conduct in the case of a patient under the age of 3 months with Global development disorder, left torticollis.The protocol in our clinic for left torticollis is Vojta therapy (4 sessions per day) and elongation for recovery.

HISTORY: Mother’s Reminiscences

The patient is aged 3 months and one week, was born after a 42-week physiologically developed pregnancy; weight at birth = 3900 g, APGAR score = 6.He is presented to our clinic for neurological evaluation of the delay in psycho-motor development. Transfontanellar ultrasound (ETF) (in maternity) = normal.

SOMATIC AND NEUROLOGICAL EXAM

Somatic examination: afebrile, general well-being, balanced cardio-respiratory and digestive functions, weight = 6300 grams.

Neurological examination:

• PC = 42 cm
• FA = 2/2
• Left laterocollis
• Unsteady control of the head
• Open fist
• In prone position does not lift his head from the examination table
• Bone-tendon reflexes (BTR) symmetrical without plantar clonus
• Babbles
• Follows a moving object with the sight
• Age of motor development – 1-2 months.

LABORATORY INVESTIGATIONS:

ETF – normal
Abdominal ultrasound – normal
Consultation in paediatric surgery – right testicular ectopia
Electroencephalogram (EEG) during wakefulness no epileptiform changes
Consultation in functional recovery: at the age of 3 months and 1 week – first hospitalization in our clinic

• At traction from dorsal decubitus position, the head lags behind
• In ventral decubitus, the head is in the I-II Gesell zone
• He bring his hands under the chest, especially the left one
• Postural reactions corresponding to the first quarter
• Maintains himself in sub-axillary suspension, at the contact of the feet with the examination table, they move in equinus (at birth he had a cast for equinus varus predominantly left)
• In crouching position he has no anti-gravity response
• Active return from dorsal decubitus to lateral decubitus.

DIAGNOSIS:

Global development disorder (motor developmental age – 1-2 months, psychological development – 3 months)

Left torticollis.
Vojta therapy starts at the age of 3 months and a week – 4 sessions per day.

The first Vojta session:

• spontaneous motility in supine position
• spontaneous motility in prone position

After four days of Vojta therapy:

• spontaneous motility in supine position before therapy
• Vojta stimulation – the first phase of reflex rolling.
• Vojta stimulation – the second phase of reflex rolling.
• spontaneous motility prone position after therapy.
• spontaneous motility in supine position after therapy.

Consultation for functional recovery at the age of 4 months and 3 weeks – the second admission to our clinic

• Posture in supine position with arching of the spine with convexity to the right
• Head and neck tilted to the left, with slight rotation of the face to the right
• At the active rotation of the head, a slight resistance to the rotation to the left is perceived
• At the traction from supine position, the head is in the trunk axis
• In prone position, the head is in Gesell II zone, without proper support of the doll type posture
• At Collis horizontal reaction: hand is put on the examination table with the fist closed (especially on the right)
• He maintains himself in sub-axillary suspension
• In crouching position, supports his own weight
• Does not have anti-gravity response
• Mild tension in the triceps surae muscles
• Does not stretch out his hands sideways to catch a toy
• Motor Age – 3 months
• Continues Vojta therapy – 4 sessions per day.

Evaluation and therapy at the age of 4 months and 3 weeks – the second hospitalization in our clinic

a. evaluation

• In prone position
  • support in the forearms
  • pelvis in ventral flexion
  • hyperlordosis
  • fingers flexed, toes flexed, thumb adducted to the palm.
• In supine position
  • follows a toy with the eyes that is offered from the lateral side
  • does not catch a toy that is offered from the lateral side
  • hand mouth contact.
• Postural reactions
  • At the reaction of traction, head aligns with the trunk axix (slight tendency to retroduction)
  • The response to the Landau reaction – the cervical spine start s to extend
  • The reaction to the sub-axillary suspension, the legs are slightly bent
  • At Vojta reaction of lateral rolling – the child performs no abduction in the upper thigh
  • At Collis horizontal reaction – tendency to support the fist on the examination table
  • At Peiper reaction – arms are moving in adduction + opistotonus
  • At Collis vertical reaction – the child is flexing the free leg + tendency to hyperextension at the level of the cervical spine.

b. Therapy

• spontaneous motility in supine position before therapy
• spontaneous motility in prone position before therapy
• Vojta stimulation – the second phase of reflex rolling
• Vojta stimulation – crawling reflex
• Vojta stimulation – crawling reflex
• Vojta stimulation – the first phase of reflex rolling
• spontaneous motility in supine position after therapy
• spontaneous motility prone position after therapy

Functional recovery consultation at the age of six months – the third hospitalization in our clinic

• Right parietal-occipital plagiocephaly with facial asymmetry, head rotated clockwise, virtually equal right-left passive rotation of the head
• The child sits with anterior support of hands, he rolls
• Possible prehension in the midline
• Motor age: 5-6 months
• Diagnostic – left laterocollis (possibly KISS syndrome)
• Continues Vojta therapy – 4 sessions per day.
• Evaluation at the age of six months – the third hospitalization in our clinic
  • in prone position
    • support on the elbows
    • making active head rotation left and right.
  • in supine position
    • hand-knee contact
    • lateral grip with the right hand.
    • can be positioned in sitting (sits with dorsal kyphosis)
    • rolls from supine to prone position
  • Postural reactions
    • corresponding to the second quarter
    • at Collis horizontal reaction – support on the examination table with the left palm; right upper limb in the flexion phase
    • At Peiper reaction – limited abduction of the upper limbs.

Functional recovery consultation at the age of 8 months – the fourth hospitalization in our clinic

• The child maintains himself in sub-axillary suspension
• In crouching position, he has anti-gravity response
• Equal head rotation right and left
• Laterocollis no longer present
• The right parietal-occipital plagiocephaly is more subdued
• The child rolls over
• He sits in balance – only positioned
• Tries to crawl
• Parachute reflex is absent
• Prehension grasp – present
• Motor age – 6 ½ months

The evolution was favourable, so that the patient will continue the intensive physical therapy in the territory.

• It will focus on – crawling exercises
  • lifting to the sitting position
  • positioning and moving on the four limbs.

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