Vol.1, No.2, 31-35 (2013) Open Journal of Therapy and Rehabilitation
http://dx.doi.org/10.4236/ojtr.2013.12006
The status of the cervical spine in preschool children
with a history of congenital muscular torticollis
Anna M. Öhman
Department of Paediatrics, University of Gothenburg, Queen Silvia Children’s Hospital, Gothenburg, Sweden;
Received 6 September 2013; revised 8 October 2013; accepted 15 October 2013
Copyright © 2013 Anna M. Öhman. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Infants with congenital muscular
torticollis are born with an asymmetric range of
motion and a muscular imbalance in the cervical
spine, as a result of a shortening or excessive
contraction of the sternocleidomastoid muscle.
Purpose: The study aimed to investigate passive
range of motion (PROM) for rotation and lateral
flexion, and muscle function of the cervical
spine in children that ha d a history o f CMT a s in-
fants. Study design: a prospective cohort study.
Patient sample: 58 children at the age of 3.5 to 5
years that had been treated fo r CMT hav e infants
participated in the study. Method: PROM was
measured with protractors and muscle function
was estimated with a modified Muscle Function
Scale. Data from infancy were taken from earlier
records. Result: PROM in rotation of the neck
was mean 98.7˚ and PROM in lateral flexion of
the neck was mean 69.1˚. Symmetric PROM of
the neck was found in 74% of the ch ildren for ro -
tation and in 88% of the children for lateral flex-
ion. Multiple regression showed that gender and
PROM in rotation as infants had a significant
impact on asymmetric PROM. Forty-five percent
of the children had some degree of muscular
imbalance in the lateral flexors of the neck. Con-
clusion: Possible risk factors for later asymmet-
ric PROM are: gender, birth weight, gestation
week and PROM in rotation as infants. These
factors ought to be taken into consideration
when developing guidelines for long-term fol-
low-up.
Keywords: Congenital Mu scular Torticollis;
Cervical Spine; Passive Range of Motion; Rotation;
Muscle Function; Children
1. INTRODUCTION
Congenital muscular torticollis (CMT) is a result of
shortening or excessive contraction of the sternocleido-
mastoid muscle, often with limited Range of Motion
(ROM) of the neck, in rotation on the affected side and
in lateral flexion on the non-affected side. For infants/
children with CMT there is also an imbalance in muscle
function i.e. they have a lack of muscular strength and
endurance around the neck on the non-affected side and
sometimes an excessive muscular strength on the af-
fected side [1,2]. This imbalance is not found in healthy
infants [3]. The reported incidence of CMT is 0.4% -
2.0% [1], however the incidence may be higher as Stell-
wagen et al. found that 16% of newborns had torticollis
[4]. The cause of CMT has been discussed but it seems
likely to be the sequela of intrauterine or perinatal com-
partment syndrome [5,6]. Treatment mostly gives an ex-
cellent or good result within the first year. However, the
child is a growing individual and this fact may change
the status of the cervical spine over the years. An excel-
lent treatment result when the child is less than one year
old may not last long-term. At later ages some children
are found to be in need of surgery in spite of an excellent
or good result as an infant. We need more knowledge
about the status of the cervical spine for the growing
child with a history of CMT.
The reference values for Passive ROM (PROM) in ro-
tation of the neck for healthy children aged 3.5 to 5 years
have been shown to be mean 100.1˚ (SD 7.7˚) [7]. This is
ten degrees less than for healthy infants with a mean of
110˚ (SD 6.2˚) [3]. There seems to be a natural loss of
about 10˚ rotation of the neck up to preschool age.
PROM in lateral flexion of the neck for healthy children
aged 3.5 to 5 year is mean 68.5˚ (SD 3.4); this is very
close to the mean for healthy infants which is 70˚ (SD
2.2). This indicates that PROM for rotation decreases
and PROM in lateral flexion stays almost the same dur-
ing the first five years of life [7]. The aim of this study

A. M. Öhman / Open Journal of Therapy and Rehabilitation 1 (2013) 31-35
32
was to investigate PROM in rotation and lateral flexion
of the neck and to investigate whether PROM is sym-
metric or asymmetric in children aged 3.5 to 5 years who
had a history of CMT. Also to see if PROM at the start
of treatment for CMT, age at the start of treatment, gen-
der and current head tilt, muscular imbalance, remain-
ing plagiocephaly, birth weight and gestation week had
any influence on the PROM at the age of 3.5 to 5 years.
And also to investigate if there were any detectable dif-
ferences in muscle function/strength between the right
and left sides in the lateral flexor muscles of the neck.
The local ethical committee approved the study and the
parents gave their informed consent.
2. METHOD
Neck rotation was measured with an arthrodial pro-
tractor [1]. The child was lying supine on the examina-
tion table with the shoulders stabilized. The examiner
supported the head and neck in the neutral position, over
the edge of the examination table. In this position the
neck could be rotated and moved freely in all directions.
According to Cheng et al. there is an inter-examiner re-
liability correlation coefficient of 0.71 for neck ROM in
infants [1].
Lateral flexion was measured with the child lying in
supine on a large protractor with the shoulders stabilized
[2,8]. This method was found to have a high intra-rater
reliability of ICC 0.94 - 0.98 [9]. The maximal values for
PROM in rotation and lateral flexion of the cervical
spine were recorded; both left and right sides were
measured.
Muscle function/strength of the lateral flexor muscles
of the neck was estimated by using the same technique as
when tested with the Muscle Function Scale [10]. Hold-
ing the child horizontally around the trunk without sup-
port for the head, the child was asked to lift the head as
high as possible. A modified method to score was used:
no difference (score 0), marginal (score 1), distinct
(score 2) or extensive difference (score 3) between right
and left sides. Head tilt and plagiocephaly i.e. posterior
flattening of the skull were also recorded similarly with
scores 0 to 3. Data from infancy were taken from earlier
records. The same paediatric physiotherapist was re-
sponsible for carrying out all the measurements on all
children.
3. STATISTICS
The mean, the standard deviation (SD) and the ranges
were calculated for PROM in rotation and lateral flexion.
Differences between children with asymmetric and sym-
metric PROM at their current age were assessed by
analysis of covariance (ANCOVA), using the degree of
asymmetric PROM as an infant, age at the start of treat-
ment as an infant and current MFS scores, head tilt, pla-
giocephaly, age and gender as covariates. Any differ-
ences in mean weight at birth and mean gestation week
between children with asymmetric and symmetric PROM
were investigated with the Mann Whitney test. The SPSS
statistical programme was used and p-values of 0.05 or
less were considered evidence of statistically significant
findings.
4. RESULT
Fifty-eight children participated 25 female and 33
male, they were at a mean age of 4.3 years SD 0.57
(range 3.5 - 5 years). PROM in rotation was measured
for 57 children and lateral flexion for 58 children. One
child was not investigated for rotation, as he did not want
to cooperate in this measurement. PROM in rotation of
the neck was mean 98.7˚, SD 8.4˚ and PROM in lateral
flexion of the neck was mean 69.1˚, SD 4.2˚. Symmetric
PROM of the neck was found in 74% of the children for
rotation and in 88% of the children for lateral flexion.
Twenty-six percent of the children had asymmetric
PROM in rotation and/or lateral flexion of the neck (Ta-
ble 1); six children had asymmetry in both motions, eight
children only in rotation and one child only in lateral
flexion. Multiple regressions showed that both PROM in
rotation as infants and gender (female) had a significant
impact on asymmetric PROM at the age of 3.5 - 5 years
(Tables 2 and 3). Twenty-six (45%) of the children had
some degree of muscular imbalance in the lateral flexors
of the neck. Fourteen (54%) had marginal imbalance,
eight (31%) had distinct imbalance and four (15%) had
extensive imbalance in the lateral flexors of the neck.
Three children had some degree of head tilt, two mi-
nor and one moderate, the latter was in need of surgery
because of a muscular string and limited PROM in both
rotation and lateral flexion. She had an excellent result
after surgery.
Four children had minor plagiocephaly. There was a
trend that children with asymmetric PROM at the age of
3.5 - 5 years were born slightly later and had higher birth
weight than children with symmetric PROM (Table 4).
These differences were not significant.
5. DISCUSSION
In the current study the majority of the children who
had CMT as infants had excellent PROM for rotation and
lateral flexion of the neck at the age of 3.5 to 5 years.
The mean PROM for both rotation and lateral flexion of
the neck in this study were very close to the reference
values for healthy children who had not had neck prob-
lems as infants [7]. Twenty-six percent of the children
had some degree of asymmetry in PROM, however as
the children were rather young at the time of the assess-

A. M. Öhman / Open Journal of Therapy and Rehabilitation 1 (2013) 31-35 33
Table 1. Data for the seven females and eight males who had asymmetric PROM, only four children had less than 90˚ in rotation of
the neck.
Child Rotation
left-right
Rotation difference
between sides in degrees
Lateral flexion difference
between sides in degreesGestation weekMFS difference in scores between sides Tilt degree Age at assessmentGender
I 100 - 110 10 0 43 0 0 4.5 M
II 100 - 90 10 5 43 1 0 5 M
III 110 - 100 10 10 42.6 1 2 4.5 M
IV 105 - 100 5 5 42.8 0 0 4 M
V 90 - 85 5 10 38.1 3 0 4 M
VI 95 - 95 0 5 40.7 1 0 5 M
VII 85 - 100 15 5 42 1 0 4.5 F
VIII 110 - 120 10 0 39 2 0 5 F
IX 85 - 100 15 10 40 3 2 4 F
X 85 - 90 5 0 41.4 1 3 3.5 M
XI 95 - 100 5 0 41 1 1 3.5 F
XII 90 - 95 5 0 40.3 1 0 3.5 M
XIII 90 - 95 5 0 39.6 0 0 5 F
XIV 100 - 110 10 0 38 0 0 4 F
XV 90 - 100 10 0 39.7 2 0 5 F
Table 2. Multiple regression, effects of covariates, the PROM as infants and gender had a significant impact on PROM at the age of
3.5 - 5 years.
Standard error Beta 95% confidence interval p-value
PROM as infant 0.035 0.579 0.079 - 0.223 <0.001
Current MFS scores 0.882 0.129 −0.954 - 2.621 0.351
Head tilt at age 3.5 - 5 years 1.430 0.167 −1.055 - 4.745 0.205
Remaining plagiocephaly at age 3.5 - 5 years 3.067 0.037 −5.432 - 7.010 0.799
Current age 0.981 −0.019 −2.136 - 1.842 0.881
Treatment start as infant 0.450 0.056 −0.741 - 1.083 0.706
Gender 1.219 −0.291 −5.073 - −0.130 0.040
Table 3. This shows that females had higher frequency of
asymmetric PROM in rotation than males in the current study.
FemaleMale
Asymmetric PROM for rotation in any degree 28% 25%
Asymmetric PROM for rotation with at least 10˚ 20% 9%
Asymmetric PROM for rotation with 15˚ 8% 0%
ment, the risk of long-term effects cannot be excluded
yet. As PROM in rotation at the start of the treatment as
infants was found to have a significant impact on asym-
metric PROM at the age of 3.5 - 5 years, this ought to be
Table 4. There was a trend towards higher birth weight and
later gestation week in children with asymmetric PROM at the
age of 3.5 - 5 years.
At birth
Children with
asymmetric PROM at
age 3.5 - 5 years
Children with
symmetric PROM at
age 3.5 - 5 years
Gestation week mean40.7 40.0
Birth weight mean 3694 grams 3478 grams
taken into consideration when developing guidelines for
long-term follow-up. Of the 15 children with asymmetric
PROM for rotation only four had less than 90˚ in the

A. M. Öhman / Open Journal of Therapy and Rehabilitation 1 (2013) 31-35
34
limited direction, this is more than adult PROM for rota-
tion. For children in need of surgery there is often also a
muscular band that limits the motion. There may not be a
problem if a child has asymmetric but large PROM and
no muscular band, but it may still be important to ob-
serve the child for possible long-term effects. Chang et al.
found that ROM in lateral flexion is limited in those
cases that need surgery. Unfortunately, in the studies that
were found about long-term follow-up [2,5,11,12], there
is a lack of information about raw data and how the
measurements were performed. This makes it difficult to
compare with the current study. Later gestation week and
higher birth weight may be risk factors for later problems
with asymmetric PROM for children with CMT. Chen et
al. screened 1021 newborn infants for CMT with sono-
graphy and found that the infants with CMT were statis-
tically significantly longer and heavier than the norma-
tive group [13]. It is common that mothers of infants
with CMT state that the infant was in the birth canal for a
rather long time before birth. Intrauterine malposition is
one possible cause for CMT; both old and recent studies
support this theory [4,5,14,15].
In the current study 21% still had obvious muscular
imbalance in the lateral flexors of the neck. For those
children with head tilt it was more common with muscu-
lar imbalance than with asymmetric PROM. There is a
need for strategies of how to best prevent later problems
due to muscular imbalance. At the time of the study six
children had minor tilt that was not a problem. However,
the parents have to be observant to notice if it becomes
worse as the child gets older. For the child who had sur-
gery after the study, the parents were not aware of the
problem before the study, but could after the assessment
not understand how they could have missed the obvious
head tilt and muscular band. This reflects that the parents
can become blind to flaws and miss a very obvious head
tilt. We usually tell the parents to observe the child’s
head position once or twice a year until the child stops
growing; they also receive this information in writing.
We have to consider how we can further improve the
information. Chang et al. suggest that infants with CMT
ought to be followed up until four years of age [5].
6. LIMITATIONS
MFS are developed for infants and are not adjusted for
children of an older age. To use it in a modified version
demands experience when assessing children at this age
for this diagnosis. An alternative would be a handheld
dynamometer, but clinical experience has shown that it is
less reliable in younger ages. However for older children,
from about 6 years, the dynamometer seems to function
well [2,8].
7. CONCLUSION
The PROM for rotation as infants, gender and also
birth weight and gestation week may be risk factors for
later asymmetric PROM in lateral flexion and rotation of
the neck. Muscular imbalance in the lateral flexors of the
neck but not necessary asymmetric PROM seems to be a
risk factor for a later tendency of head tilt. This ought to
be taken into consideration when developing guidelines
for long-term follow-up.
REFERENCES
[1] Cheng, J.C.Y., Wong, M.W.N., Tang, S.P., Chen, T.M.K.,
Shum, S.L.F. and Wong, M.A. (2001) Clinical determi-
nants of the outcome of manual stretching in the treat-
ment of congenital muscular torticollis in infants. Journal
of Bone and Joint Surgery, 83, 679-687.
[2] Öhman, A. and Beckung, E. (2005) Functional and cos-
metic status in children treated for congenital muscular
torticollis as infants. Advances in Physiotherapy, 7, 135-
140. http://dx.doi.org/10.1080/14038190500213836
[3] Öhman, A. and Beckung, E. (2008) Reference values for
range of motion and muscle function in the neck—In in-
fants. Pediatric Physical Therapy, 20, 53-58.
http://dx.doi.org/10.1097/PEP.0b013e31815ebb27
[4] Stellwagen, L., Hubbard, E., Chambers, C. and Lyons,
J.K. (2008) Torticollis, facial asymmetry and plagiocephaly
in normal newborns. Archives of Disease in Childhood,
10, 827-831. http://dx.doi.org/10.1136/adc.2007.124123
[5] Lee, Y.T., Cho, S.K., Yoon, K., et al. (2011) Risk factors
for intrauterine constraint are associated with ultrasono-
graphically detected severe fibrosis in early congenital
muscular torticollis. Journal of Pediatric Surgery, 46,
514-519.
http://dx.doi.org/10.1016/j.jpedsurg.2010.08.003
[6] Chang, P.Y., Tan, C.K., Huang, Y.F., Sheu, J.C., Wang,
N.L., Yeh, M.L. and Chen, C.C. (1996) Torticollis: A
long-term follow-up study. Zhonghua Min Guo Xiao Er
Ke Yi Xue Hui Za Zhi, 37, 173-177.
[7] Öhman, A. and Beckung, E. (2012) A pilot study on
changes in passive range of motion in the cervical spine,
for children aged 0 - 5 years. Physiotherapy Theory and
Practice, 29, 457-460.
http://dx.doi.org/10.3109/09593985.2012.753495
[8] Öhman, A., Perbeck, K.E., Beckung, E. and Haglund-
Åkerlind, Y. (2006) Functional and cosmetic status after
surgery in congenital muscular torticollis. Advances in
Physiotherapy, 8, 182-187.
http://dx.doi.org/10.1080/14038190600780213
[9] Perbeck, K.E., Elfving, B., Haglund, Y. and Brogren, C.E.
(2005) Intra-rater reliability in measuring range of motion
in infants with congenital muscular torticollis. Advances
in Physiotherapy, 7, 84-91.
http://dx.doi.org/10.1080/14038190510010331
[10] Öhman, A., Nilsson, S. and Beckung, E. (2009) Validity
and reliability of the Muscle Function Scale, aimed to as-
sess the lateral flexors of the neck in infants. Physio-
therapy Theory and Practice, 25, 129-137.
http://dx.doi.org/10.1080/09593980802686904
[11] Binder, H., Eng, G.D., Gaiser, J.F. and Koch, B. (1987)

A. M. Öhman / Open Journal of Therapy and Rehabilitation 1 (2013) 31-35 35
Congenital muscular torticollis: Result of conservative
management with long-term follow-up in 85 cases. Archives
of Physical Medicine and Rehabilitation, 68, 222-225.
[12] Canale, S.T., Griffin, D.W. and Hubbard, C.N. (1982)
Congenital muscular torticollis. Journal of Bone and J oint
Surgery, 64, 810-816.
[13] Chen, M.M., Chang, H.C., Hisieh, C.F., Yen, M.F. and
Chen, T.H.H. (2005) Predictive model for congenital
muscular torticollis: Analysis of 1021 infants with sono-
graphy. Archives of Physical Medicine and Rehabilitation,
86, 2199-2203.
http://dx.doi.org/10.1016/j.apmr.2005.05.010
[14] Jones, P. (1968) Torticollis in infancy and childhood.
Charles C Thomas, Springfield, 17-21.
[15] Davis, J., Wenger, D. and Mubarak, S. (1993) Congenital
muscular torticollis: Sequela of intrauterine or perinatal
compartment syndrome. Journal of Pediatric Orthopae-
dics, 13, 141-147.