Torticollis and Plagiocephaly

Dr Mirav Newman PT DPT, 2024

Fifty percent of all babies born today will be diagnosed with torticollis and plagiocephaly. What is happening? Why the increase?

Babies have been sleeping on their backs since the ‘Back To Sleep’ campaign in the 1990s. Before this, babies slept on their bellies with their right cheek for one nap and their left cheek for the next nap, and within a week or two, they had symmetry. Babies are usually born with some degree of asymmetry in their physiologic contractures. In today’s times, these contractures are left unstretched due to back positioning, lack of tummy time, a surge in container use, long-term swaddling, and lack of parental education. How can we make a change and turn this around?

First, we must increase awareness and educate new parents on the importance of tummy time. We can provide help with modifications to make tummy time less stressful and more fun using the Tumtum. It is crucial to advocate for good positioning from day one to avoid flat spots and ensure babies have the full range of motion in their necks. Babies should be able to turn to both sides with no particular preference for one side. Tummy time during wake hours is a must from day one of life. 

Second, we need to educate the public about containers and how they perpetuate the situation and can contribute to the worsening of the misshaped head and limitations in the range of motion at the neck. The best place for the baby is on the floor. On a firm surface, such as a flat crib or playpen, they can easily move and turn their head to both sides, overcoming a flat spot if needed. An incline wedge, such as the tumtum, can also help to make floor time more tolerable and provide a firm surface. The tumtum will help to improve midline control.

Finally, if there is a preference for the head to turn to one side, such as in torticollis, in combination with a flat spot, such as plagiocephaly, a referral for early intervention with a trained professional is indicated. The recent updated APTA guidelines call for early screening and early referral as soon as any asymmetry is noted in infants. No more wait and see!

As a pediatric physical therapist, I use a three-pronged approach to treating torticollis and plagiocephaly. This approach includes stretching, repositioning, and strengthening.

The stretching can take the form of soft tissue mobilization, traditional PT, stretching methods, Long holds such as the football hold, TMR techniques, and massage. The goal is to improve the cervical range of motion so that the baby has symmetrical and full active and passive range of motion for head rotation and side bending bilaterally.

The re-positioning is used to reshape the head and improve symmetrical weight-bearing through the skull. This repositioning may include side-lying, tummy time, sitting with support, or lying on babies back on an incline with the buttocks elevated to help improve midline control. A firm, flat surface provides counter pressure to the skull to help unload the flat spot and put pressure on the opposite side. The tumtum is ideal for repositioning and applying counter pressure to the skull for reshaping.

Strengthening is vital to ensure the baby strengthens and can hold their head in midline. Midline control emerges around 4 to 6 months of age. Strengthening the infant’s trunk and neck to improve head and trunk control may be accomplished through tummy time, traditional strengthening, tummy time on a wedge, developmental sequencing, such as rolling and sitting, and working on head righting and balance.

This three-pronged approach will help your baby in all areas of development, including strength, range of motion, motor skills, and even correction of cosmetic skull asymmetry.

I hope this helps clarify some of the questions about why we’re seeing such an increased number of incidents and how to best approach prevention and correction.

Cited:
Sargent, Barbara PT, PhD, PCS; Coulter, Colleen PT, DPT, PhD, PCS; Cannoy, Jill PT, DPT, PCS; Kaplan, Sandra L. PT, DPT, PhD, FAPTA. 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. Pediatric Physical Therapy 36(4):p 370-421, October 2024. | DOI: 10.1097/PEP.0000000000001114
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