…by Holly Putnam Bacasa, PT
In my 10+ years as an Early Intervention pediatric Physical Therapy evaluator, Torticollis, which causes neck tightness and a head position preference in babies, is the most common diagnosis (and often undiagnosed condition) that I have evaluated and helped treat. It has become my passion to coach families to help prevent it, as well as to help get rid of it!
Let’s talk about it ….. What is Torticollis and its possible consequences? Why does Torticollis happen? How can you prevent Torticollis?
WHAT IS TORTICOLLIS?
Torticollis is a latin word meaning “twisted neck.” It primarily involves the neck muscle whose job is to actually “twist the neck”- the sternocleidomastoid muscle (SCM). Just remember SCM! This muscle is on the right and left side of our necks, and it’s has two jobs- to turn the head to its opposite direction and to tilt the head to the same direction. And when both sides work at the same time they tuck the baby’s chin to their chest so they can flex their neck to support it while they sit up, such as when you pull your baby up to sitting from laying on their back.
- the LEFT SCM turns the head RIGHT and tilts the head LEFT (as in photo above)
- the RIGHT SCM turns the head LEFT and tilts the head RIGHT (b/w photo)
- the LEFT & RIGHT SCM work together at the same time to flex the neck, such helping baby to tuck their chin when pulled to sit.
And you’re RIGHT – I mean CORRECT-ha ha- this is confusing!!! Here’s a quick neck anatomy lesson that may help…
NECK ANATOMY 101
…by PT Holly….. quick lesson, I promise! I am a big believer that your understanding of simple neck anatomy will make a difference in how you are able to help your baby. Here it goes…
- The major neck mover is the Sternocleidomastoid Muscle (SCM). Yes, it’s a long name and you don’t have to remember it. It’s job is to TURN AND TILT the neck.
- There is a RIGHT SCM and a LEFT SCM.
- The confusing part, is that the RIGHT SCM’s job is to TURN THE HEAD LEFT & TILT THE HEAD RIGHT, and the LEFT SCM’s job is to TURN THE HEAD RIGHT & TILT THE HEAD LEFT.
- When the RIGHT SCM & the LEFT SCM work at the same time, their job is to flex the neck– tucking the chin toward the chest.
- The SCM starts by attaching at the base of the bone behind your ear. The muscle then splits, such that it looks like an upside down “Y”, and one split connects to the collar bone and the other split connects to the breast bone.
- Since the muscle splits, it has the two functions- to TURN AND TILT the neck.
- If you put your fingers there and turn your neck, you will feel it working, and if you look in the mirror you can see it working. You can also see and feel it when you tilt your head to the side.
So a “classic” or “textbook” presence of torticollis would be to see your baby’s head turned to one side but tilted to the other, causing tightness on one side of the neck ( as in photo). But this is not always the case…
It is important to thoroughly evaluate the baby, as sometimes, a baby will have their own unique presence of torticollis. They will learn to prefer to turn and tilt their head to the same side, or not even turn their head much at all causing flatness straight across the back, and due to anatomy and the job of the SCM, this can be causing tightness on both sides of their neck.
LEFT SIDED NECK TIGHTNESS-present when the primary preference or habit is to turn right & tilt left (as in photo with boy)
RIGHT SIDED NECK TIGHTNESS– present when the primary preference or habit is to turn left & tilt right
RIGHT & LEFT SIDED NECK TIGHTNESS– tightness present on both sides of the neck when preference or habit it to turn & tilt to the same side. Note, this can also occur when baby has flatness straight across the back of their head.
So really, anyone, infants to adults, can get torticollis. It’s a basic orthopedic type of diagnosis, but it has become a very common and treatable diagnosis among infants. Again, in my 10+ years as an Early Intervention pediatric PT evaluator, it is the most common diagnosis ( and often undiagnosed condition) that I have seen.
WHAT CAN TORTICOLLIS CAUSE?
I have seen numerous cases of torticollis over the years. I will share with you what I have personally witnessed. This information is certainly not to scare you. It is just to make you realize what possibly could happen, so that you can be aware and help prevent it. I stress- possibly! The earlier this is detected, the less of the following you will experience, but it is real!
- Tightness in the SCM and weakness in the opposite SCM. This can possibly limiting baby’s ability to support themselves when held or when playing in certain positions
- Tight side of neck may be the dirtier side of the neck. This is possibly because maybe they tilt this way and gravity takes liquid that direction and/or baby is not airing that side of their neck out by tilting it to the other side. This will cause moisture to build up. Their skin may also appear red and shiny
- Compensations with more eye movement than head movement may be noted when baby looks toward their non-preferred side, and can limit movement of their head and eyes to track across midline
- Tightness in the trunk muscles and weakness on the opposite side
- Head flatness, which can cause misshaping in other areas of the skull
- Early dominance on hand/arm usage when grasping and reaching
- Preference to roll more in one direction
- Can cause tightness in jaw and facial muscles, and this can cause a shift in jaw alignment when baby closes their mouth
- Eye on tight side of neck may appear smaller
- Shoulder on tight side of neck may lack end range shoulder flexion ( the “So Big” arm position when it is moved straight up along side the head) compared to the other arm.
- Shoulder on tight side of neck may appear higher than other shoulder
WHY DOES TORTICOLLIS HAPPEN?
- Baby may have not moved much in utero or may have had limited space, causing neck tightness because they didn’t move their neck around enough
- The SCM may have gone into spasm during delivery.
- After looking at this picture, I am now questioning if the SCM may go into spasm when the Moro Reflex or the Startle Reflex is activated in the young infant. Looking past how strongly the MD is gripping his neck (I’m guessing once that baby kicked in that Moro Reflex, it made it hard to hold him), notice the tendons of the SCM bulging outward as baby tries to lift his head forward.
- The cervical spine (the bones of the neck) may have been compressed during delivery, causing the baby to avoid turning their head in one direction. This will cause SCM tightness.
- Baby may have already been born with a flat spot that developed in utero. A flat spot can cause them to turn their head toward the flat spot, causing neck tightness.
- In my experience, I see that it is common for babies that spend time in the Neonatal ICU seem to develop a flat spot on the back of the right side of their head. I attribute this to the baby’s natural instinct to turn toward people, lights and sounds. In the NICU, it seems they are being cared for by more right handed people and being approached more from their right side when cared for, and this can cause a flat spot to develop, and a flat spot can cause tightness.
- Babies prefer to look at special things, such as you, the light, the window, toward sound and toward patterns, such as ceiling fans, blinds and picture frames. If your baby is preferring to look at these and is always turning in the same direction to see or hear these things, then they can develop a flat spot, and a flat spot can cause tightness.
- Baby rests (hangs out or sleeps) too long in an inclined positioner ( a positioner that is not completely flat), like a bouncy seat, swing or an angled bassinet, and gravity causes their head to fall to one side more often than it falls to the other side. If baby develops a tilt preference, this will cause muscle tightness on the side your baby is tilting to.
- Baby may dislike tummy time and is not getting enough position changes, causing a flat spot to develop….and flat spots can cause Torticollis
- Parent has a habit of how they hold their baby and it is causing the baby to turn or tilt their head more often to one direction.
- Baby sleeps so well or they are swaddled so cozy that they barely move their neck, causing neck muscle tightness and also possibly head flatness at the same time.
- I will also add that I personally think that a vacuum assisted delivery can cause a bulge in the baby’s head, causing them to turn or tilt away from it when they rest. They develop a preferred position, and this can cause tightness.
HOW CAN YOU PREVENT TORTICOLLIS?
Just knowing what torticollis is and what torticollis can cause are your first steps to prevention!
Here are more things you can do….
- Notice your baby’s head shape when they are born and position them as needed to help re-shape their head. A baby that is born with a flat spot will commonly lay on the flat spot because gravity wins as a newborn.
- Be aware that your baby’s NICU stay can draw their attention to the right, so just counteract any preferences the best you can when in the NICU and especially when you get home.
- Reposition your baby positioners ( swing, bouncy seat, etc.) so your baby is having equal opportunity to turn to the right and left, as well as look straight forward sometimes , when they find something they enjoy looking at, such as you, light, windows, blinds, picture frames and other high contrast colors.
- When you lay your baby in their crib or bassinet, alternate which end you put their head at.
- Sleep and nap your baby on a safe flat surface so that gravity does not cause it to tilt.
- If baby is a good sleeper- which is great- you can try to reposition their head in their sleep to help redistribute the pressure. This one is your call. You know your baby best. Some babies may sleep right through it.
- If baby is a good sleeper and you do not want to intervene during sleep time, then when baby is awake, during face to face play, family can gently turn their babies head to the right and left by supporting it on the back with your hand in a cupping position (turning it so that the baby’s chin moves toward and maybe just over-top of the shoulder) to give the neck muscles a gentle stretch.
- During face to face play, family can also gently tilt baby’s head side to side to keep it flexible (tilting it so that their ear moves close to each shoulder)….Think of opening up/exposing/airing out their skin wrinkles on each side of their neck.
- Caregivers(parents- grandparents, day care staff)- can think about being more ambydextryous when they hold and carry the baby. Switch arms! This will give your baby opportunity to use their muscles on each side of their body to begin to help support themselves, and can prevent them from developing a strength imbalance early on.
Check out my blog, “A Parents Guide To Identifying Neck Tightness or Head Flatness in Your Baby – The Turn-Tilt-Top Method“, to help identify if your baby could benefit from some stretching and repositioning.
Remember, you know your baby best! Take advantage of this window of opportunity to receive coaching in how to help your baby.
Do you think your baby has a head position preference or neck tightness? If so, don’t hesitate to consult with your county’s Service Coordination Unit for Early Intervention Services, as well as your pediatrician. Visit my blog, “Early Intervention Works!”, to learn more about early intervention and how it can help your child and family.
Here’s the link to Early Intervention contacts in each US state.