Effectiveness of activity configuration approach based occupational therapy intervention for children with congenital muscular torticollis: A case study
M. Mahendran*
Consultant Paediatric Occupational Therapist, Unit of HAMSA Kids for REHAB, Kauvery Hospitals, Trichy, India
*Correspondence: maherichy987@gmail.com
Abstract
This study explores the effect of Occupational Therapy Interventions on children with a Congenital Muscular Torticollis in a KMC hospital in Trichy, Tamil Nadu. Paediatric Occupational Therapy Management on children with Congenital Muscular Torticollis help to restore full neck movement as early as possible to help reverse or control the progression of skull regional deformity, cranial facial asymmetry, and to particular prevent bony components and postural alignment and changes that may cause asymmetric motor development accomplishment. An Occupational therapist will assess the child’s range of motion and head shape, and develop a stretching activity program for the family. Intervention schedule often include approaches for positioning and playing with your baby in a way that reassures active movement to the non-preferred side. Statistical tools like descriptive statistics, mean and standard deviation were utilized to analyse the effect of Occupational Therapy Interventions on Children with a CMT. The analysis reviews the Paediatric Occupational Therapy Spatial Play-based Interventions in Children with a CMT, activities and advancement strategy and practices of KMC hospital.
Keywords: Congenital, Sternocleidomastoid muscle, Paediatric occupational therapist, Torticollis,
Introduction
The Pediatric occupational therapists’ sector is growing at a brisk pace by serving through its Spatial Play-based Interventions.[2] Occupational Therapy (CMT) treatment helps to restore full neck movement as early as possible to help reverse or control the progression of neck regional deformity, cranial facial asymmetry, and to prevent bones and postural alignment changes that may root cause asymmetric motor development accomplishment .An Occupational therapist will assess the child’s range of motion and head shape, and develop a stretching program for the family. Intervention will often include strategies for positioning and playing with your baby in a way that encourages dynamic movement to the non-preferred side. When identified and treated early, the majority of children with Torticollis recover completely with no long-term effects.[1, 2, 3]
Positions at onset vary, including flexion, extension, right or left tilt. There are clinical variations of Torticollis at presentation such as horizontal, vertical, oblique, or torsion. The sternocleidomastoid is the most involved muscle. It is in the anterior region of the neck, where it is visible and palpable on the lateral side. The action of the sternocleidomastoid is to facilitate a range of motions- contra lateral rotation, ipsilateral inclination, and flexion of the head.[2,5]
Congenital muscular Torticollis (CMT) is a painless condition caused due to unilateral shortening of the sternocleidomastoid muscle (SCM), usually presenting during infancy.[3,9,10] Occupational therapy is used to treat Torticollis. It helps to stretch the child’s tight neck muscles. Occupational therapist can also help monitor the child’s growth and development. The child will need to go to occupational therapy 3 to 4 times a week. Therapist will also make a home program for the child, to engage in activities 35 times a day to help improve the muscles, based on multisensory integrative approach These home programs will include positioning and stretching to help your child move the head to a more midline position.4,7,8
Importance of Paediatric Occupational Therapists Spatial Play-Based Intervention among Children with Congenital Muscular Torticollis (CMT)
Spatial Play-based (activity configuration approach) intervention sessions were carried out for 45 min, five days 4 week for scheduled. This was done for gaining trust and compliance of parents for the child’s treatment sessions. The focus in the sessions was on the spatial play. Various social-emotional skills such as salutations, turn-taking, expression of emotions, hide and seek, energetic activity, focused activities, and initiating a conversation were experienced, using play as an intermediate. Activity schedules were used to correct neck movement and avoid abnormal positions. The sessions were digitally/manually recorded. Debriefing of the session was done after every assembly and it was documented.
Source: Fastest Musculoskeletal Insight Engine
Resource: Mayoclinic
Case presentation
A two years and six months old male child presented with neck inflexibility and restricted head motion. The patient was the first-born child, with no positive family history for muscular torticollis. Congenital muscular torticollis was diagnosed in the 1st year of life. He had undergone paediatric occupational therapy of neck – stretching activities at the age of two and a half, as part of the facilitation procedure. Medical history indicated unusual obstetric presentation eg. Breech management, and delivery was by Caesarion section. Complete evaluation revealed no malfunction. Radiographs of the cervical spine, hips and lower extremities were normal. Paediatric occupational therapy was started for the child to achieve SCM muscle stretching.
After 8 weeks of exercise, there was significant improvement in the condition. The patient was admitted; with the patient in a supine position, maximum stretch and tension of the affected SCM muscle was achieved by hyperextension of the neck and rotation of the head to the opposite shoulder. Three months of regular muscular rehabilitation including passive and active secondary ending stretching and paediatric occupational therapy were necessary. Aggressive occupational therapy, which included neck strengthening and extension activities, was started, and maintained for the duration of 3 months.
Methodology
Research involves a series of steps using which the researcher may find out the solution to the selected problem in such a way that the solution helps in planning the occupational therapy and management for the future. The procedure using which the researcher goes about occupational therapist work of describing, explaining and predicting phenomena is called methodology. It comprises of the procedures used for generating, collecting, processing and analyzing data.
Objectives
Paediatric occupational therapy plays an important role in the management of congenital muscular torticollis. However, it was observed from the literature review that studies analyzing the occupational therapy between these two variables significant in determining success are very scarce. Therefore, this researcher recognized the above research problem. Based on the research problem identified, the following research objectives were formulated.
- Paediatric occupational therapists analyse Spatial Play, Range of motion, developmental milestones.
- Planning manpower and activity knowledgeable paediatric occupational therapists.
- Neck movement as early as possible to help reverse or stop the progression of skull deformity
- Evaluation sensory profile-2 performance and credible on an ongoing basis.
- Building commitment on Cooperative Behaviour, Developmental millstones based.
Population |
Sampling size |
Sample techniques |
Study place |
Variables |
Duration of the period |
| Accessible population was adapted in this study. | Mono subjects are included in this study. | Convenient sampling technique was adapted. | The subjects were selected from Unit of Hamsa rehab centre, Kauvery Hospitals, Trichy,
Tamil Nadu. |
Independent variablesOccupational therapy sensory spatial play-based management Dependent variablesCongenital Muscular Torticollis(CMD) |
Total duration of the study was 8 weeks. |
Procedure
This qualitative true experimental research conducted on children with Congenital Muscular Torticollis for 8weeks. In this study, one children and age group between 2.6 years were included.Initially; permission for doing research was received from the subject’s parents or caregiver by getting consent form. Then details such as name, age, sex, history of Congenital Muscular Torticollis was taken by using assessment form and the procedure was explained to the parents or caregiver.Pre and Post test data were collected through Child Sensory Profile – 2, Manual muscle power test (MMT), Toronto western spasmodic torticollis rating scale (TWSTRS) and were examined using Spatial play Based occupational therapy interventions. The collected data were divided into two variables based on intervention. The Occupational therapy interventions plan based Activity Configuration Approach. Further, Research data were analyzed by calculating mean value, t value and p value.
Paediatric Occupational Therapy Management on Children with Congenital Muscular Torticollis-Session schedule
Intervention
Single subject was taken in this study. The subject’s were selected from the age between 26 years with Congenital Muscular Torticollis. The therapy was planned for 8weeks. It would be at 45 min group session with the frequency of five days a week. Total of 08 treatment sessions (each session of 5 days/3 Month) is planned for the child
Session Schedule
Week 1 |
Warm-up |
Main activities |
Session 1 |
Arm wake-up
aerobics -jumping |
Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 2 |
Arm wake-up
aerobics -jumping |
Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 3 |
Arm wake-up
aerobics -jumping |
Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Week 2 |
Warm-up |
Main activities |
Session 1 |
Football carrying stretch | Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 2 |
Football carrying stretch | Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 3 |
Football carrying stretch | Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Week 3 |
Warm-up |
Main activities |
Session 1 |
Arm wake-up
aerobics -jumping |
Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 2 |
Arm wake-up
aerobics -jumping |
Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 3 |
Arm wake-up
aerobics -jumping |
Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities,proprioception activity
-stair calming ,kneeling, rollover |
Week 4 |
Warm-up |
Main activities |
Session 1 |
Football carrying stretch | Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 2 |
Football carrying stretch | Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 3 |
Football carrying stretch | Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Week 5 |
Warm-up |
Main activities |
Session 1 |
Arm wake-up
Pencil aerobics |
Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 2 |
Arm wake-up
aerobics -jumping |
Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 3 |
Arm wake-up
aerobics -jumping |
Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Week 6 ,7 and 8 |
Warm-up |
Main activities |
Session 1 |
Football carrying stretch | Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 2 |
Football carrying stretch | Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Session 3 |
Football carrying stretch | Neck rotation-disc swing, neck rotation visual stimulation, transfer activities, Feel the pressure multisensory stimulation with beg board activities, proprioception activity
-stair calming ,kneeling, rollover |
Fig (1) Pre-Intervention Fig (2) Post-Intervention
Statistical Analysis
This study used were collected the data of pre and post-intervention. The entire statistical test was performed using statistical package for graph pad instate software version 3.1 respectively.
Table 1: Characteristic of data pre and post evaluation- Denver developmental profile
Characteristic of data paired t-test |
Denver (pre-test performance) |
Denver (post-test performance) |
| Mean | 55.71 | 77.14 |
| standard deviation | 13.97 | 9.51 |
| Sample size | 1 | 1 |
| The standard error (SE) means | 5.28 | 9.51 |
| 95% confidence interval | -31.32 | 11.54 |
Table 1; data shows of pre-post-evaluation (Denver scale) – of subject, mean values are 55.71 and 77.14, respectively standard deviation 13.97 and 9.51 respectively sample size 01, standard error of mean 5.28 and 9.51, 95% confidence interval – 31.32 and 11.54, respectively.
Table 2: Characteristic of data pre and post evaluation- Denver developmental profile
S. No. |
Variable 1 |
Variable 2 |
Pvalue |
tvalue |
Level ofSignificance |
| 1 | pre-test evaluation | post-test evaluation | 0.0018 | 5.3033 |
Very statisticallySignificant |
Table 2: This shows that comparison between the pre-post-evaluation- Denver scale of subject,t’ value is 5.3033 p-value is 0.0018, This difference is considered to be very statistically significant.
Graph 1: Characteristic of data pre and post evaluation- Denver developmental profile
Table 3: Characteristic of data pre and post evaluation- Toddler sensory profile-2
Characteristic of data paired t-test |
Toddler sensory profile-2 (pre-test performance) |
Toddler sensory profile-2(post-test performance) |
| Mean | 88.75 | 39.25 |
| standard deviation | 22.50 | 20.79 |
| Sample size | 1 | 1 |
| The standard error (SE) means | 11.25 | 10.40 |
| 95% confidence interval | 13.53 | 85.47 |
Table 3; data shows of pre-post-evaluation (Toddler sensory profile-2) – of subject, mean values are 88.75 and 39.25, respectively standard deviation 22.50 and 20.79 respectively sample size 01, standard error of mean 11.25 and 10.40, 95% confidence interval 13.53 and 85.47, respectively.
Table 4: Characteristic of data pre and post evaluation- Toddler sensory profile-2
S. No. |
Variable 1 |
Variable 2 |
Pvalue |
tvalue |
Level ofSignificance |
| 1 | pre-test evaluation | post-test evaluation | 0.0220 | 4.3795 | Statistically
Significant |
Table 4; This shows that comparison between the pre-post-evaluation- Toddler sensory profile-2 of subject, t’ value is 4.3795 p-value is 0.0220, This difference is considered to be statistically significant.
Graph 2: Characteristic of data pre and post evaluation- Toddler sensory profile-2
Table 5: Characteristic of data pre and post evaluation – Manual muscle power grade test (MMT)
Characteristic of data paired t-test |
MMT (pre-test performance) |
MMT (post-test performance) |
| Mean | 65.00 | 85.00 |
| standard deviation | 30.00 | 19.15 |
| Sample size | 1 | 1 |
| The standard error (SE) means | 15.00 | 9.57 |
| 95% confidence interval | -45.98 | 5.98 |
Table 5; data shows of pre-post-evaluation Manual muscle power grade test (MMT) of subject, mean values are 65.00 and 85.00, respectively standard deviation 30.00 and 19.15 respectively sample size 01, standard error of mean 15.00 and 9.57, 95% confidence interval – 45.98 and 5.98, respectively.
Table 6: Characteristic of data pre and post evaluation- Manual muscle power grade test (MMT)
S.No. |
Variable 1 |
Variable 2 |
Pvalue |
tvalue |
Level ofSignificance |
| 1 | pre-test evaluation | post-test evaluation | 0.0917 | 2.4495 |
Not quite statisticallySignificant |
Table 6: This shows that comparison between the pre-post-evaluation- Manual muscle power grade test (MMT) of subject, t’ value is 2.4495 p-value is 0.0917, This difference is considered to be not quite statistically significant.
Graph 3: Characteristic of data pre and post evaluation- Manual muscle power grade test (MMT)
Table 7: Characteristic of data pre and post evaluation- Range of motion (ROM)
Characteristic of data paired t-test |
Range of motion (pre-test performance) |
Range of motion (post-test performance) |
| Mean | 42.50 | 61.25 |
| standard deviation | 32.27 | 18.87 |
| Sample size | 1 | 1 |
| The standard error (SE) means | 16.14 | 9.44 |
| 95% confidence interval | -58.99 | 21.49 |
Table 7; data shows of pre-post-evaluation (Range of motion )- of subject, mean values are 88.75 and 39.25, respectively standard deviation 42.50 and 61.25 respectively sample size 01, standard error of mean 16.14 and 9.44, 95% confidence interval -58.99 and 21.49, respectively.
Table 8: Characteristic of data pre and post evaluation- Range of motion
S.No. |
Variable 1 |
Variable 2 |
Pvalue |
tvalue |
Level ofSignificance |
| 1 | Control pre-test evaluation | Control post-test evaluation | 0.2348 | 1.4828 |
Not statisticallySignificant |
Table 8; This shows that comparison between the pre-post-evaluation- Range of motion of subject, t’ value is 4.3795 p-value is 0.0220, This difference is considered to be statistically significant.
Graph 4: Characteristic of data pre and post evaluation- Range of motion
Discussion
- The reported occurrence of CMT varies from 0.32% .it can be 1 in 250 is alive births. An assortment of theories have been proposed as an aetiology but exact etiology is still not known. Some authors believe that there is a hematoma formation in the SCM from an intrauterine vascular disturbance, intrauterine apposition of the head or due to compartment set of symptoms where the SCM shortens. Birth injury, infections, and transmissible theories have also been proposed.
- The commonest presentation of children with CMT is a head tilt toward the affected side and the chin pointing to the contra lateral side. The diagnosis of congenital muscular torticollis is based on clinical palpation of the firm fibrous band within the SCM muscle. Few studies showed that 90100% of infants with CMT who received early occupational therapy treatment improved within the 1-2 year of life. Majority of the studies showed male ascendancy with slight male preponderance in few series.
- There are well-established associations between sternocleidomastoid and a breech presentation, forceps delivery, and primiparous birth. In present study history of prolonged or difficult labour was found in half of the case. Most cases of torticollis presented with sternocleidomastoid in this study. One to three month was the most common age of presentation found in most studies.
- Most cases of pseudo tumor of infancy (POI) presented earlier as compared to congenital muscular torticollis. In this study Paediatric occupational therapy resulted in an acceptable response rate in high proportion of cases with complete resolution of symptoms.
Conclusion
From the result of this study, it was concluded that there is significant benefit from Paediatric Occupational Therapy interventions on Children with a Congenital Muscular Torticollis. If congenital muscular torticollis is diagnosed in early infancy and childhood it can resolve in most cases after a holistic approach; some neglected cases can be occasionally seen in adults and need surgical treatment.
References
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Dr. M. Mahendran
Paediatric Occupational Therapist