The benefits of physical therapy for torticollis in children

Alecia, a young mother, noticed something strange in her baby: her daughter’s head and neck were turned to the side every time she was placed in her car seat or bassinet. She said, “Her neck seemed to turn unnaturally every time I put her in her car seat and baby swing.” So Alecia asked her doctor what was the matter during her baby’s monthly check-up. The diagnosis: torticollis. And she was referred to a physical therapist (PT) for management.

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By Brett Sears PT, Medically reviewed by Laura Campedelli PT DPT, Verywell Health December 17, 2021

Torticollis is a condition where a baby’s neck muscles are tight and in spasm and cause the child’s head and neck to bend and turn to one side. It may occur in up to 16% of babies and infants.^[1] In the majority of cases, the baby’s neck bends to one side (for example, the right ear is closer to the right shoulder) and then is rotated in the opposite direction (looking over the left shoulder). The condition can be treated successfully with physical therapy and involves working to improve flexibility in the neck muscles.

In this article, we’ll discuss the hallmark symptoms of torticollis and what physical therapy exercises can help.

Signs and Symptoms of Torticollis

Torticollis in babies may be a congenital problem and present at birth. Or, it may be acquired over time during your child’s infancy. It is caused by an unnatural tightness in the sternocleidomastoid muscle of the neck. When this muscle is tight or in spasm, it causes the head to bend towards the tight side and rotate away from the tight side.^[2]

Symptoms of torticollis in infants and babies include:

Your baby’s head bends to one side and turns to the opposite side when seated in an infant carrier or lying down.
Limited range of motion in your infant’s neck
Flattening of one side of your baby’s head or face (positional plagiocephaly)
Breastfed babies may prefer only one side during feeding
Your baby has difficulty maintaining their head in a neutral position when they are upright

If you notice any signs of torticollis in your baby, speak with your pediatrician right away. They can perform an examination to determine if your child has torticollis. (There is no diagnostic test for torticollis; diagnosis is made by clinical examination).^[1] Then, they can recommend treatment, including physical therapy, to manage the condition.

Physical Therapy Specialties
Not all physical therapists are created equal, and your baby may benefit from working with a therapist who is a pediatric specialist. You can find one on the website for the American Physical Therapy Association. If you cannot find a pediatric specialist in your area, keep an eye out for therapists who have experience working with babies.

The Effects of Physical Therapy on Torticollis in Children

If your child is diagnosed with torticollis, they may benefit from working with a physical therapist.^[2] Your therapist can provide treatments and exercises to help improve neck range of motion, neck and head positioning, and overall neck and head muscular control.

But is physical therapy really necessary for infants with torticollis?

Some research shows that torticollis may spontaneously resolve over time. But, some cases are persistent and require professional intervention to resolve. And research indicates that earlier access to physical therapy improves outcomes with infantile torticollis, so it’s a good idea to get started as soon as a diagnosis is made.^[2]

Working with a PT can ensure that your child’s torticollis quickly resolves and they can develop normally through infancy and childhood.

Torticollis Treatment: Exercises to Try

Physical therapy treatment for torticollis involves parent education, proper baby positioning, and exercises to stretch tight neck muscles and strengthen weak muscles. Be sure to check in with your PT or pediatrician prior to beginning any exercise for your baby or infant.

Proper Positioning

If your baby has right-sided neck tightness, their head will be bent to the right and slightly rotated to the left. The opposite is true if they have left-sided tightness; there will be left lateral flexion with right head and neck rotation.

Proper position of your baby can help place the neck muscles on gentle stretch, improving the flexibility of those muscles. When placing your baby in a stroller or car seat, a small towel should be rolled up and placed on one side of the head and neck, offering support and keeping your child’s head in a neutral position.

Neck Rotation

Torticollis causes neck and head rotation away from the tight side, so working on gentle stretching into rotation may be prescribed.

To perform this, sit supported with your knees bent, and allow your infant to rest on your thighs. Use a toy to get your baby’s attention, and move the toy to the side where rotation is restricted. Gently with your hand at the back of your baby’s head, help the baby to look towards the restricted side, and hold at end range for 20-30 seconds at a time. Repeat three to four times, and do this multiple times per day. Do not continue pushing if the baby is crying or is distressed.

Neck rotation can be performed when your child is lying on their back or when they are in their car seat or stroller and can be done several times each day.

Neck Rotation During Tummy Time

When your baby is enjoying tummy time, you can work on neck rotation exercises to help with torticollis. Place their favorite toys and colorful baby-safe objects to the side of your baby, and encourage active looking towards the toys. You can also assist your baby in rotating their head by gently turning their head during tummy time.

Tummy time for your baby is also a great way to improve head and neck muscular control and strength.

Lateral Head Tilt

When the sternocleidomastoid muscle becomes tight, the head and neck get pulled towards the tight side. To stretch this, sit with your knees bent and hold your infant on your thighs. To stretch the right side of the neck, hold your baby’s right shoulder down while slowly and gently bending their head away from the shoulder. Hold for 20-30 seconds and repeat four times. Do this multiple times during the day.

Cheek-to-Cheek Hold

To gently rotate your baby’s neck away from the tight side, hold your baby upright against your chest and neck. Press your cheek against your child’s cheek, and slowly press your cheeks together, allowing your child’s head to rotate away from yours. Hold this position for 5-10 seconds, and release. Repeat five times. A mirror may be used to keep baby engaged and turning their head to one side.

Lateral Neck Flexion Strengthening

Once your baby is 3 or 4 months old, they will likely be holding their head up on their own, but they may prefer to lean to one side if they have torticollis. To strengthen one side of your baby’s neck, simply hold them upright and slightly tilted to one side. The side to be strengthened should be more upright. This forces your baby to work to hold their head upright.

If your baby is unable to hold their neck against gravity, their head could drop down to the tight side again, which will make the tilt worse. Adjust the angle of the baby’s body if you find the head is drooping to make it easier for the baby to hold their head upright.

Perform this whenever you carry your baby to promote strengthening of the lateral neck muscles.

Side-Lying Head Lift

To have your baby actively engage their lateral neck muscles, you can try the side-lying head lift exercise. Place your baby on one side, and be sure they are supported by a rolled-up towel or blanket behind their body. Then, use engaging and age-appropriate toys to keep your baby’s attention, and move the toy up away from the floor.

Your baby may naturally try to follow the toy with their eyes and head, lifting their head up sideways and engaging their lateral neck muscles. Perform this for a few minutes, and then give them a rest. (Your child may become fussy if you exercise too much with them).

How Long Before We Notice a Difference?

Working closely with your physical therapist and performing daily exercises for your child can help improve your baby’s head and neck motion. Most parents notice positive changes within a few weeks of starting the exercises.

You can expect your child’s torticollis to be resolved within three to six months. If your baby’s signs and symptoms last longer, you should visit your pediatrician to discuss further treatment options. Occasionally injections of Botox may be recommended to relieve spastic muscles. Although rare, some babies with torticollis require a surgical procedure to lengthen the sternocleidomastoid muscle.^[3]

Keep in mind that torticollis can also “return” as an old motor pattern when a baby learns a challenging new skill (like crawling or walking). This is normal. Check back in with your physical therapist, as they may have another course of therapy to correct this.

Torticollis Prevention

While torticollis is not a dangerous condition, it may cause a slight delay in normal development and movement.^[1] Prevention of torticollis should be discussed with your PT as part of the therapy program.

Prevention of torticollis in infants and babies includes:

Change your baby’s body position often when they are awake.
Limit the time spent positioned in car carriers, swings, and strollers.
Provide your child with supervised tummy time to strengthen neck, shoulder, and back muscles.
Monitor your child for signs of neck tightness on one side, and check-in with your pediatrician if you suspect any problem with your baby.

Understanding the importance of varying positions and activities for your baby can help keep their muscles strong and developing normally and may prevent problems related to torticollis.

Summary

Torticollis is a condition that can limit your baby’s neck and head motion and positioning. Although it is not painful, it may cause your baby to be fussy, as they may have difficulty with normal movements. Treatment can be very successful with physical therapy exercises and proper positioning. Working with a PT can help you learn what to do to quickly and safely manage your baby’s torticollis and get them moving comfortably.

A Word From Verywell

Any abnormalities in your baby’s movement and functioning can be alarming to see. It is important to remember that torticollis is not causing your baby pain and it is not a permanent condition. By putting in the time to help your baby with their movement, they can start showing improvement very quickly.

Frequently asked questions

References

Uptake of the Congenital Muscular Torticollis Clinical Practice Guideline Into Pediatric Practice, Kaplan SL, Dole RL, Schreiber J. Pediatr Phys Ther. 2017 Oct;29(4):307-313. doi: 10.1097/PEP.0000000000000444. Full text
Management of Infants with Congenital Muscular Torticollis, Zheralldin Durguti, Ardiana Murtezani, Lidvana Spahiu, Teuta Durguti, Eqrem Gara, Journal of Pediatric Neurology 2019; 17(04): 138-142. DOI: 10.1055/s-0038-1660829.
Use of Combined Botulinum Toxin and Physical Therapy for Treatment Resistant Congenital Muscular Torticollis, Limpaphayom N, Kohan E, Huser A, Michalska-Flynn M, Stewart S, Dobbs MB. J Pediatr Orthop. 2019 May/Jun;39(5):e343-e348. doi: 10.1097/BPO.0000000000001302.

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