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					Physiotherapy for Torticollis
Congenital muscular torticollis in infants is                        Paying for
commonly treated by pediatric physiothera-
pists. Torticollis is due to tightness and/or
increased strength in one of the sternocleido-
mastoid (SCM) muscles, resulting from the                            On January 1, 2002, physiotherapy was de-listed from the British
                                                                     Columbia Medical Services Plan, meaning that most people in BC
fibrosis of its central portion. A benign mass
                                                                     must pay for physiotherapy through extended health benefits, their
may sometimes be present in the muscle.1,2,3                         own money or a combination of the two. For people with low
Torticollis is usually observed within the first                     incomes who are on premium assistance, MSP will contribute up to
few months of age with a tilting of the head                         $23 per visit for up to 10 total visits to physiotherapy. School-age chil-
toward the affected muscle and rotation away                         dren in the At-Home Program are also funded for 24 physiotherapy
from this muscle. Although the etiology of                           treatments every six months. Physiotherapy services are also available
torticollis remains unclear, several theories                        for people in hospital and for discharged patients.
have been proposed, including birth trauma,                          About two-thirds of BC adults have extended health benefits through
intrauterine malposition, infection, vascular                        a group insurance plan. These plans tend to cover a varying percent-
injury and perinatal compartment syndrome.                           age of the cost of treatment, with an annual ceiling amount. Workers’
                                                                     Compensation Board and the Insurance Corporation of BC still
Up to 90 percent of children with torticollis
                                                                     provide coverage for physiotherapy services.
will present with positional plagiocephaly
and facial asymmetry.1,4 With plagiocephaly,                         What It Costs
the occipital-parietal area of the skull con-                        On average, an initial visit to a physiotherapist in BC costs $45-65. In
tralateral to the involved SCM becomes flat-                         this initial visit, the physiotherapist takes the patient’s history, assesses
tened. As babies are typically placed supine                         the current problem, makes a physical examination, provides a physi-
for sleeping, the persistent rotating of the                         cal diagnosis, outlines a treatment protocol and provides the first
head to the same side can bring about this                           treatment. Subsequent treatment visits cost, on average, $30-55. Fees
change. Prior to treatment, other causes of                          vary with the duration of treatment and other factors.
congenital and acquired torticollis – such
as those resulting from vertebral anomolies,                         New Survey Results:
infections, and inflammation of adjacent
                                                                     Physiotherapy the Preferred Treatment
structures – should be ruled out.
                                                                     Physiotherapy is the preferred choice for people seeking rehabilitation
Physiotherapy treatment of torticollis
includes positioning, strengthening,                                 treatment in BC. According to a public opinion survey conducted in
stretching, and handling techniques. If the                          April 2005, 37 percent of British Columbians would visit a physio-
SCM is tight, stretches are highly recommended                       therapist for treatment of muscle pain or of a sore back, neck or
immediately after diagnosis.5,6 Frequent,
                                                                     joint. This is 40 percent more than would visit a massage therapist
short “tummy time” periods when the child
is awake are also recommended. If left                               and 25 percent more than would see a chiropractor.
untreated, the resulting clinical signs may                          Respondents to the survey cited their main reasons for choosing
be restricted neck movement, a persistent
tilt, facial and skull deformities, scoliosis and                    physiotherapy as positive past experience, trust in the training and
delayed motor development.                                           knowledge of physiotherapists, and the long-term effectiveness of
1 Cheng JCY et al.The clinical presentation and outcome of           physiotherapy treatment.
treatment of congenital muscular torticollis in infants. J Pediatr
Surg 2000; 35(7):1091-1096
2 Celayir AC. Congenital muscular torticollis: Early and inten-
sive treatment is critical. A prospective study. Paediatrics Int
2000;42:504-507                                                      Find a Physiotherapist in BC!
3 Davids JR, Wenger R, Mubarak SJ. Congenital muscular
torticollis: Sequel of intrauterine or perinatal compartment         Check the Physiotherapy Association of BC directory of physiothera-
syndrome. J Pediatr Orthop 1993;13:141-147
                                                                     pists (mailed to all family physicians each summer) or search online
4 Wei JI et al. Pseudotumor of infancy and congenital muscu-
lar torticollis. Laryngoscope 2001;111:688-695                       at Search within Areas of Expertise including
5 Emery C. Conservative management of congenital mus-
cular torticollis: A literature review. Physical and Occupational    urology/gynecology, women’s health, orthopaedics, pediatrics.
Therapy in Paediatrics, the Quarterly Journal of Development
Therapy. 1997;17(2):13-20
6 Cheng JCY, Wong MWN, et al. Clinical determinants of man-
                                                                     Past issues of briefings for physicians are on the website under media
ual stretching in the treatment of congenital muscular torticol-
lis in infants. J Bone and Joint Surg 2001;83-A(5);679-686           centre/briefings for physicians.
A resear ch summar y from the Physiotherapy Association of BC.

 b r i e fi n g s f o r p hy s i c i a n s
  In this issue of briefings for physicians our focus is on physiotherapy inter-
  vention for some common problems of childhood and adolescent health,
  including obesity, sports injuries, developmental delays and torticollis.

  Increased Activity an Important
  Component of Treatment for                                                        Fall 2005
  Childhood Obesity
  Canadian physiotherapists are increasingly concerned about the grow-
  ing incidence of overweight and obesity among children and adolescents
  in this country. According to a recent report 15 percent of Canadian
  children are obese,1 and the number of children who are overweight or
  obese has doubled from a decade earlier.2 Another survey indicates that
  up to 37 percent of Canadian children aged two to 11 are overweight.3
  Among children, obesity is a direct cause of many musculoskeletal condi-
  tions treated by physiotherapists, and is associated with such problems as
  lower limb pain, back pain, and poor flexibility, strength and conditioning,
                                 which can all affect a child’s gross motor
                                 development as well as contribute directly
                                 to overall inactivity.
                                  Childhood obesity also predisposes indi-
                                  viduals to obesity as adults. Research has       Physiotherapists are in a
                                  shown the probability of childhood obesity       unique position to treat
                                  persisting into adulthood is about 20 per-
                                  cent at age four, increasing to 80 percent
                                                                                   children who are overweight
                                  by adolescence.4 It is also evident that         or obese, especially those
                                  the risk of obesity increases with age dur-
                                                                                   with co-existing morbidities
                                  ing childhood and adolescence.5
                                                                                   such as hypertension, Type
                                  Although the causes of obesity are undis-
                                  puted (increased energy intake and/or            2 diabetes, musculoskeletal
                                  reduced energy expenditure),6 there is less      problems, pain or psychosocial
                                  certainty about its treatment. Increased
                                  physical activity, however, is well support-     problems.
                                  ed by research as an important component
                                  of any weight management program.7
  Research suggests that non-physically active children are more likely to
  become non-physically active adults.8 The seriousness of this issue is
  further underscored by the finding that 58 percent of BC teenagers are
  not active enough for optimal growth and development.9 This is of par-
  ticular concern with children who were born prematurely, who are at
  even greater risk of experiencing long term effects of physical inactivity. 10
  Increasingly, interventions directed at children are seen as an effective
  measure for addressing the overall problem of obesity in society.Thus,
  according to Provincial Health Officer Perry Kendall,“to improve health
  over the long term, particular emphasis must be placed please see page 2
                                                                  continued from page 1 on critically sensitive periods during the

                                                              lifespan, including prenatal, early childhood and the school years.”11
                                                              This position is also supported by the Canadian Physiotherapy
                                                              Association (CPA), which encourages increased physical activity
   Preventing Sports Injuries                                 for children toward establishing patterns that will continue into
   in Children                                                adulthood.The CPA recommends children engage in at least 30 to
   It is estimated that sports account for more               60 minutes of physical activity throughout the day to achieve and
   than 242,000 injuries among Canadian children              maintain mobility and to control weight gain.
   every year.1 These injuries fall into two main
                                                              The aim of the physiotherapist in treating children or adolescents
   categories: overuse injuries and acute injuries.
                                                              who are overweight or obese is to control weight gain or reduce
   Overuse injuries are generally preventable.                weight through increased physical activity and education.
   Research has shown that early detection of                 Physiotherapists are in a unique position to treat such children, espe-
   youth at risk for repetitive strain injuries is key        cially those with co-existing morbidities such as hypertension, Type 2
   to prevention and treatment of these injuries.2            diabetes, musculoskeletal problems, pain or psychosocial problems.
   Physiotherapy interventions that reduce
   overuse injuries in youth include gradually                Physiotherapeutic treatment of obesity begins by assessing the
   increasing training load, improving flexibility            child’s present activity level and completing a cardiorespiratory
   and strength, improving biomechanics, and                  function test and a musculoskeletal survey, including measuring
   correcting malalignment.                                   strength, flexibility and endurance. Following these assessments,
   1 Statistics Canada Health Report, 2003                    and using their advanced knowledge of body movement and tech-
   2 Kidd PS, McCoy C, Steenbergen L. Repetitive strain       niques for restoring mobility, the physiotherapist can develop a daily
   injuries in youth. J Am Acad Nurse Pract. 2000;12(10):     activity program to suit the patient’s needs and the family’s lifestyle.
                                                              A monitored program might begin with non-weight-bearing exercise,
                                                              such as swimming or cycling, to minimize the impact on joints. The
   Back Protection for Children                               frequency and duration of these activities is increased gradually over
   Canadian children risk long-term injury to their           time. The program will also include stretching to increase flexibility
   backs and arms when they use their backpacks
                                                              and education about injury prevention.
   to carry heavy loads to and from school.
                                                              Physiotherapists are strong advocates of increasing physical activity
   A recent study investigated the link between
                                                              for children and youth in the public school system and many school
   backpacks and back pain in school children.1
                                                              districts in BC now regularly employ the services of physiotherapists
   Of 1,122 backpack users, 74 percent were
   classified as having back pain, validated by sig-
                                                              as consultants.
   nificantly poorer general health, more limited             1 Report on the Health of British Columbians. Provincial Health Officer’s Annual Report 2002.
   physical functioning, and more bodily pain.                2 Canadian Community Health Survey. July, 2005
   Heavy and badly fitted backpacks can create                3 Statistics Canada, 2002
                                                              4 Taking a Bite Out of Childhood Obesity, Canadian Physiotherapy Association News Release,
   numbness or tingling in the arms and hands due             Sept. 2003
   to nerve compression, as well as pain in areas of          5 Reilly JJ, Wilson ML, Summerbell CD, Wilson DC. Obesity: diagnosis, prevention and treatment;
   the spine. Based on research, physiotherapists             evidence based answers to common questions. Arch Dis Child 2002;86:392-395
   recommend that loaded backpacks should weigh               6 Reilly JJ. Physical activity and obesity in childhood and adolescence. The Lancet
   less than 15 percent of the child’s body weight.           2005;366(9482):265
                                                              7 Maziekas MT, et al. Follow-p exercise studies in paediatric obesity: implications for long-term
   Physiotherapists also suggest that children                effectiveness. Br J Sports Med 2003;37:425-429
   keep their backpacks centred on the back,                  8 Watts K, Jones TW, Davis EA, Green D. Exercise training in obese children and adolescents:
   use both shoulder straps, limit the amount of              current concepts. Sports Med. 2005;35(5):375-392
   weight they carry, and maintain good posture               9 Report on the Health of British Columbians. Provincial Health Officer’s Annual Report 2002.
                                                              10 Rogers M, Fay T,Whitfield MF, Grunau RE,Tomlinson J. Aerobic capacity, strength, flexibility
   while wearing their weighted backpacks.
                                                              and activity level in unimpaired ELBW (£800 gram) survivors at 17 years of age compared to
   The Canadian Physiotherapy Association offers              term born controls. Pediatrics 2005;116: e58-e65
   therapeutic exercises for children designed to             11 P. R. W. Kendall, Provincial Health Officer (BC) – An Ounce of Prevention - A Public Health
                                                              Rationale for School as a Setting for Health Promotion, October 2003.
   keep their muscles flexible and relaxed, their
   joints mobile, and to relieve tension. For more
   information, visit
                                                                         b r i e fi n g s f o r p hy s i c i a n s
   1 Sheir-Neiss GI, et al. The association of backpack use
   and back pain in adolescents. Spine 2003; 28(9):922-930      Published by: Physiotherapy Association of British Columbia
                                                                               402 - 1755 West Broadway, Vancouver, BC V6J 4S5
                                                                               Phone 604-736-5130 or toll-free 888-330-3999
Physiotherapy Briefings for Physicians
Treatment for ACL Injuries
Reduces Risk of Osteoarthritis
Anterior cruciate ligament (ACL) injuries are one of the most com-
mon sports injuries among adolescents. An ACL injury is debilitating,                                      Early Intervention Improves
requiring surgical reconstruction and up to 12 months of rehabilitation.                                   Outcomes in Developmental
ACL injury can triple the risk of osteoarthritis (OA) developing by                                        Delays
middle age1,2 and surgical intervention is not effective in reducing                                       Early intervention of physiotherapy has been
this risk.3                                                                                                well documented as significantly improving
                                                       Multidirectional sports, includ-                    outcomes for infants and children at risk for
                                                       ing soccer and basketball,                          developmental delays.1
                                                       are among those most likely                         Developmental delays among infants and
                                                       to result in ACL injury,4,5 and                     children are associated with a variety of medi-
                                                       young women participating in                        cal, physical, social and emotional conditions,
                                                       these sports are between four                       including:
                                                       and six times more likely to sus-                   • Congenital syndromes
                                                       tain an ACL injury than young                       • Trauma
                                                       men.13,14,6,7 The rapid increase                    • Cerebral palsy
                                                       of female participation in youth                    • Down syndrome
                                                       soccer and other sports has con-                    • Significant prematurity
                                                                                                           • Complications of pregnancy and/or delivery
                                                       tributed to the growth of this
                                                                                                             resulting in brain injury
                                                                                                           • Congenital anomalies such as heart, limb and
                                      In a systematic review, Hewett                                         brain malformations
                                      and coworkers concluded “there                                       • Autism
                                      is evidence that neuromuscular                                       • Prenatal exposure to drugs and alcohol
training not only decreases the biomechanical risk factors for ACL                                         Physiotherapists specialized in pediatrics use
injury, but also decreases knee and, specifically, ACL injury incidence                                    standardized and reliable tools to monitor and
in female athletes.”9 Further research has shown that knee injury                                          direct intervention for children with motor
prevention programs are effective at reducing the occurrence of OA                                         impairments and developmental delays and to
in the knee by 25 percent for men and 19 percent for women.10                                              promote improved functional motor develop-
                                                                                                           ment.2 These interventions also include the
Physiotherapist and researcher Rick Celebrini is an expert in the area
                                                                                                           use of specialized equipment and orthotics to
of injury prevention among young athletes. According to Celebrini,
                                                                                                           assist the child in achieving an optimal level of
the current research suggests that injury prevention programs, such
                                                                                                           functional ability.
as those developed by sports physiotherapists, could be effective in
reducing the incidence of primary ACL injury among adolescents and                                         Physiotherapists provide both centre-based
possibly at reducing their risk for the later development of OA.                                           and in-home services for children at risk for
                                                                                                           developmental delays. These services are avail-
1 MacKay M, et al. Looking for the evidence: a systematic review of prevention strategies address-         able through child development centres in
ing sport and recreational injury among children and youth. J Sci Med Sport 2004; 7(1): 58-73.             communities throughout BC.
2 Nadler SF, et al. The relationship between lower extremity injury, low back pain, and hip muscle         The Physiotherapy Association of BC has a
strength in male and female collegiate athletes. Clin J Sport Med 2000;10(2):89-97.
                                                                                                           list of qualified private physiotherapists spe-
3 Roos H, et al. The prevalence of gonarthrosis and its relation to meniscectomy in former soccer
players. Am J Sports Med 1994;22(2):219-222                                                                cialized in pediatrics. In addition, the Infant
4 Roos H. Are there long-term sequelae from soccer? Clin Sports Med 1998;17(4):;819-831                    Development Program of BC offers in-home
5 Griffin LY, et al. Non-contact anterior cruciate ligament injuries: risk factors and prevention strat-   physiotherapy consultation for families of
egies. J Am Acad Orthop Surg 2000; 8(3): 141-150                                                           infants up to three years of age diagnosed
6 Hewett TE, Neuromuscular and hormonal factors associated with knee injuries in female ath-               with, or at risk for developmental delays.
letes. Strategies for intervention. Sports Med, 2000;29(5):313-327
                                                                                                           1 Frank, DA, et al. Level of prenatal cocaine exposure and
7 Huston LJ, Greenfield ML, Wojtys EM, Anterior cruciate ligament injuries in the female athlete:
                                                                                                           scores on the Bayley scales of infant development: modify-
Potential risk factors. Clin Orthop Relat Res 2000;(372):50-63
                                                                                                           ing effects of caregiver, early intervention, and birth weight.
8 Hewett TE, Myer GD,Ford KR. Decrease in neuromuscular control about the knee with matura-
                                                                                                           Pediatrics 2002;110 (6):1143-1153
tion in female athletes. J Bone Joint Surg Am 2004;86-A(8):1601-1608
9 Hewett TE, Myer GD, Ford KR. Reducing knee and anterior cruciate ligament injuries among                 2 Lekskulshai R, Cole J. Effect of a developmental program
female athletes: a systematic review of neuromuscular training interventions. J Knee Surg 2005;            on motor performance in infants born preterm. Australian
18(1):82-88.                                                                                               Journal of Physiology 2001;47:169-176
10 Felson DT, Zhang Y. et al. An update on the epidemiology of knee and hip osteoarthritis with a
view to prevention. Arthritis Rheum.1998;41(8):1343-55.

                                                                                                                                                                  Fall 2005

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