RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGALORE
ANNEXURE-II
PROFORMA FOR REGESTRATION OF SUBJECTS FOR DESERTATION
1 / NAMEOF CANDIDATE AND ADDRESS (IN BLOCK LETTERS) / Ms.DEEPA. P
SHREE DEVI COLLEGE OF PHYSIOTHERAPY,
MAINA TOWERS,
BALLALBAGH,MANGALORE-3
2 / NAME OF INSTITUTION / SHREEDEVI COLLEGE OF PHYSIOTHERAPY,
MAINATOWERS,
BALLALBAGH,
MANGALORE-3
3 / COURSE OF STUDY AND SUBJECT / MASTERS OF PHYSIOTHERAPY,
2 YEARS DEGREE COURSE,
(PEDIATRICS)
4 / DATE OF ADDMISSION TO THE COURSE / 10/04/2013
5 / TITLE OF THE TOPIC / “A COMPARATIVE STUDY TO DETERMINE THE EFFECTIVENESS OF PASSIVE STRECHTING OVER MICROCURRENTS TO STERNOCLEIDOMASTOID MUSCLEIN TREATMENT OF CONGENITAL TORTICOLLIS.”
6 / BRIEF RESUME OF INTENDED WORK:
6.1 NEED OF STUDY:
Congenital muscular torticollis(CMT) is an intriguing condition of unknown origin characterised by shortening and tightness of the sternocleidomastoid muscle. Patients usually present with head tilt, facial asymmetry and plagiocephaly. A sternomastoid mass or tumour may or may not be clinically apparent. Untreated, cervical function and facial cosmesis may be severely compromised. Most patients with congenital muscular torticollis present early and respond well to physiotherapy..1
Congenital torticollis tilts the head to the side on which the neck muscles are shortened so that the chin points to the other side. The neck muscles that are shortened are principally supplied by the spinal accessory nerve. From the Latin "tortus", twisted + "collum", neck = twisted neck. Also called wry neck. 2
Early detection and initiation of physical therapy are related to improved outcomes and a decreased need for surgical intervention. Repositioning is a required element of early management for torticollis . Usually detected at 2-3 months of age during normal follow-up visits with pediatrician.CMT occurs in 1 in 300 live births.CMT with sternocleidomastoid muscle (SCM) impairment is the most frequent cause of torticollis Three clinical subgroups:
  1. Infants with palpable swelling/pseudo-tumor.
  2. Infants with SCM tightness but no tumor.
  3. Infants with all features of CMT without tightness or tumor.3
PHYSICAL THERAPY INCLUDE:
  1. Assessment of infant/family to identify causes of movement disorder
  2. Implement and manage rehabilitation/home program (Home Program Guidelines)
  3. Gentle ROM stretching, strengthening/activation of head and trunk muscles with upright positioning, massage, myofacial release, craniosacral therapies, microcurrents and therapeutic taping.
  4. Discharge guidelines are not well defined. Torticollis can reappear during periods of growth, illness, teething, and acquisition of new motor skills4
The purpose of the study is to check effect ofpassive stretching verses microcurrents in the treatment of children with congenital muscular torticollis.
RESEARCH QUESTION:
Is there a significant difference in the effectiveness between passive stretching and microcurrents in children with congenital torticollis?
NULL HYPOTHESIS:
There is no significant difference in effectiveness between passive stretching and microcurrentsin children with congenital torticollis.
ALTERNATIVE HYPOTHESIS:
There is significant difference in group of children treated with passive stretching V/S group of children treated with microcurrents in congenitaltorticollis.
6.2 REVIEW OF LITERATURE:
DaentzerD,StuderD conducted study on congenital muscular torticollis,they concluded that correction of malalignment of cervical spine with head tilted to the side of the shortened muscle can be done.Attainment of increased range of motion of cervical spine is also found.5
Department of physiotherapy, The queen Silva children’s hospital conducted a study on normal cervical spine range of motion in rotation and lateral flexion with neck flexors in normal individual. They concluded that it will be helpful in assessing and initial evaluation of torticollis.6
Wong MWetc conducted study of clinical determinants of outcome of manual stretching in congenital torticollis in infants. They concluded that controlled manual stretching is safe and effective in treatment of congenital muscular torticollis, if patient is seen earlier age.7
WeiJl,Schwatrz conduct a study to suggest algorithm for treatment of torticollis. They include 81 boys and 89 girls before 24months of age. Passive range of motion was initial treatment recommended for patients.85.5%experianced total resolution.8
Department of pediatric sugery, Zynep kamil maternal and child hospital,Istanbul conducted study to determine treatment duration and exercise frequency in congenital muscular torticollis .They assess 45 infants and concluded that patient with early diagnosed congenital muscular torticollis can be successfully treated using intensive protocol of passive stretching exercises.9
Cheng JC,tang SP etc did a study on the clinical presentation and outcome of treatment of congenital muscular torticollis in infants. They gave passive stretching for congenital muscular torticollis child below one year. The outcome depands on age of patients ,The initial deficit in rotation of neck. Patient undergone 6 months of controlled manual stretching and they concluded that patient below 15 degree of lateral bending on neck can get relief totally.10
Deparment of orthopedics and traumatology ,The Chinese university of hongkong conducted study on children with congenital muscular torticollis and sternocliedomastoid pseudo tumor. They concluded that subgrouping patients with sternocliedo mastoid tumor and congenital torticollis according to passive limitation of rotation of neck has prognostic significance with good overall results of conservative treatment with manual stretching.11
Demirbilek conducted study on non operative treatment of congenital muscular torticollis. They treated 57 infants with strenoclidomastoid tumor and congenital muscular torticollis over a five year period with passive and active stretching under 18 months of age.They concluded that passive stretching and active stretching exercises are highly effective for treatment of congenital muscular toticollis.the success rate of conservative treatment is primarily depends on the patients age at initiation of exercises.12
Department of orthopaedics and traumatology,Faculy of medicine conducted a study on infantile torticollis in 624 cases. They concluded that in patients presenting in early stages 97%of all infentile torticollis cases resolved with congenital torticollis cases resolved with conservative treatment, active stimulation and a passive stretching program with mean treatment period less than 6 months for varying degree of neck rotational deficit.13
Min Young Kimconducted a study on 15 infants with congenital torticollis. The contolled group underwent stretching exercises for 30 min after Ultrasound therapy, the experimental group underwent stretching exercises for 2 min after 30 min of microcurrent therapy. Each group received 3 treatments for two consecutive weeks. The result showed that microcurrent therapy in infant with torticollis appears more effective in improving tilting angle and rotation range and shows more better therapeutic compliance than traditional therapy.14
Kwon DR, Park GYcompared the effects of a combination of therapeutic exercise and ultrasound with or without additional microcurrent therapy in infants with congenital muscular torticollis involving the entire sternocleidomastoid muscle. Passive cervical rotational range of motion was measured at before treatment and one, two, three, and six months after initial treatment. Thickness, cross-sectional area, and red pixel intensity on colour histograms, which were all assessed before treatment and at three months after initial treatment. Additionally, the duration of treatment was measured. Results showed that Microcurrent therapy may increase the efficacy of therapeutic exercise with ultrasound for the treatment of congenital muscular torticollis involving the entire sternocleidomastoid muscle.15
6.3 OBJECTIVE OF THE STUDY:
To establish effectiveness of passive stretching in congenital torticollis.
To establish effectiveness of microcurrents in congenital torticollis.
To compare effectiveness of passive stretching andmicrocurrents in congenital torticollis.
7. / MATERIALS AND METHODS:
7.1 SOURCE OF DATA:
1. Government Wenlock Hospital,Manglore.
2.Shree Devi college of Physiotherapy,Manglore
(Out Patient Department).
7.2 METHOD OF COLLECTION OF DATA:
Primary data will be collected from the samples and 15 patients in each group will be choosen based on inclusion and exclusion criteria.
INCLUSION CRITERIA:
1. Patient with congenital muscular torticollis.
2.Fibrous band formation in sternocliedomastoid muscle
3.Pseudotumor in sternocliedomastoid muscle.
4. Patient with plegiocephaly and face assymetry with congenital torticollis
5.Age:from Birth- 2 years
EXCLUSION CRITERIA:
1.Any spinal abnormalities
2. Spine fracture
3. Vertebral anamoly
4. Occular imbalance
5. Nerve injury treatment
6. Neurological disorder
DESIGN:
Group A-Consist of 15 people with congenital muscular torticollis given passive stretching.
Group B-Consist of 15 people with congenital muscular torticollis given only microcurrents.
Group A and Group B individual are compared to know which treatment is more effective.
STATISTICAL ANALYSIS:
t-test. Paired and unpaired.
SAMPLE SIZE:
Sample size used for the research study is 30.
SAMPLE METHOD: Random sampling
STUDY DURATION:
The total duration of the study is 3 months.
OUTCOME MEASURE:
  1. ROM of cervical spine using goniometer on both left and right..
Rotation of cervical spine.
Lateral flexion of cervical spine.
TOOLS:
  1. Microcurrent Generator
  2. Goniometer.
  3. Pillows.
  4. Toys with attractive colors and voice.
METHODOLOGY:
All the participants with congenital muscular torticollis will be selected and screened; by considering inclusion and exclusion criteria. Those parents whose child participate in the study will be given brief idea about the nature of the study. The demographic data will be taken. Active range of motion of cervical rotation and lateral flexion (both right and left) for affected and unaffected side will be measured with goniometer by a therapist.
The participants will then randomly allocate to two groups, Group A and Group B using an envelope method.
For group A Participants , Interventions will be given in form of Passive stretching.
For Group B participants , Interventions will be given in form of microcurrents.
PROCEDURE:
Group A (Passive stretching group) children will be treated with passive stretching given by therapist only .Prior to the treatment assessment of rotation and lateral flexion of cervical spine will be noted and assessment of physiological functions will be done. Position of the child will be in supine. The head of the child will be held outside to the couch with in the therapist’s hand. He /she will give mild traction to the spine and than child’s head will be stretch towards lateral flexion opposite to the affected side. Therapist will also turn his /her head towards the affected side. 5 times stretching will be given with rest period of 1 minute in between and the stretch duration will be of 30 seconds each. These session will be continued till 7 days. After that again ROM of rotation and lateral flexion of cervical spine will be measured by using Goniometer.
Group B (Microcurrents): These children when come to the hospital, Before any treatment has started child’s ROM of rotation and lateral flexion of cervical spine will be noted. The Therapist will measure ROM of child’s cervical spine with a Goniometer. The microcurrent generator will be programmed to provide an alternating current. The current intensity is set to 100 MA and current frequency is 8Hz. The current level should be significantly below the threshold of sensation of the patient. Electrical probes were attached over each muscle. One assistant is needed to secure the child in a supine or side lying position. The SCM muscle is isolated by turning the child’s head towards the contralateral side, thus allowing the muscle to be easily palpated during the attachement of an electrical probe.
At the end of the treatment measurement of the rotation and lateral flexion of cervical spine will be done by therapist with Goniometer. It will be done in both the Groups and the results will be compared to each other to know which treatment will be more effective.
7.3Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so , please describe briefly.
Yes. Group A receives passive stretching and Group B receives microcurrents to the sternocleidomastoid muscle.
7.4 Has ethical clearance been obtained from your institutions in case of above:
Yes.
8. / REFRENCES:
  1. B C S Ho, E H Lee, K Singh, Singapore Med J 1999; Vol 40(11):
  2. NZ Journal of Physiotherapy – November 2009, Vol. 37 (3) 127
  3. Ballock RT, Song KM. The prevalence of nonmuscular causes of torticollis in children. J Pediatr Orthop 1996;16:500-504.
  4. Section 4: The Identification and Treatment of Congenital Muscular Torticollis in Infants.
  5. Muscular torticollis. Oper Orthop Traumatol.2010;May22(2):177-87 Author:DaentzerD,StuderD,WirthCJ
  6. Reference values for range of motion and muscle function of neck in infants. Pediatr Phys Ther.2008Spring;20(1):53-8.Author:Ohman AM,Beckung ER.
  7. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis. Journal of Bone joint surgeryAm.2001 May;83A(5):675-87.Author:Wong Mw,Tang SP, Chen TM, Shum SL, Wong EM.
  8. Congenital muscular torticollisand pseudomotor tumor. Laryngoscope.2001apr;111:688-95. Author:WeiJL,SchwartzKM,Weaver AL, Orvidas LJ.
  9. Congenital muscular torticollis:early and intensive treatment is critical. A prospective study. Pediatr Int.2000Oct;42(5):504-7. Author:Celayir AC.
  10. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants. Journal pediatr.Surg.2000 July;35(7):1091-6. Author: Cheng JC,Tang SP.Chen TM, Wong MW,Wong EM.
  11. Sternocliedomastoid pseudo tumor and congenital muscular torticollis in infants. J Pediatr.1999 Jun;134(6):712-6.Author:Cheng JC, Tang SP, Chen TM.
  12. Congenital muscular torticollis and sternomastoid tumor:results of non operative treatment. J.Peditr.surg 1999Apr:34(4)549-51.Author:demirbilekS, Atayurt HF.
  13. Infentile torticollis: J pediatr.Orthop.1994.Nov-de:14(6):802-8. Author: Au Aw
  14. Min Young Kim, MD, Dong Rak Kwon et al. therapeutic effects of mirocurrent therapy in infants with congenital muscular torticollis. American Academy of Physical Medicine and Rehabilitation. 2009 Aug: vol (1); pp 736-739.

15.Kwon DR, Park GYet al: Efficacy of microcurrent therapy in infants with congenital muscular torticollis involving the entire sternocleidomastoid muscle: a randomized placebo-controlled trial. Clin Rehabil.2013: Nov ;15.

9. / SIGNATURE OF CANDIDATE
10. / REMARK OF GUIDE
11. / NAME AND DESIGNATION (In Block letters)
11.1 GUIDE / Ms. SANGEETHA P.
ASSISTANT PROFESSOR,
SHREE DEVI COLLEGE OF PHYSIOTHERAPY,MANGALORE-3
11.2 SIGNATURE
11.3 CO-GUIDE / -
11.4 SIGNATURE
11.5 HEAD OF DEPARTMENT / DR.VIJAY P
PRINCIPAL,
SHREE DEVI COLLEGE OF PHYSIOTHERAPY,
MANGLORE-3
11.6 SIGNATURE
12 / 12.1 REMARK OF CHAIRMAN AND PRINCIPLE
12.2 SIGNATURE

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