CASE STUDY. Objective: To describe the chiropractic care of an infant with congenital muscular torticollis and plagiocephaly.

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1 CASE STUDY Improvement in, Plagiocephaly & Breastfeeding Issues in an Infant Following Subluxation Based Chiropractic Care: A Case Study Sian Williams, D.C. 1 Joel Alcantara, D.C. 2 Abstract Objective: To describe the chiropractic care of an infant with congenital muscular torticollis and plagiocephaly. Clinical Features: A 6-week-old boy was presented by his mother for chiropractic consultation and possible care with a chief complaint of left sided plagiocephaly and right sided contractures of the sternocleidomastoid (SCM) muscles. Patient was a twin born via Caesarean section. Static and motion palpation revealed a hypertonic right SCM muscles and left lateral atlas subluxation. Interventions and Outcomes: The patient was cared for using the Activator Instrument to address spinal subluxations along with cranial therapy to address the patient s cranial dysfunctions. Manual stretching of the SCM was instituted as part of a home exercise program. Initial response to care was full and symmetric ROM in the cervical spine and the ability to nurse, bilaterally. The patient s torticollis and concomitant plagiocephaly improved with 6 visits over a 3 week period. Conclusion: This case report supports evidence-informed practice in the care of patients through the detection and removal of spinal subluxations and its concomitant salutary effects. Key Words: Congenital muscular torticollis, plagiocephaly, vertebral subluxation, chiropractic, breastfeeding Introduction A core aspect of the pediatric physical examination procedure is to determination normal from abnormal. Towards these efforts, the chiropractor examines for structural and/or functional asymmetry (i.e., abnormal shapes or unequal postures and movements) from a global or localized perspective. For infants presenting with torticollis, one observes preferential/static posture of the head with asymmetric cervical spine range of motion (ROM). Of interest in this case report is congenital muscular torticollis (CMT), a type of torticollis first characterized by Tubby in 1912 as a congenital or acquired deformity, characterized by lateral flexion and contralateral rotation of the head and neck with possible facial distortions. 1 The incidence of CMT has been placed among infants and newborns at % of all live births. 2 Pathophysiological theories have been proposed that include intrauterine constraint and compartment syndrome during the prenatal period, myopathy of the sternocleidomastoid (SCM) and birth trauma. 3-4 The medical approach to the patient with torticollis commonly involves manual stretching, the use of botox and if unresponsive to physical therapy or orthotic devices, surgical intervention. 5 Cheng 6 reported that 95% of CMT resolves within one year of manual stretching. Fair to poor outcomes are associated with the presence of an SCM tumor (76.1% fair/poor outcome), rotation of the cervical spine greater than J. Pediatric, Maternal & Family Health - December 22,

2 15 0 from neutral (77.5% fair/poor outcome) and if the patient s age was greater than one year at time of initial treatment (67.6% fair/poor outcome). With surgical interventions, complications may result in damage to nervous and vascular structures near the SCM (i.e., the spinal accessory nerve, the anterior and external jugular veins, the carotid vessel and the facial nerve). 7 Poor outcomes of care and concerns of safety prompt many parents to seek alternative care for their child. In the interest of evidenceinformed practice, the purpose of this case report is to describe the successful care of an infant with CMT and concomitant plagiocephaly under the paradigm of chiropractic care. Case Report A 12-week-old boy was presented by his mother for chiropractic consultation and possible care with a chief complaint of left sided plagiocephaly and right contractures of the sternocleidomastoid (SCM) muscles. The infant is a twin and had been fully engaged in an anterior occiput position inutero. According to the infant s mother, her labor was prolonged with a Caesarean section being performed. During the history, patient s mother revealed that the child s pediatrician had informed her that the child s plagiocephaly would resolve a few weeks after birth and that the neck contracture was not as a result of congenital torticollis but rather as a result of the position of comfort found by the infant due to the flattened aspect of the left cranium. A wait-andsee approach had been suggested by the child s pediatrician. However, at three months postnatal, the infant s mother was concerned that there had been no change or improvement in her child s plagiocephaly or SCM contractures. The baby was observed to have a generally happy disposition but the mother was concerned about her difficulties in feeding her child as the infant could only be bottle fed in very specific positions. At the time of consultation, the patient s mother informed the attending chiropractor that she was pumping and using a bottle due to exhaustion with breastfeeding her twins. On physical examination, the following were noteworthy. Passive ROM was restricted in left lateral flexion and right rotation by 25%. All other passive ROM directions were within normal limits given their lack of restriction and demonstrated symmetry. Motion palpation determined that the patient s atlas was subluxated laterally, superiorly and posteriorly to the left or ASLP listing (i.e..-θx, +θy) according to Palmer-Gonstead-Firth listing. In addition, posterior restrictions were noted at T4, T6 and L4. Static palpation revealed a hypertonic right sternocleidomastoid (SCM) muscle. With passive repositioning of the patient s head the SCM muscle would relax momentarily and then contract to create the classic torticollis head positioning (i.e., rotation of the head to the left with cervical spine extension). The patient s mother was advised of the examination findings and a trial of chiropractic care was suggested for her son with a frequency of twice a week for three weeks followed by reassessment. The patient s mother consented and with the first treatment, an Activator Instrument 8 applied to correct for the lateral atlas subluxation. A craniosacral suture 9 release was performed of the occipitomastoid suture (crossing the jugular foramen); 88 J. Pediatric, Maternal & Family Health - December 22, 2014 contact was taken on either side of the suture and a very gentle, sustained traction was applied for approximately thirty to forty-five seconds until a softening was felt by the practitioner. A craniosacral dural release was also performed at the foramen magnum; with the patient supine contact was taken on either side of the occiput and a gentle, sustained lateral traction was held until dural release was perceived by the practitioner. Both aforementioned foraminas were involved in the path of the accessory nerve (cranial nerve XI) which provides motor innervation to the SCM and trapezius muscles. In addition, passive stretching of the SCM was performed. The T4, T6 and L4 posteriority (i.e., -Z) were addressed with a sustained finger contact reversing the subluxation direction until joint motion was perceived. Immediately following the initial treatment the patient s head remained in right rotation, when passively rotated, without recontracture of the SCM muscle. Passive range of motion (ROM) examination revealed full range of motion in all directions. Sustained active rotation to the right was difficult for the patient due to the enlarged right posterior cranium: he could achieve rotation but then rolled back onto the flattened left cranial hemisphere. The patient s mother was instructed in passive SCM stretching and head repositioning as well as encouraging active right cervical rotation movements at home. For example, placing any objects of interest, like toys, noisemakers etc, as well as the patient s twin sister, on his right side to encourage active rotation to that side. In addition, due to the plagiocephaly making sustained right rotation difficult in a supine position, the mother was strongly encouraged to utilize tummy-time activities that allowed for strengthening of the cervical musculature in a way that was not hindered by the asymmetry of the cranium. On a follow up visit the next day the baby continued to have full range of passive cervical motion with no indication of SCM hypertonicity; however the mother reported that he would return to the rotated extended position when upset or crying. Motion palpation revealed that the atlas was well positioned. In addition, the patient s mother reported that the patient was bottle-feeding equally from a right and left arm hold. At this second visit, the Webster Coronal Suture adjustments were utilized to address the plagiocephaly. A fingertip contact was taken on either side of the coronal suture on the right (enlarged) side of the cranium followed by a scissor impulse applied across the suture four times at different locations along the suture. The baby continued to be treated on a schedule of twice weekly visits for two weeks until the family went on a onemonth vacation. Upon their return the mother voluntarily decreased the visit frequency due to her perception of the success of the treatments: the baby s active cervical range of motion was full and his facial symmetry had visibly improved. She had decided to follow her child s pediatrician s advice and at six months of age, the child was fitted for a cranial helmet. Discussion As previously described, the child presenting with CMT demonstrates the postural deformity of lateral flexion of the head and neck and concomitant contralateral rotation and hyperextension. The true etiology of CMT remains uncertain with a number of theories implicated that includes intrauterine

3 crowding or vascular phenomenon, fibrosis from peripartum bleeds, compartment syndrome, primary myopathy of the SCM and traumatic delivery. 3-4 In terms of classification of specific torticollis and their associated pathogenesis, these are summarized in Table 1. According to Tomczak and Rosman 10, the prevalence of congenital muscular torticollis in newborn infants range from 0.3% to 2%. 11 In a retrospective analysis of 288 patients in a tertiary care pediatric orthopedic facility for the evaluation of torticollis over a 10-year period, Ballock and Song 12 found that 18.4% had a non-muscular etiology for their torticollis. Of these 53 patients, Klippel-Feil anomalies were present in 16 and an underlying neurologic disorder was present in 27. These neurologic conditions included ocular disorders in 12 patients, brachial plexus palsies in nine patients, and lesions involving the central nervous system in six patients. We echo the sentiments of the authors that for the chiropractor with a child presenting without an identifiable muscular etiology for torticollis, Klippel-Feil anomalies or an underlying neurologic disorder must be considered in the diagnostic work-up. Despite the popularity of the congenital muscular type of torticollis (i.e., thickening and tightnes s of the sternocleidomastoid), one must also consider postural torticollis (head tilt but no tumor, thickening, or tightness of the sternocleidomastoid) from the chiropractic perspective. In a prospective study to evaluate the outcomes of 821 consecutive patients with congenital muscular torticollis, Cheng et al. 13 found that 55% had a sternocleidomastoid tumor, 34% were muscular and11% had postural torticollis. Given the patient s response to care to the upper cervical adjustments (i.e., improvement in t orticollis posture), the attending clinician is of the opinion that the patient presented suffered from both muscular and postural torticollis. In terms of pathogenesis, the two most commonly cited causes of congenital muscular torticollis are intrauterine malposition and birth trauma. In support of this, consider that incidence of breech presentation is higher in children with congenital muscular torticollis (17%-40%) than in the general population (1.5%-7%). 11 This intrauterine malposition and birth trauma pathogenesis is consistent with the patient presented he was a twin and had been fully engaged in an anterior occiput position in-utero with a prolonged and difficult labor, culminating in a Caesarean section being performed. Of interest in this case report was the parental report that the child s medical physician stated that there was a lack of association between the child s plagiocephaly and congenital muscular torticollis. In a retrospective, random review of 100 patients referred for orthotic correction of their positional plagiocephaly, Golden et al. 14 found that of 83 patients, 66% was found to have some degree of SCM dysfunction, whether it be SCM imbalance or CMT. The finding that over three quarters of their population suffered from some form of SCM dysfunction, either SCM imbalance or CMT, suggests that any degree of SCM dysfunction may act as a precursor to positional plagiocephaly and therefore should be recognized and treated at the earliest opportunity. As such, we advocate for the early correction of torticollis to prevent progression of facial asymmetry in congenital muscular torticollis patients. In a retrospective study that measured preoperative craniofacial asymmetry using the Cranial Vault Asymmetry Index and intercommissural angle and preoperative rotational and flexional deficit of neck movement for 123 congenital muscular torticollis patients who underwent surgical release, Seo et al. 15 found that in patients with congenital muscular torticollis, facial asymmetry is progressive if the contracted sternocleidomastoid muscle is not released, despite for the presence of cranial asymmetry as determined in those younger than 6 months. Lee et al. 16 demonstrated quantitatively that improvement in the craniofacial deformity occurred after surgical release of the sternocleidomastoid muscle. A number of alternative therapies describe the successful care of the child with torticollis. These include kinesiology taping 17, massage 18, moxibustion 19 and acupuncture 20 to name a few. Chiropractic Care To provide context to our discussions, we performed a review of the literature using MANTIS [ ), Index to Chiropractic Literature ( ) and Pubmed ( ) in the chiropractic care of children (i.e., 17 years of age) presenting with torticollis or congential muscular torticollis. Our review (see Table 2) found 12 case reports 21-32, one case series 33 and 3 commentaries examining the pathophysiology and advocating for chiropractic care. A great deal of heterogeneity was found with respect to the technique and adjunctive therapies employed by chiropractors in the care of children with torticollis. Although this may challenge cause and effect inferences to be made, these nonetheless provide some evidence for care. However, based on the evidence hierarchy 37 this evidence is limited to case reports and case series. This level of evidence is similar to the use of conservative medical treatments including pharmaceutical and invasive treatments. According to an examination of the evidence by the Parker College of Chiropractic Research Institute 38, no controlled trials or quasi-experimental studies were located. Generally the allopathic physician initially utilizes some form of traction followed by muscle relaxants and/or anti-inflammatory medications. Surgical interventions are utilized only in extreme cases. As described in the case report narrative, the child improved significantly with respect to his torticollis as noted with full cervical spine ROM and his facial symmetry visibly improved. However, the patient s mother elected to follow the pediatrician s advice and fit her child with a molding helmet at six months of age to address the child s plagiocephaly. This is in keeping with evidence-informed practice and biomedical ethics. Ultimately, it was the parent s right to choose the care approach her child received despite the success of chiropractic in addressing the child s torticollis with some improvement in the child s facial asymmetry and the inconclusive evidence for or against allopathic or chiropractic care. The traditional view of case reports has been their lack of generalizability. The presence of confounders (i.e., lacking a control group, spontaneous remission, self-limiting course and natural history of the disorder, subjective validation, and expectations for clinical resolution) limits one s ability to make cause and effect inferences. Conversely, the traditional approach to patient care has been to make generalizations based on our clinical experience. Case reports are J. Pediatric, Maternal & Family Health - December 22,

4 epistemologically in harmony with our clinical experiences and those of our patients and increase our conviction on the effectiveness of our care approaches. Conclusion This case report provides supporting evidence on the role of chiropractic care in children presenting with torticollis and plagiocephaly. We encourage further research on the benefits of chiropractic care in similar patients. References 1. Tubby AH. Deformities and diseases of bones and joints, 2nd ed. London, England: MacMillan; 1912:pp Wei JL, Schwartz KM, Weaver AL, Orvidas LJ. Pseudotumor of infancy and congenital muscular torticollis: 170 cases. Laryngoscope. 2001;111: Davids JR, Wenger DR, Mubarak SJ. Congenital muscular torticollis: Sequela of intrauterine or perinatal compartment syndrome. J Pediatr Orthop. 1993;13: Tang S, Liu Z, Quan X, Qin J, Zhang D. Sternocleidomastoid pseudotumor of infants and congenital muscular torticollis: Fine-structure research. J Pediatr Orthop. 1998;18: van Vlimmeren LA, Helders PJ, van Adrichem LN, Engelbert RH. Torticollis and plagiocephaly in infancy: therapeutic strategies. Pediatr Rehabil. 2006;9(1): Cheng JC, Au AW. Infantile torticollis: A review of 624 cases. J Pediatr Orthop. 1994;14: Morrissy R, Weinstein S. Lovell and winter's pediatric orthopaedics. 5 th ed. Philadelphia: Lippincott Williams & Wilkins; Fuhr AW, Green JR, Colloca CJ, Keller TS: Activator Methods Chiropractic Technique. Mosby- Year Book, Inc., Chaitow L. Cranial manipulation. Theory and Practice. Elsevier, New York, Tomczak KK, Rosman NP. Torticollis. Journal of Child Neurology 2012;28(3): Emery C. The determinants of treatment duration for congenital muscular torticollis. Phys Ther. 1994;74: Ballock RT, Song KM. The prevalence of nonmuscular causes of torticollis in children. J Pediatr Orthop. 1996;16: Cheng JC, Wong MW, Tang SP, Chen TM, Shum SL, Wong EM. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases. J Bone Joint Surg Am. 2001;83-A: Golden KA, Beals SP, Littlefield TR, Pomatto JK. Sternocleidomastoid imbalance versus congenital muscular torticollis: their relationship to positional plagiocephaly. Cleft Palate Craniofac J 1999;36(3): Seo SJ, Yim SY, Lee IJ, Han DH, Kim CS, Lim H, Park MC. Is craniofacial asymmetry progressive in 90 J. Pediatric, Maternal & Family Health - December 22, 2014 untreated congenital muscular torticollis? Plast Reconstr Surg. 2013;132(2): Lee JK, Moon HJ, Park MS, Yoo WJ, Choi IH, Cho TJ. Change of craniofacial deformity after sternocleidomastoid muscle release in pediatric patients with congenital muscular torticollis. J Bone Joint Surg Am 2012;94(13):e Öhman AM. The immediate effect of kinesiology taping on muscular imbalance for infants with congenital muscular torticollis. PMR. 2012;4(7): Kang Y, Lu S, Li J, Meng F, Chang H. Primary massage using one-finger twining manipulation for treatment of infantile muscular torticollis. J Altern Complement Med. 2011;17(3): Zhou L. Adolescent spasmodic torticollis treated by moxibustion--a report on 30 cases. J Tradit Chin Med. 2007;27(2): Samuels N. Acupuncture for acute torticollis: a pilot study. Am J Chin Med. 2003;31(5): Drobbin DD, Woodruff SW. Resolution of a Motor Tic Disorder in a 7-year-old Female Following Subluxation Based Chiropractic Care: A Case Report. J Ped, Matern Fam Health- Chiropr 2013 SUM; 2013(3): Rubin DR, Istok MI. Resolution of Infantile Colic, Torticollis, Plagiocephaly & Feeding Difficulties Following. J Ped, Matern Fam Health- Chiropr 2013 SPR; 2013(2): Alcantara JA, Fleuchaus SF, Oman REO. Resolution of Torticollis, Neck Pain and Vertebral Subluxation in a Pediatric Patient. J Ped Matern Fam Health Chiropr 2009 FAL; 2009(4): Alcantara J, Anderson R. Chiropractic care of a pediatric patient with symptoms associated with gastroesophageal reflux disease, fuss-cry-irritability with sleep disorder syndrome and irritable infant syndrome of musculoskeletal origin. J Can Chiro Assoc 2008; 52(4): Stone-McCoy PA. Reduction of congenital torticollis in a four month old child with vertebral subluxation: a case report & review of literature. J Vert Sublux Res. 2008;JAN(7): McWilliams JE, Gloar CD. Chiropractic care of a six-year-old child with congenital torticollis J Chiro Med 2006 SUM; 5(2): Smith-Nguyen EJ. Two approaches to muscular torticollis. J Clinical Chirop Pediatr 2004 SUM; 6(2): Pederick FO. Treatment of an infant with wry neck associated with birth trauma: Case report. Chiropr J Aust. 2004;34(4): Colin N. Congenital muscular torticollis: a review, case study, and proposed protocol for chiropractic management. Topics Clin Chiro 1998; 5(3): Moore TM, Pfiffner TJ. Pediatric Traumatic Torticollis: A Case Report. J Clinical Chirop Pediatr 1997; 2(2): Killinger L. Torticollis: A Chiropractic Case Study. Palmer J Res 1995; 2(1): Toto B. Chiropractic correction of congenital muscular torticollis. J Manipulative Physiol Ther 1993; 16(8):556-9.

5 33. Aker P, Cassidy J. Torticollis in infants and children: a report of three cases. J Can Chiro Assoc 1990; 34(1): Fallon JM, Fysh PN, chiropractic care of the newborn with congenital torticollis. J Clinical Chirop Pediatr 1997; 2(1): Wood K. Acute Torticollis: chiropractic therapy and management. Chiropr Tech 1991; 3(3): Bolton P. Torticollis: a review of etiology, pathology, diagnosis and treatment, J Manipulative Physiol Ther 1985; 8(1): Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh: Churchill Livingstone; Parker College of Chiropractic Research Institute. Acute juvenile cervical torticollis evidence based pharmaceutical & invasive treatment. Accessed mar 6, 2014 at: a8ef dd-84454a867c46 J. Pediatric, Maternal & Family Health - December 22,

6 Torticollis type Congenital Muscular Intrauterine Constraint Birth Trauma Nonparoxysmal Paroxysmal Osseous Congenital Traumatic Inflammatory Central Birth Posterior fossa System/Peripheral Basal ganglia Nervous System Spinal cord Spinal nerve root/peripheral nerve Ocular Superior oblique muscle palsy Other ocular deviations Spasmus mutans Non-muscular, softtissue Infectious Benign paroxysmal Spasmodic (cervical Primary vs. dystonia) Secondary Sandifer syndrome Drug-induced torticollis Increased intracranial pressure Torticollis as a conversion disorder Table 1. Classification of Torticollis. Modified from Tomczak & Rosman J. Pediatric, Maternal & Family Health - December 22, 2014

7 Reference Design Age/Gender Description Drobbin et al. 21 Case Report Rubin et al. 22 Case Report 7-yr-old 3-month-old male The patient s primary complaint was motor tic disorder and a secondary complaint of torticollis that began at 6 weeks of age. The Thompson Technique was used over 3 patient visits with resolution of her presenting complaints. The patient presented with incessant crying, torticollis, plagiocephaly, difficulty feeding, abdominal distension, gas and restless sleep. Chiropractic adjustments over 4 visits using sustained contact and craniosacral therapy resulted in resolution of his excessive crying, colic, feeding difficulties and torticollis. Alcantara et al. 23 Case Report 10-yr-old male Torque Release Technique in combination with Activator Methods at a 3 times per week for 4 weeks were applied to care for this child with neck pain and torticollis. Adjunctive therapies were interferential, moist heat and icing and PNF stretching. Following 12 visits, the patient was pain-free with improved posture and full range of motion in the cervical spine. Alcantara et al. 24 Case Report 3-month-old Stone-McCoy et al. 25 Case Report 4-month-old McWilliams and Gloar 26 Case Report 6-year-old Smith-Nguyen et al. 27 Case Report 10-month old Pederick et al. 28 Case Report 7-month-old male Colin 29 Case Report 7-month-old infant This patient presented with acid reflux in addition to interrupted sleep, excessive intestinal gas, frequent vomiting, excessive crying, difficulty breastfeeding, plagiocephaly and torticollis. Improvements were observed within four visits and total resolution of symptoms within three months of care. The child presented with congenital torticollis with a history of physical therapy, cranial-sacral therapy and myofascial release therapy with limited improvement. Chiropractic adjustments, stretching and trigger point therapy were used to address sites of vertebral subluxations in the cervical spine and pelvis. Postural and functional improvements were observed. The patient presented with congenital torticollis and cared for using the Frogley and Wallace technique along with Diversified Technique resulting in changes in her clinical presentation including a distinct improvement in head-tilt. This patient presented with congenital torticollis. Physical therapy over two months was effective in correcting the patient s postural deformity but her symptoms progressively returned over the course of 3 months. The patient received 5 chiropractic adjustments over a period of six weeks and the torticollis resolved without returning. The authors describe the successful treatment of an infant with torticollis and plagiocephally attributed to birth trauma using low-force, relatively long-duration cranial adjusting (i.e., CV4 Technique), and soft-tissue techniques to the whole body with special attention to the cervical region along with parental management of home care procedures. The infant was cared for over 6 sessions of involving low force adjusting and gentle myofascial release work with resolution of symptoms and 1-year follow-up. J. Pediatric, Maternal & Family Health - December 22,

8 . Moore & Pfiffner 30 Case Report 4-yr-old male A child presented with a left lateral head tilt, mild right head rotation, and left high shoulder due to trauma. Care involved cryotherapy followed by Diversified spinal adjustment to the C 3-4 functional spinal unit. Two weeks later since ending care, the patient returned to the clinic reporting complete resolution Killinger 31 Case Report The patient received the Palmer Upper Cervical Specific Technique, and followed up for a four month period. With only 4 chiropractic adjustments given over this period of time, excellent results were seen. Toto 32 Case Report A 7-month-old male Aker et al. 33 Fallon and Fysh 34 Case Series Commentary 8-yr-old 15-month 5-month-old male old This patient presented with congenital muscular torticollis and cared for with chiropractic manipulation, trigger point therapy, specific stretches, pillow positioning and exercises with excellent results. Care for this patient with torticollis involved spinal manipulations and stretches to the neck. At 4 months follow-up, the patient had facial asymmetry and restricted ROM. The mother decided to continue with chiropractic care and 4 months later, the contracture of the left SCM muscle persisted. A surgical release of both ends of the left SCM muscle was performed. The procedure was completed without complication and she underwent an uneventful post-operative recovery. This child wad diagnosed with Grade II (low grade, relatively low risk for malignancy) astrocytoma of the spinal cord. Plain CT showed enlargement of the posterior aspects of the lateral ventricles, indicating obstructive hydrocephalus. On a contrast-enhanced view, an infiltrating tumor in the posterior fossa was visualized. This was thought to be consistent with a primary neoplasm, most likely an ependymoma, neuroblastoma, or embryonal cell tumour. The patient eventually died. Fallon and Fysh reviewed the most common etiologies of torticollis in the neonate and provides recommendations on the evaluation and management for the child presenting with torticollis. Wood 35 Commentary ---- Wood described 3 adjusting procedures in the supine, prone and seated positions along with adjunctive therapies and the use of radiographic evaluation to confirms the level of lesion for the child presenting with acute torticollis. Note that Wood did not qualify these adjustments as they apply to children. Bolton 36 Commentary Bolton provides a brief discussion of the diagnosis and treatment of torticollis. Table 2. Summary of literature review on the chiropractic care of children with torticollis 94 J. Pediatric, Maternal & Family Health - December 22, 2014