Chiropractic Care for Infantile Torticollis: Not Recommended
Physical therapy—not chiropractic manipulation—is the evidence-based first-line treatment for a 7-month-old infant with muscular torticollis. 1
Why Physical Therapy Is the Standard of Care
The 2024 Clinical Practice Guideline from the American Physical Therapy Association establishes physical therapy as the definitive conservative treatment for congenital muscular torticollis (CMT) in infants. 1 This guideline, which updated the 2013 version after demonstrating improved clinical outcomes with implementation, provides the most current and authoritative recommendations for this condition. 1
Evidence Supporting Physical Therapy
Physical therapy is superior to repositioning education alone for reducing prevalence of infantile positional plagiocephaly in infants as young as 7 weeks of age (Level I evidence). 2
Specific stretching protocols are well-defined: Hold each stretch for 10-30 seconds, repeat 3-4 times per session, and perform multiple sessions throughout the day. 3
Positioning strategies between stretches include placing toys to encourage the infant to turn toward the restricted side during supervised tummy time (≥30 minutes total daily). 3
Meta-analysis findings show that adding manual therapy (performed by physical therapists) to active control resulted in short-term improvements in passive cervical rotation (OR 9.79), passive cervical lateroflexion (OR 2.66), and symmetric head posture (OR 4.55). 4
Critical Safety Concerns with Chiropractic Manipulation
A catastrophic case report documents an infant who developed quadriplegia after chiropractic manipulation for congenital torticollis. 5 The infant had respiratory insufficiency, seizures, and quadriplegia within hours of manipulation; a holocord astrocytoma with extensive acute necrosis—believed to result from the neck manipulation—was discovered. 5
Key Safety Principles
Every child with torticollis, regardless of age, should undergo neurologic and radiologic evaluation before any form of physical treatment. 5
This case underscores the necessity for meticulous patient selection when considering manual therapies in this population. 6
Evidence Gap for Chiropractic in Torticollis
A 2019 systematic review examining manipulation techniques for infant torticollis found:
Two studies on manual therapy suggested that manipulation techniques do not have any greater effect on symmetry and motor outcomes than parental guidance, physiotherapy, and home exercises. 7
Manipulation techniques have not been shown to be efficacious in the treatment of infant torticollis, though the available evidence is uncertain. 7
While three randomized studies and a large series of 695 infants found no serious adverse events, three patient histories demonstrated that manipulation techniques may cause harm if the observed asymmetry has serious underlying causes. 7
Red Flags Requiring Urgent Imaging Before Any Treatment
Before initiating any manual therapy (including physical therapy), rule out the following:
Altered mental status mandates urgent diagnostic imaging to rule out life-threatening intracranial or cervical pathology. 6
Focal neurologic deficits (weakness, sensory loss) require immediate imaging. 6
Neck pain, especially after trauma, warrants cervical spine imaging. 6
Resistance to head or neck motion on examination signals possible cervical spine injury. 6
Recent trauma (diving accidents, high-impact motor-vehicle crashes, significant torso injury) requires immediate cervical imaging. 6
Non-Traumatic Red Flags
Ocular torticollis from eye muscle weakness should be ruled out by observing if head tilt resolves when one eye is covered. 3
Pupillary abnormalities (anisocoria) suggest possible drug/toxin ingestion or cranial-nerve compression and should trigger imaging. 6
Ataxia, nystagmus, or gait disturbances raise suspicion for posterior-fossa pathology (cerebellar tumor) and warrant MRI of brain and cervical spine. 6
Recommended Treatment Algorithm for 7-Month-Old with Torticollis
Step 1: Rule Out Red Flags
Perform neurologic examination looking specifically for altered mental status, focal deficits, pupillary abnormalities, ataxia, or resistance to neck motion. 6, 5
Step 2: Refer to Physical Therapy
Initiate physical therapy with a therapist trained in pediatric CMT management. 1
Step 3: Implement Home Stretching Program
- Hold each stretch 10-30 seconds, 3-4 repetitions per session, multiple sessions daily. 3
- Position toys to encourage turning toward restricted side during ≥30 minutes daily supervised tummy time. 3
Step 4: Monitor Response
- Most patients (96.1%) who receive physical therapy for an average of 13.3 months experience resolution (51.2%) or improvement (45.5%) of symptoms. 8
Step 5: Consider Advanced Therapies Only If Refractory
- If symptoms persist past 1 year despite conservative therapy (recalcitrant torticollis), consider botulinum toxin injection or, in severe cases, surgical release. 8
Common Pitfalls to Avoid
Do not perform chiropractic manipulation without first ruling out serious underlying pathology such as spinal cord tumors, which can present as torticollis. 5
Do not use positioning pillows in the infant's sleep environment, as the American Academy of Pediatrics recommends against soft positioning devices to ensure safe sleep. 2
Do not perform acute flexion-extension radiographs, as they are generally unhelpful and may increase injury risk. 6