TOT Collar Science
The Tot Collar for Torticollis is assembled from premade plastic parts and employs lateral obstruction to limit head tilt toward the side of the torticollis, but permits freedom of movement in other directions. The Tot Collar is more dynamic than a foam collar; it produces it produces mild discomfort on lateral head tilt, thereby stimulating active lifting of the head away from the noxious input and toward verticle alignment.
Tot Collar use is added to the conservative management of infants with congenital muscular torticollis if they are 4 months of age or older and show a consistent head tilt of 5 degrees or more. The infant must have adequate range of motion and lateral head righting reactions (head control and strength) to lift his or her head away from the side of the Tot Collar.
A length of tubing twice the circumference of the neck plus 4-6 inches is cut and joined into a circle using an end connector. Two struts provide a lateral stimulus on the affected side are selected, allowing half an inch for the t-junctions at the top and bottom: strut A spans from posterior to the crest of the trapezius to the occiput and strut B from anterior to the crest of the trapezius to the tip of the mastoid process. A T-junction is fitted over the tubing approximately one inch from the end connector and inserted into strut A.
A second T-junction is similarly positioned on the other side of the end connector and inserted into the other end of the strut A. Strut B is joined to the tubing about one inch from strut A at one end, and about three inches away at the other end, using two more T-junctions. The ends of the Tot Collar are fastened together with a clip. Occasionally, the end connector can cause skin irritation and pressure when placed centrally. An alternative in this case is to place the end connector along the base of the neck and join the tubing by tying it at the side of the neck with twill tape. Note: The connector has been replaced with a velcro closure.
The Tot Collar is placed on the infant and any necessary adjustments are made to length and position of struts and length of tubing. For correct fit, the infant should be holding his or her head in midline, slightly away from the struts, and there should be room for 1 or 2 adult size fingers to fit between the clip and the back of the neck, or between the tubing and the anterior neck.
To increase comfort, moleskin can be wrapped around the two layers of tubing in the area under the chin. The struts and t-junctions can also be covered with moleskin although this makes it more difficult to adjust the fit of the Tot Collar. Alternatively, the Tot Collar can be placed inside a sleeve of stockinette.
Tot Collar Application
Application of the collar is generally easiest with the young infant in prone position. The center of the Tot Collar is placed under the chin, the struts positioned spanning the shoulder on the affected side, with the top of the anterior strut on the mastoid process (just behind the earlobe.) The clip is then fastened. As both the infant and caregiver become more accustomed to the process, the Tot Collar can be put on with the infant sitting or standing.
Because the Tot Collar is easily adjusted, it can initially be made to fit looser than is optimal in order to facilitate the build-up of wearing tolerance and the learning of application by caregivers. The goal is full-time wear during the waking hours and most infants achieve this within the first week (toddlers may require a bit longer). Tot Collar fit is then adjusted by changing the length of the struts or tubing to stimulate active correction of head position to achieve midline orientation. Further adjustments are made as required for growth.
The Tot Collar is removed for stretches. Active strengthening exercises may be done while wearing the collar. Collar wear is generally required for a minimum of 2 to 3 months and may be needed for 8 months or more in some instances.
The infant’s head position without the collar is reassessed at each clinical visit. When the head tilt is less than 5 degrees consistently, Tot Collar use is gradually decreased. The collar is removed for 1 to 2 hours at a time of day when the infant is most rested and likely to maintain a good head position (often on rising in the morning or following naps). Head position is monitored by the parent at these times. If a midline position is maintained consistently, time without wearing the Tot Collar is gradually extended. The collar is reapplied if head tilt recurs. This may be seen near nap times, at the end of the day, or following exercise sessions when the muscles are fatigued. Head tilt may also increase with teething or when the child is ill.
Clinical observation of infants with congenital muscular torticollis demonstrated that, although conservative treatment of congenital muscular torticollis improved muscle length and strength, some infants and children did not adapt an upright head position. The addition of the customizable Tot Collar which stimulates active use of the contralateral sternocleidomastoid (SCM) muscle throughout the day results in improved strength of that muscle and a more consistently upright position of the head. Infants who also have plagiocephaly may have improved symmetry if the Tot Collar use is initiated early.
The use of the Tot Collar as an adjunct to conservative treatment of congenital muscular torticollis has been readily accepted by parents, children and infants with no deleterious effects. Its use in infants with congenital muscular torticollis over 4 months of age who consistently have a head tilt of more than 5 degrees has become a routine part of management of congenital muscular torticollis.
Tot Collar & Torticollis Scientifc Papers
References, articles and clinical examples, with more information on Congenital Muscular Torticollis as well as studies and papers on treatment.
Tubular Orthosis for Torticollis: A new approach to the Correction of Head Tilt in Congenital Muscular Torticollis.