Beruflich Dokumente
Kultur Dokumente
Sandra L. Kaplan, PT, DPT, PhD; Colleen Coulter, PT, DPT, PhD, PCS; Linda Fetters, PT, PhD, FAPTA
Department of Rehabilitation and Movement Sciences (Dr Kaplan), Doctoral Programs in Physical Therapy, Rutgers, The
State University of New Jersey, Newark, New Jersey; Children’s Healthcare of Atlanta (Dr Coulter), Orthotics and
Prosthetics Department, Atlanta, Georgia; Division of Biokinesiology and Physical Therapy at the Herman Ostrow School
of Dentistry, Department of Pediatrics (Dr Fetters), Keck School of Medicine, University of Southern California, Los
Angeles, California.
Acknowledgments.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Appendix 1: ICF and ICD 10 Codes.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Appendix 2: Operational Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
This clinical practice guideline for physical therapy tion of Infants With CMT; Physical Therapy Intervention
management of infants with congenital muscular torticol- for Infants With CMT; and Physical Therapy Discharge
lis (CMT) is intended as a reference document to guide and Follow-Up of Infants With CMT. Thirteen recommen-
physical therapy practice and to inform the need for con- dations for research are placed within the text where the
tinued research related to physical therapy management of topics arise, and are collated at the end of the document.
CMT. The methods of critical appraisal, assigning levels Table 1 presents the criteria used to determine the
of evidence to the literature, and summating the evidence evidence level of diagnostic, intervention studies and prog-
to assign grades to the recommended action statements nostic studies that support each of the recommended ac-
follow accepted international methodologies of evidence- tion statements. Levels 1 and 2 differentiate stronger from
based practice. The document is organized to present the weaker studies by integrating the research design and the
definitions of the levels of evidence and grades for action quality of the execution and/or reporting of the study.
statements (Tables 1 and 2), the list of 16 action statements, Table 2 presents the criteria for the grades assigned
followed by the descriptions of the aims, methods, and each to each action statement. The grade reflects the overall
action statement with a standardized profile of information and highest levels of evidence available to support the
that meets the Institute of Medicine’s criteria for transpar- action statement. Throughout the guideline, each action
ent clinical practice guidelines. The 16 action statements statement is preceded by a letter grade, followed by the
are organized under 4 major headings: Identification and statement, and a summary of the quality of the supporting
Referral of Infants with CMT; Physical Therapy Examina- literature.
LEVEL CRITERIA
I Evidence obtained from high-quality diagnostic studies, prognostic or prospective studies, cohort studies or randomized
controlled trials, meta-analyses or systematic reviews (critical appraisal score >50% of criteria)
II Evidence obtained from lesser-quality diagnostic studies, prognostic or prospective studies, cohort studies or randomized
controlled trials, meta-analyses or systematic reviews (eg, weaker diagnostic criteria and reference standards, improper
randomization, no blinding, <80% follow-up) (critical appraisal score <50% of criteria)
III Case-controlled studies or retrospective studies
IV Case studies and case series
V Expert opinion
IDENTIFICATION AND REFERRAL OF INFANTS WITH sistent with CMT), or when, after 4 to 6 weeks of initial
CONGENITAL MUSCULAR TORTICOLLIS (CMT) intense intervention, in the absence of red flags, little
A. Action Statement 1: IDENTIFY NEWBORNS AT or no progress in neck asymmetry is noted. (Evidence
RISK FOR CMT. Physicians, nurse midwives, obstet- Quality: II; Recommendation Strength: Moderate)
rical nurses, nurse practitioners, lactation specialists, B. Action Statement 6: REQUEST IMAGES AND
physical therapists (PTs), or any clinician or family mem- REPORTS. Physical therapists should obtain copies of
ber must assess the presence of neck and/or facial or all images and interpretive reports, completed for the di-
cranial asymmetry within the first 2 days of birth, using agnostic workup of an infant suspected of having or diag-
passive cervical rotation, passive lateral flexion, and/or nosed with CMT, to inform prognosis. (Evidence Quality:
visual observation as their respective training supports, II; Recommendation Strength: Moderate)
when in the newborn nursery or at time of delivery. (Ev-
idence Quality: I; Recommendation Strength: Strong) PHYSICAL THERAPY EXAMINATION OF INFANTS
WITH CMT
B. Action Statement 2: REFER INFANTS WITH
ASYMMETRIES TO PHYSICIAN AND PHYSICAL B. Action Statement 7: EXAMINE BODY STRUC-
THERAPIST. Physicians, nurse midwives, obstetrical TURES. Physical therapists should document the initial
nurses, nurse practitioners, lactation specialists, PTs, examination and evaluation of infants with suspected or
or any clinician or family member should refer infants diagnosed CMT for the following body structures:
r Infant posture and tolerance to positioning in
identified as having positional preference, reduced cer-
vical range of motion, sternocleidomastoid masses, fa- supine, prone, sitting, and standing for body sym-
cial asymmetry and/or plagiocephaly to the primary metry, with or without support, as appropriate
pediatrician, and a PT as soon as the asymmetry is for age. (Evidence Quality: II; Recommendation
noted (Figure 1). (Evidence Quality: II; Recommendation Strength: Moderate)
r Bilateral passive cervical rotation and lateral
Strength: Moderate)
flexion. (Evidence Quality: II; Recommendation
B. Action Statement 3: DOCUMENT INFANT HIS- Strength: Moderate)
TORY. Physical therapists should obtain a general med- r Bilateral active cervical rotation and lateral flexion.
ical and developmental history of the infant prior to an (Evidence Quality: II; Recommendation Strength:
initial screening, including 9 specific health history fac- Moderate)
tors: age at initial visit, age of symptom onset, pregnancy r Passive range of motion (PROM) and active range of
history, delivery history including birth presentation and motion (AROM) of the upper and lower extremities,
use of assistance, head posture/preference, family his- inclusive of screening for possible hip dysplasia or
tory of CMT, other known or suspected medical condi- spine/vertebral asymmetry. (Evidence Quality: II;
tions, and developmental milestones. (Evidence Quality: Recommendation Strength: Moderate)
II; Recommendation Strength: Moderate) r Pain or discomfort at rest, and during passive and
B. Action Statement 4: SCREEN INFANTS. When a active movement. (Evidence Quality: IV; Recom-
clinician, parent, or caretaker indicates concern about mendation Strength: Weak)
r Skin integrity, symmetry of neck and hip skin folds,
head or neck posture and/or developmental progres-
sion, PTs should perform a screen of the neurological, presence and location of an SCM mass, and size,
musculoskeletal, integumentary, and cardiopulmonary shape, and elasticity of the SCM muscle and sec-
systems, including screens of vision, gastrointestinal ondary muscles. (Evidence Quality: II; Recommen-
functions, positional preference and the structural and dation Strength: Moderate)
r Craniofacial asymmetries and head/skull shape.
movement symmetry of the neck, face, and head, spine
and trunk, hips, upper and lower extremities, consistent (Evidence Quality: II; Recommendation Strength:
with state practice acts. (Evidence Quality: 22-15; Rec- Moderate)
ommendation Strength: Moderate) P. Action Statement 8: CLASSIFY THE LEVEL OF
B. Action Statement 5: REFER INFANTS FROM SEVERITY. Physical therapists and other health care
PHYSICAL THERAPIST TO PHYSICIAN IF RED providers should classify the level of CMT severity choos-
FLAGS ARE IDENTIFIED. Physical therapists should ing 1 of 7 proposed grades (Figure 2). (Evidence Quality:
refer infants to the primary pediatrician for additional V; Recommendation Strength: Best Practice)
diagnostic testing when a screen or evaluation identi- B. Action Statement 9: EXAMINE ACTIVITY AND
fies red flags (eg, poor visual tracking, abnormal muscle DEVELOPMENTAL STATUS. During the initial and
tone, extramuscular masses, or other asymmetries incon- subsequent examinations of infants with suspected or
diagnosed CMT, PTs should document the types of r Infant time spent in equipment/positioning de-
and tolerance of position changes, and examine motor vices, such as strollers, car seats, or swings.
development for movement symmetry and milestones, (Evidence Quality: II; Recommendation Strength:
using an age-appropriate, valid, and reliable standardized Moderate)
tool. (Evidence Quality: II; Recommendation Strength:
Moderate) B. Action Statement 11: DETERMINE PROGNOSIS.
Physical therapists should determine the prognosis for
B. Action Statement 10: EXAMINE PARTICIPA- resolution of CMT and the episode of care after comple-
TION STATUS. The PT should document the par- tion of the evaluation, and communicate it to the parents/
ent/caregiver responses regarding: caregivers. Prognoses for the extent of symptom resolu-
r Whether the parent is alternating sides when breast tion, the episode of care, and/or the need to refer for
or bottle-feeding the infant. (Evidence Quality: II; more invasive interventions are related to the age of ini-
Recommendation Strength: Moderate) tiation of treatment, classification of severity (Figure 2),
r Sleep positions. (Evidence Quality: II; Recommen- intensity of intervention, presence of comorbidities,
dation Strength: Moderate) rate of change, and adherence with home program-
r Infant time spent in prone. (Evidence Quality: II; ming. (Evidence Quality: II; Recommendation Strength:
Recommendation Strength: Moderate) Moderate)
PHYSICAL THERAPY INTERVENTION FOR INFANTS r Neck PROM. (Evidence Quality: II; Recommenda-
WITH CMT tion Strength: Moderate)
r Neck and trunk AROM. (Evidence Quality: II; Rec-
B. Action Statement 12: PROVIDE THE FOLLOW-
ING 5 COMPONENTS AS THE FIRST-CHOICE ommendation Strength: Moderate)
r Development of symmetrical movement. (Evi-
INTERVENTION. The physical therapy plan of care
for the infant with CMT or postural asymmetry should dence Quality: II; Recommendation Strength:
minimally address these 5 components: Moderate)
Incidence and Progression of Congenital Muscular any persistent postural asymmetries are referred as early as
Torticollis possible for physical therapy intervention.
Congenital muscular torticollis is a common pedi- Typical physical therapy management of CMT is a
atric musculoskeletal condition, described as a postural conservative approach that includes passive stretching, po-
deformity of the neck evident at birth or shortly there- sitioning for active movement away from the tightness, and
after. Synonyms include fibromatosis colli for the mass parent education for home programs.22,48 Earlier inter-
type,34 wry neck,35 or twisted neck.36 It is typically char- vention is more quickly effective than intervention started
acterized by a head tilt to one side or lateral neck flexion, later. If started before 1 month of age, 98% achieve near
with the neck rotated to the opposite side due to unilateral normal range within 1.5 months, but waiting until after 1
shortening or fibrosis of the sternocleidomastoid (SCM) month of age prolongs intervention to about 6 months, and
muscle. It may be accompanied by cranial deformation37 waiting until after 6 months can require 9 to 10 months
or hip dysplasia,38 brachial plexus injury,39-41 distal ex- of intervention, with progressively fewer infants achiev-
tremity deformities, and less frequently, presents as a head ing near normal range49 ; current CMT guidelines do not
tilt and neck rotation to the same side. The incidence address the time of referral.
of CMT ranges from 0.3 to 2%42 of newborns, but has Reports of untreated CMT are rare,3,5 but there are de-
been reported as high as 16% (n = 102),37 and may occur scriptions of unresolved or reoccurring CMT in older chil-
slightly more frequently in males.17,43 Congenital muscu- dren or adults, who later undergo Botox injections42,50,51
lar torticollis may be present at birth when selected mor- or surgery for correction of movement limitations and con-
phologic and birth history variables converge, such as in sequent facial asymmetries.5,52,53 The incidence of spon-
larger babies, breech presentation, and/or the use of for- taneous resolution is unknown, and there are no fool-
ceps during delivery,44 or it may evidence during the first proof methods for predicting who will resolve and who
few months,18,37 particularly in those with milder forms. will progress to more severe or persistent forms.
Congenital muscular torticollis is typically catego- Finally, CMT has been associated with hip dysplasia,4
rized as one of 3 types: postural CMT presents as the brachial plexus injury,39-41 distal extremity deformities,
infant’s postural preference15,45 but without muscle or pas- early developmental delay,14,39 persistent developmental
sive ROM restrictions and is the mildest presentation; mus- delays,13 facial asymmetry, which may affect function and
cular CMT presents with SCM tightness and passive ROM cosmesis,6 and temporal–mandibular joint dysfunction.54
limitations; and SCM mass CMT, the most severe form, Thus, early identification and treatment is critical for early
presents with a fibrotic thickening of the SCM and passive correction, early identification of secondary or concomi-
ROM limitations.46 These presentations, in combination tant impairments, and prevention of future complications.
with the age of initial diagnosis, are highly predictive of the
time required to resolve ROM limitations. In general, in-
fants identified early with postural CMT have shorter treat- Early Referral
ment episodes, and those who are identified later, after 3 to The evidence is strong that earlier intervention results
6 months of age and who have SCM mass CMT, typically in the best outcomes11,49 ; thus, early referral is the ideal. A
have the longest episodes of conservative treatment, and referral flow diagram is provided (Figure 1) that outlines
may ultimately undergo more invasive interventions.10,46 the possible referral and communication pathways based
Pediatricians or parents may be the first to notice on time of observation, identification of “red flags,” prior
an asymmetry, and pediatricians may provide the ini- models, and current literature.1,39,42,55-57
tial instructions about positioning and stretching to the The referral flow diagram is divided into 2 distinct
parents.21 The American Academy of Pediatrics, in its time frames: birth to 3 days, representing the newborn pe-
Bright Futures Guidelines For Health Supervision of Infants, riod; and 3 days and older, representing the typical time
Children, and Adolescents publication, recommends check- after discharge to home. During the newborn period, many
ing the newborn for head dysmorphia at 1 week and skull different health care providers may observe the infant be-
deformities at 1 month, but does not specify checking the cause they are involved in the birth and/or postnatal care.
neck for symmetry until 2 months, when the term torticol- These health care providers are in the ideal position to
lis is first mentioned.47 If the asymmetry does not resolve observe the symmetry of the head on the shoulders and
after initial exercise instructions by pediatricians, infants screen for passive and active movement limitations, though
are typically then referred to physical therapy.21 While this screening for CMT at this point in development is not con-
pattern of identification and eventual referral to physical sidered the norm. After the infant is at home, the most
therapy is described in the literature, the GDG is in strong likely observers will be the primary pediatrician and the
agreement that pediatricians should be screening for CMT parents or other caregivers. Regardless of who performs
throughout the first 3 to 4 months, such that infants with the initial screen, infants with asymmetry should undergo
368 Kaplan et al
TYPE OF LEVEL OF EVIDENCE, POSITION FOR
MEASUREMENT MEASUREMENT VALIDITY, AND MEASUREMENT (INFANT STRENGTHS AND WHAT NORMS ARE
OF INTEREST TOOL CITATIONS RELIABILITY AND EXAMINERS) LIMITATIONS USED
Passive cervical Arthrodial Cheng et al, Interrater reliability Supine with the head S—reproducible and used in 110◦ cervical rotation
rotation protractor 1999,17 2000,18 ICC 0.71 Unpublished supported off the edge many studies
20019 data of the surface; 2 L—unpublished data
examiners, 1 measures
and 1 stabilizes the
shoulders
Öhman and Interrater reliability Cheng’s method S—assigned PROM values 110◦ mean PROM
Beckung, 200883 ICC 0.71 per Cheng’s L—infants did not have
unpublished data torticollis
Goniometer Klackenberg Right CMT ICC Supine with head and S—establishing intrarater ICC higher when
et al, 200584 0.82-0.95 for rotation body on the surface. The reliability measuring the
and side for rotation PT measures and the L—cervical rotation is limited affected side than
and lateral flexion. second examiner by supporting surface unaffected; 70-80◦
ICC 0.58-0.65 for stabilizes the shoulders when the infant’s
rotation and side for chin touches the
rotation and lateral supporting surface
flexion to the
nonaffected side
Goniometer Karmel-Ross, NA Supported sitting S—values can be assigned 100-120◦ of cervical
with the level 199719 according to the infant’s L—accounting for rotation per Emery
adaptation development. The second compensations of trunk and values 1994
examiner stabilizes shoulders
shoulders
Visual Boere- NA Supine S—easy to administer NA
inspection Boonekamp and
FREQUENCY
380 Kaplan et al
WHO WHO PER DAY OR DURATION
CITATION LEVEL PERFORMS INSTRUCTS WEEK REPETITION OF HOLDS HOME PROGRAM OUTCOMES
Celayir, 200010 II 2 persons MD 8×/d, every 10 10 s Positioning, handling, promoting No surgery needed: 100% success for
3 hrs active cervical ROM infants <4 mo
Asymmetry: 80% achieved full
rotation with no asymmetry; 20%
achieved full rotation with mild
asymmetry or mild rotation limitation
and no asymmetry
Chon et al, II 2 persons, a PT 5×/wk in re- 4 sets of 15 3 min rests Gentle stretching and massage, Muscle thickness: significant reduction
2010112 parent and a PT habilitation repetitions positioning and handling. Home in SCM (P < .00) in those with
department; program was monitored daily sternomastoid mass and muscular
home torticollis. Infants were <3 mo at start
exercise of treatment
Emery, 19942 II 2 persons PT stretching
2× 5 10 s Positioning and handling for neck PROM: 99% (100/101) achieved full
program not rotation to the affected side and tilt range and complete CMT resolution; 1
defined away from the affected side. Sleep required surgery. Duration of care: x =
positions and prone exercises were 4.7 mo. Infants with SCM mass were
instructed. Righting reactions were correlated with severity and longer
used to strengthen the opposite duration of care.
weaker side 36% received a TOT collar.
Cameron and III 2 persons NA 2×/d 10 NA NA PROM: 100% of infants who started
Cameron, 19948 treatment <3 mo resolved without
surgery; 45% infants who started
treatment >3 mo required surgery.
65% of infants had excellent results
(full ROM and no asymmetry), 27%
good results (full rotation and mild
asymmetry or mild rotation limitation
and no asymmetry), and 8% poor
results (no improvement)
DURATION
10-30 s
NA
repetitions
unlimited
performing
ance to treatment.
PT
PT
home program.
LEVEL PERFORMS
PT
II
techniques.
200814
201059
A growing body of literature exists on the uptake of Strategies for Facilitating CPG Implementation in
evidence into practice. The following suggestions are pro- Other Clinicians
vided as possible strategies for clinicians to implement the r Recognize that adoption of the recommendations by
action statements of this CPG, but are not an exhaustive others may require time for learning about the CMT
review. Many variables affect the successful translation of CPG content, developing a positive attitude toward
evidence into practice; clinicians will need to assess their adopting the action statements, comparing what is
own practice structures, cultures, and clinical skills to de- already done with the recommended actions, trying
termine how to best implement the action statements as selected changes in practice to determine their ef-
individuals and how to facilitate implementation by others. ficacy, and finally, routine integration of the tested
changes.161,163
r Identify early adopting clinicians as opinion leaders
Strategies for Individual Implementation
r Keep a copy of the CMT CPG in a location that is to introduce the guideline via journal clubs or staff
presentations.161,163
easy to reference. r Identify gaps in knowledge and skills following pre-
r Compare items in the recommended examination list
sentation of content to determine needs of staff for
to determine what should be added to an examination
adopting recommendations.163
to increase adherence. r Use documentation templates to facilitate standard-
r Adapt examination forms to include a place to docu-
ized collection and implementation of the recom-
ment each of the recommended measures.
r Seek training in the use of the recommended mended measures and actions.164,165
r Institute quality assurance processes to monitor the
standardized measures and/or intervention
routine collection of recommended data and imple-
approaches.160
r Build relationships with referral sources to encourage mentation of recommendations, and to identify bar-
riers to complete collection.161,166
early referral of infants. r Measure structural outcomes (eg, dates of refer-
r Measure individual service outcomes of care (eg, pa-
ral, equipment availability), process outcomes (eg,
tient effect across the ICF domains, costs, and par-
use of tests and measures, breadth of plan of
ent/caregiver satisfaction).161,162
care), and service outcomes (eg, patient effect
across the ICF domains, costs, and parent/caregiver
satisfaction).161,162
Plan for Revision: The GDG recommends that the
CPG be updated in 5 years, as the body of evidence
expands.23
R. Research Recommendation 1: Researchers should con- R. Research Recommendation 9: Researchers should con-
duct studies to determine whether routine screening at duct studies to identify the best developmental screening
birth increases the rate of CMT identification and/or in- tests to use for infants with suspected or diagnosed CMT,
creases false positives. from birth through 12 months. This research would enable
R. Research Recommendation 2: Researchers should con- standardization of measures to document outcomes across
duct studies to clarify the predictive baseline measures studies.
and characteristics of infants who benefit from immediate R. Research Recommendation 10: Researchers should
follow-up, and compare the cost–benefit of early physical conduct studies to define home exercise program inter-
therapy intervention and education to parental instruction vention dosages and link them to classifications of severity.
and monitoring by physicians. Longitudinal studies of in- Dosage should address the type and duration of stretches
fants with CMT should clarify how the timing of referral or active movements, the repetitions within each treatment
and initiation of intervention affect changes in body struc- session, the frequency of treatment sessions per day, the
ture, function, and overall costs of care. overall duration of care, and the frequency of clinic visits,
R. Research Recommendation 3: Researchers should con- including tapering schedules.
duct studies to identify the precision of screening proce- R. Research Recommendation 11: Researchers should
dures specific to CMT. conduct studies to describe and clarify the efficacy of all
R. Research Recommendation 4: Researchers should con- supplementary interventions, including determinants for
duct studies to determine who would benefit from imaging, their choice, principles of application, dosage, and out-
at what time in the management of CMT images are useful, comes measures.
and how images affect the plan of care. R. Research Recommendation 12: Researchers should
R. Research Recommendation 5: Researchers should con- conduct studies to determine the most reasonable follow-
duct studies to develop a reliable, valid, and time-efficient up times after discharge from physical therapy services
method of measuring infant cervical ROM and determine based on initial presentations, to establish the level of risk
normative data for cervical passive ROM. of developing asymmetries following an episode of physi-
cal therapy.
R. Research Recommendation 6: Researchers should con-
duct studies to: R. Research Recommendation 13: Researchers should
a. Determine the sensitivity and specificity of the conduct studies to document parent/caregiver concerns or
Muscle Function Scale to differentiate infants with satisfaction with physical therapy intervention.
clinically significant limitations from infants who
are typically developing. ACKNOWLEDGMENTS
b. Establish a clinically practical, objective method of This CPG is the product of many people’s work and
measuring active ROM in infants 0 to 3 months and support, particularly the support provided by the Section
infants older than 3 months to assess baselines and on Pediatrics of the American Physical Therapy Associa-
change over time. tion. From the initial period of conceptualization through
c. Determine what, if any, correlation between active each phase of development, the authors have benefitted
and passive ROM should be used for discharge cri- from the work and advice of clinicians, methodologists,
teria. and patients with whom we work. We formally acknowl-
edge and express appreciation to the many contributors
along the way.
R. Research Recommendation 7: Researchers should con-
Literature search and abstract review: Karen Gage
duct studies to describe and differentiate signs of discom-
Bensley, PT, DPT, PCS; Catie Christensen, PT, DPT; Stacie
fort from the types of pain reactions typically observed in
Lerro, PT, DPT, PCS; Barbara Sargent, PT, PhD, PCS; Kath-
infants with CMT during specific testing or interventions,
leen Kelly, PT, PhD; Magdalena Oledzka, PT, MBA, PCS;
as well as determine the validity of the FLACC in rating
Melanie O’Connell, PT, PCS; Allison Yocum, PT, DSc, PCS
true pain reactions during CMT examinations or interven-
Literature review, appraiser reliability training, and
tions.
critical appraisal ratings: Karen Bensley, PT, DPT, PCS;
R. Research Recommendation 8: Researchers should con- Carol Burch, PT, DPT, Med; Yu-Ping Chen, PT, ScD; Catie
duct studies to determine a reliable, valid, and clinically Christensen, PT, DPT; Hsiang-han Huang, OT, ScD; Sta-
practical method of measuring lateral flexion, and deter- cie Lerro, PT, DPT, PCS; Barbara Sargent, PT, PhD, PCS;
mine the relationship between the severity of lateral flexion Kathleen Kelly, PT, PhD; Caitlin McSpadden, PT; Allison
and the severity grades. Yocum, PT, DSc, PCS
S7108 Structure of head and neck region, other Facial and skull symmetry
specified
S7401/ S5001 Hip joint Hip dysplasia
Activity limitations