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Frequency-Specific Microcurrent for Treatment of Longstanding Congenital Muscular Torticollis

Authors: Regina Thompson, PT, PCS; Sandra L. Kaplan, PT, DPT, PhD

Affiliations:

Therapy Services, Cleveland Clinic Children’s Hospital for Rehabilitation, Cuyahoga Falls, Ohio
Department of Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey, Newark, New Jersey

Published in: Pediatric Physical Therapy (2019)
Cleveland Clinic Article: https://consultqd.clevelandclinic.org/case-report-fsms-big-impact-in-congenital-muscular-torticollis

Abstract

Purpose: This case describes the first episode of care, using conservative treatment, massage, and frequency-specific microcurrent (FSM), for a 19-month-old boy with grade 8 left congenital muscular torticollis with fibrotic nodules.

Methods: Ten weeks of physical therapy provided stretching, strengthening, massage, and parent education, adding FSM in weeks 3 to 10 for this patient.

Results: Full passive cervical rotation and lateral flexion, 4/5 lateral cervical flexion strength, improved head tilt, and inability to palpate fibrotic nodules were achieved by week 8, with partial home program adherence.

Conclusions and Recommendations for Practice: Excellent outcomes were achieved with conservative care in a patient with poor prognosis and likelihood of surgical referral. Combining stretching, strengthening, massage, postural reeducation, and FSM resulted in full range and good strength in an exceptionally short time. The combination of massage and FSM, not previously reported, are tools that may be effective in congenital muscular torticollis treatment.

Key words: frequency-specific microcurrent, grade 8 CMT, torticollis

Introduction

Congenital muscular torticollis (CMT) is a common musculoskeletal disorder of infancy, with an incidence of 3.92% to 16%. It is characterized by cervical lateral flexion and ipsilateral rotation limitations, with or without a sternocleidomastoid (SCM) muscle mass. Concomitant conditions may include cranial deformation and cervical spine musculature imbalances.

While one SCM is shortened, evidence suggests that both sides are affected. The shortened SCM has fibrotic tissue and disorganized muscle fibers, but animal models suggest strength changes on the opposite side due to overlengthening.

Treatment Outcomes and Classification

Best treatment outcomes for CMT result when infants are referred to physical therapy before 3 months of age. Better outcomes are inversely correlated with the amount of rotation restriction and type of CMT (postural, muscular, or fibrotic).

The 2013 clinical practice guideline provided a severity classification scale with 7 grades. The 2018 update added an eighth classification for children older than 12 months with any asymmetry in posture, range of motion (ROM), or an SCM mass:

Early referral: Children younger than 6 months receive lower severity grades
Later referral: Those referred between 7 and 12 months receive higher grades
Very late referral: Those referred after 12 months

Children referred after 12 months of age with cervical rotation restrictions greater than 30 degrees and SCM fibrotic nodules typically have incomplete recovery and are often referred for surgical consults following a trial of conservative therapy.

Conservative Management

Conservative management includes:

Stretching cervical, trunk, and upper extremity muscles to gain passive ROM (PROM)
Active ROM (AROM)
Strengthening
Parent/caregiver education for home program activities to promote symmetry
Facilitating age-appropriate development and participation
Positioning to prevent cranial deformity

Massage techniques are appropriate for infants with CMT younger than 6 months. Infants who received ultrasound, massage, and stretching to the involved SCM sustained improvements in head tilt and Torticollis Overall Assessment scores when assessed at 3 and 6 months.

Electrical Stimulation and Microcurrent

Electrical stimulation is effective in wound healing, tissue regeneration, pain reduction, and muscle function. In humans, muscle disuse has been associated with degradation of myofibrils and intracellular Ca²⁺ elevation.

Microcurrent’s therapeutic action may be twofold:

Pain reduction: Similar to transcutaneous electrical nerve stimulation (TENS), it may reduce pain perception, allowing for greater SCM stretching without discomfort
Calcium regulation: It may correct Ca²⁺ dysregulation in the muscle tissue

High cellular Ca²⁺ levels activate calpain, a protease involved in programmed cell death. Ca²⁺ dysregulation and increased calpain activation are thought to disturb muscle and connective tissue structure, trigger atrophy and necrosis of muscle tissue, and disturb muscle excitation-contraction coupling.

Evidence for Microcurrent in CMT

Microcurrent (MC) is considered a supplemental intervention to conservative care based on two level 1 randomized controlled trials:

Study 1: Demonstrated effectiveness on 7- to 8-month-old infants (n = 15) using 30 minutes of MC combined with only 2 minutes of manual stretching; the control group received 30 minutes of manual stretching. Both groups had home programs administered by their parents. Results of 6 visits over 2 weeks showed that MC was, on average, more effective than stretching in:

Reducing head tilt angle (from 16 to 7 degrees)
Improving passive cervical rotation (from 70 to 80 degrees)
Improving infant tolerance of interventions (with significantly less crying)

Study 2: Compared 20 infants younger than 3 months with CMT who received ultrasound and therapeutic exercises; 10 additionally received MC. Infants receiving MC had:

Significantly greater increases in passive cervical rotation at 1, 2, and 3 months
Shortened average treatment duration (2.6 months vs 6.3 months)
Greater reductions in SCM thickness

Traditional MC vs. Frequency-Specific Microcurrent

Traditional MC delivers current through 1 frequency channel using 2 body contacts. Alternating current flows from one electrode to the other using a ramped square wave. Voltages of 1 to 600 μA match the electrical current found in human tissue.

Frequency-specific microcurrent (FSM) uses the same ramped square wave and voltages as traditional MC, but differs in delivery:

Delivered through 2 channels using 4 body contacts
Uses wet towels, gel electrodes, or a combination of both
Channel A frequencies target clinical conditions
Channel B targets the tissues with the condition

For example, channel A frequencies can target edema while channel B can target the edematous muscle. The FSM frequencies are thought to cause biologic resonance with the electromagnetic bonds in living tissue, similar to vibration. When FSM frequencies match the electromagnetic bond frequencies in the targeted tissue, oscillations of the bonds may disrupt them, allowing for reorganization.

Frequencies have been established for different conditions and tissue types. Correctly diagnosing the condition causing the tissue impairments is critical to FSM success and may require trial and error.

Description of Case

This 19-month-old male toddler was referred for a first episode of physical therapy for left (L) CMT. Parents reported performing some stretches given by the pediatrician during infancy but admitted low adherence.

Initial Presentation

12 degrees of left head tilt in sitting
25 degrees restriction of passive left cervical rotation compared with the right
Mild postural cervical hyperextension that increased with active left rotation
Left upper trapezius restriction compared with the right
Two pea-sized palpable nodules in the middle and distal thirds of the SCM

Classification

The patient was classified as grade 8 CMT due to:

Referral age
Cervical rotation restrictions
Postural preference for left lateral cervical flexion/right cervical rotation
Presence of palpable nodules

Systems Review

An initial comprehensive systems review revealed:

No other confounding conditions
Age-appropriate developmental skills (independent walking, running, and jumping)
Good bilateral hand use
2- to 3-word sentences
A Peabody Developmental Scales-II at week 10 confirmed age-appropriate gross motor skills

Clinical Impression

The clinical impression was a longstanding, untreated grade 8 left CMT with a poor prognosis for full recovery using only conservative methods. Most late-presenting patients with grade 8 CMT are considered surgical candidates.

Examination Processes

The following measures were taken at the start of each session:

Passive ROM (PROM): Measured bilaterally in the supine position with an arthrodial protractor. Overpressure was not applied if the child resisted.
Active cervical rotation: Measured bilaterally using the rotating chair test
Active lateral cervical flexion: Measured in degrees and with the Muscle Function Scale (MFS)
Resting head tilt: Measured via photography in sitting, with the parent stabilizing the toddler’s pelvis

Interventions

Weekly, 1-hour outpatient sessions were combined with a home program for the parents. Conservative treatment consisted of stretching with massage, strengthening, and instruction for the home program. After 2 weeks, FSM was added to each clinic visit.

Stretching

This active, inquisitive toddler disliked being held for long periods. Stretches were held for 30 to 120 seconds as tolerated, with at least 2 repetitions per stretch.

Right lateral cervical flexion stretch: Obtained while carrying him in the left side-lying position, with his shoulder stabilized, applying gentle overpressure to facilitate PROM
Cervical rotation: Achieved by holding his trunk against the PT’s trunk and rotating his head left, or positioning him prone in the PT’s lap with toys on his left
Cervical extensors: Stretched in the supported supine position, approximating his head toward his pelvis while playing

Strengthening

Strengthening and postural reeducation exercises included:

Tipping or swinging him to the left for right lateral flexion responses
Backward tipping for symmetrical SCM activation
Transitioning to sitting through right lateral trunk flexion
Prone wheelbarrow positioning for bilateral shoulder girdle activation and scapular depression
Right upper extremity reaching in prone to load the left upper extremity for stabilization and postural control
Combinations of whole body flexion or extension with rotation (reclined sitting with toys on the left, supported side plank, overhead left upper extremity reaching)

Manual cues to correct head tilt were provided for postural reeducation throughout treatment. The treatment area was well prepared with toys to keep the patient engaged and promote the highest quality movement patterns.

Massage Techniques

Massage and soft tissue mobilization during stretching and play activities were performed throughout the 10 weeks. Techniques included:

Gentle longitudinal and cross-friction massage
Trigger point release
Muscle bending to the left SCM, scalenes, and upper trapezius

Frequency-Specific Microcurrent Protocol

A Custom Care© microcurrent unit (Precision Distributors Inc, Newberg, Oregon) was used to deliver the treatment protocol. This and other microcurrent machines are approved by the Food and Drug Administration as TENS devices for the treatment of pain; its contribution to tissue reorganization may be an additive effect.

Electrode Setup:

Gel electrodes did not adhere well to the small neck contours and interfered with massage
The 2 channel A leads were attached to a wet terrycloth bib secured gently around the patient’s neck using alligator clip adaptors
Current was conducted through skin contact with the bib
Gel electrodes on the anterior chest distal to the SCM insertions provided conductivity for the 2 channel B leads
Electrode placement directed current from the origins to the insertions to treat both SCMs
Setup took less than 5 minutes and remained secure without interfering with treatments

Custom Protocol Development:

The standard protocols provided with the Custom Care software did not address the combination of fibrosis and SCM tissues associated with CMT. The first author, trained and experienced in FSM application and programming, customized a protocol based on the hypothesized Ca²⁺ issues and the apparent fibroma in the left SCM.

Channel A (Condition)	Channel B (Tissue)	Duration
359 — calcium	46 — muscle	5 min
606 — calcium	46 — muscle	5 min
217 — calcium oxite crystals	46 — muscle	5 min
601 — fibroma	46 — muscle	5 min

Total treatment time: 20 minutes at an undetectable intensity of 50 μA

Session Structure

First 30 minutes: Measurements and a combination of stretching and massage in preparation for functional activity
Remaining 30 minutes: Facilitating movement patterns, developmental activities, and providing parent education
Beginning in week 3: FSM was added to the first half of the session

With progress, less time was spent on stretching and massage, with more time given to strengthening and postural awareness.

Home Program Intervention

The home program emphasized stretching into left cervical rotation, right lateral flexion, and midline cervical flexion. A picture booklet and activity descriptions were provided with hands-on training of the parents.

Research-Based Dosing:

A frequency of 100 stretches distributed over 10 sessions per day, holding for 10 to 15 seconds, is more effective than 50 stretches per day for increasing ROM in infants with CMT. This stretching schedule (100 stretches × 10 seconds) equates to 1000 seconds or 16.67 minutes of stretching per day, nearly 2 hours per week.

Modified Protocol for This Case:

Parents were advised to perform each of the 3 stretches 4 times each day, holding 1 to 2 minutes for 2 repetitions. This schedule ranged from 720 to 1440 seconds of stretching per day (12-24 minutes total), providing an adequate dosage while increasing the likelihood of parental adherence due to scheduling and family demands.

Home Stretches:

Cervical flexion: Child positioned supine in the parent’s lap, approximating his shoulders and pelvis in trunk flexion while entertained with toys
Lateral flexion: Holding the child in the left side-lying position with his left shoulder stabilized while the parent stood or walked, facilitating cooperation for 1- to 2-minute holds
Cervical rotation: Placing the child in long sitting on the floor at a 90-degree angle to the parent, resting his head on the parent’s leg during the stretch while offering toys for distraction. Alternately, the child could be upright with the parent placing both hands on either side of his head to guide him into left rotation with gentle trunk stabilization.

Strengthening Activities:

Carrying the child on a parent’s left hip to promote active right lateral cervical flexion
Tipping to the left in sitting or while suspended and facilitating upright orientation
Wheelbarrow positioning during play
Active neck flexion with left rotation in reclined sitting to promote right SCM activation

Parents were advised to engage in targeted strengthening activities after each stretching session.

Treatment Timeline and Results

Weekly Progress

Week	L Rotation PROM	L Rotation AROM	R Lat Flex PROM	R Lat Flex AROM	Head Tilt	MFS	SCM Masses	Home Adherence
1	75° (R: 110°)	60° (R: 85°)	50° (L: 70°)	25° (L: 70°)	12°	3	Present	HEP given
2	80°	65°	55°	45°	10°	4	Present	3 days, 1 rep
3	95°	60°	55°	25°	10°	3	Present	No stretching
4	95°	70°	60°	55°	10°	4	Present	1 day, 1 rep
5	95°	70°	55°	45°	10°	4	Present	5 days, 1-2 reps
6	95°	70°	65°	60°	10°	4	Present	5 days, 1 rep
7	105°	65°	65°	65°	6°	4	Present	4 days, 1 rep
8	110°	70°	65°	70°	5°	4	Not palpable	4×/wk, 1-2 reps
9	110°	70°	70°	70°	2°	4	Not palpable	No report
10	110° (R: 110°)	75° (R: 85°)	70° (L: 70°)	60° (L: 70°)	2°	4 (L: 5)	Not palpable	Limited

Note: FSM was added beginning in week 3. In week 3, lower AROM values were attributed to resistant behavior.

Outcomes

Cervical Range of Motion

The guidelines of greater than 100-degree rotation and 70-degrees lateral flexion were used as normal passive ROM. This patient achieved complete PROM resolution, despite his advanced age at referral.

By week 8:

Passive left cervical rotation increased 35 degrees (from 75° to 110°)
Passive right lateral cervical flexion increased 20 degrees (from 50° to 70°)
Resting head tilt reduced 10 degrees (from 12° to 2°)

Active ROM in the seated swivel test increased from 60° to 75°. Active ROM measurements were within 10 degrees of the uninvolved side for rotation and lateral flexion by week 10.

Strength

Ability to hold head in right lateral flexion against gravity improved from 25° to 70° above the horizon
MFS score improved from 3 to 4
Active midline neck flexion improved, demonstrated by ability to hold a chin tuck for 5 to 10 seconds without a head tilt when tipped backward

Posture

Seated head tilt angle reduced from 12° to 2° at rest, with an increased ability to hold head in midline. Since vision was not assessed prior to treatment to rule out ocular causes of torticollis, persistent intermittent head tilt was indication for a referral.

Tissue Quality

The 2 fibrotic nodules in the middle and distal SCM present at evaluation were not palpable by week 8.

Initially, the left SCM tissue quality felt more firm and dense than the right, with palpable strands of muscle. By week 10, these muscle strands were reduced in diameter and the muscle was more pliable, feeling like thread rather than piano wire.

The reduction in size of palpable nodules may have reduced pressure on pain-sensitive structures, improving tolerance to massage and stretching.

Home Programming Adherence

Throughout the 10 weeks, the parents reported low adherence to the recommended stretching program:

No more than 4 days and 1 repetition per stretch completed at home during any week
Averaging about 1 hour of stretching per week (approximately 50% of recommended)

Barriers to stretching included:

The child’s resistance to stretching
Apartment living and not wanting to disturb neighbors if the child cried
Limited time for both parents to participate due to work schedules

Greater consistency occurred with positioning (especially carrying on the left hip) and strengthening activities because they could more easily be worked into play and family activities.

Despite the reduced home program intensity, improvements were obtained in all measures and sustained from week to week.

Discussion

Three variables have been consistently identified as predictive of longer treatment durations in torticollis:

Older age at referral
Presence of fibrotic nodules
Greater rotation restriction

Treatment duration for CMT can range from 6.9 months with fibrotic nodules to 10.3 months in children referred after 12 months of age. Consults for more aggressive interventions are warranted if:

6 months of conservative treatment does not resolve ROM and strength asymmetry
The child is older than 12 months at evaluation
The child presents with SCM masses

Exceptional Results

This case describes conservative management of a patient referred very late for a first episode of physical therapy. His complete recovery of PROM and good recovery of strength in only 10 weeks are a fraction of the 7- to 10-month episodes previously reported for younger patients.

The key differences between this case and other reports of conservative care are the addition of massage and FSM to traditional stretching, strengthening, and home programming. Both studies on single-channel MC resulted in significantly shorter times for achieving PROM; it is posited that FSM likely accounts for the rapid gains in ROM in this case.

FSM Mechanisms of Action

The mechanism for pain relief is unknown; however, it has been suggested that low-amplitude current may have an effect on human cell signaling and increase endorphin release. Thus, FSM may reduce stretching discomfort, consistent with evidence supporting pain relief in athletes and greater tolerance of interventions in infants by less crying.

Microcurrent has been reported to reduce nonspecific neck pain in adults by 80%. In this case, pain management may have improved tolerance to stretching farther, holding the stretches longer, or massaging more deeply, resulting in the rapid ROM gains.

The more plausible explanation may be on a cellular level, since this boy’s response to stretching and massage prior to the use of FSM were the same as after its introduction.

At the tissue level, when Ca²⁺ homeostasis is disrupted in skeletal muscle (as reported in muscle trauma, disuse, and specific diseases including torticollis), the strict regulation of calpains is disturbed. Tissue samples from 185 patients with CMT (age 4 months to 16 years) had an average composition of 55% fibrous tissue to total muscle and significantly higher positive staining for calpain than controls.

These histological changes may explain the clinical findings of increased SCM fibrosis and the associated reduction in muscle function. Restoring Ca²⁺ homeostasis in the injured tissue may balance calpain activation and facilitate muscle fiber healing and SCM extensibility.

The FSM frequencies in this study were chosen to target calcium and fibroma in the SCM and are theorized to have provided a stimulus or created a favorable environment for tissue repair and regeneration of the SCM.

Although objective measures of fibrosis through ultrasound images were not obtained, the fibrotic nodules dissipated by week 8. Adding FSM, STM, and massage to standard conservative interventions appears to have hastened improvements.

Home Programming Effect

The home program is considered an important first-choice intervention component recommended for all patients with torticollis. Parent education for positioning, stretching, and strengthening is thought to ensure consistency of the stimulus needed for CMT resolution and prevention of motor delays and cranial deformity.

Evidence supports that treatment duration is shorter when a PT performs stretching as opposed to parents; however, ROM can still be increased in either case.

In this study, the home stretching program was delivered at approximately 50% of the recommended time per week, but the active strengthening activities were more consistently used throughout the day. Despite less home stretching, PROM increases were maintained following each treatment, and aside from one low measure in week 3 due to cooperation, the AROM steadily improved as well.

More studies are needed to determine whether parental stretching can be substituted with active strengthening when FSM and massage are used during clinical visits.

Treatment Practicality

Adding FSM to conservative care requires knowledge of the equipment and frequency parameters, but its use with this toddler was well tolerated.

Early in treatment, resistance occurred during the 5-minute setup; however, during subsequent sessions once engaged in play, he was undaunted by the electrode placement, and they did not interfere with treatment activities.

The use of the wet bib is practical for young children who are accustomed to wearing bibs, as electrodes do not conform well to the small contours of the neck and can interfere with access of muscle tissue during massage.

Combining massage with FSM was well tolerated and easy to deliver during a range of activities. Massage is thought to provide a mechanical stimulus to increase PROM, while FSM is postulated to stimulate cellular changes in the muscles and reduce pain signals if stretching causes discomfort.

Limitations

This is a study of one patient-PT dyad. The approach to care is relative to the PT’s training and the changes reported may not be representative of other children. Behavioral cooperation may have affected some ROM measures, but the error more likely resulted in lower ROM measures than higher.

What This Case Adds to the Evidence

The uses of FSM and massage in torticollis treatment have not previously been reported. They were effective in obtaining excellent results in a child with grade 8 CMT whose prognosis would have been for an extended episode of conservative care and a high likelihood for surgical referral.

Conclusions

This case describes a 19-month-old male toddler, grade 8 CMT, who was referred very late for a first trial of physical therapy.

Conservative care combined with FSM and massage resulted in:

Full ROM recovery
4/5 strength in lateral flexors
Reduction in head tilt by the eighth week of care

Gains in ROM were maintained from week to week, allowing strength and head tilt to improve. This rate of range and strength recovery is much faster than expected for a child of this age and CMT severity.

Acknowledgments

The authors sincerely thank Dr. Carol McMakin for her dedication to FSM education, Dr. Ryan Suder for his counsel and encouragement, and especially to this patient’s family for allowing him to illustrate the results of frequency-specific microcurrent and massage.

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Frequency Specific Microcurrent for Treatment of Longstanding Congenital Muscular Torticollis