Conservative Management of Freiberg Disease with Shoe Modification and Insole:A Case Report with 2-Year Follow-up / 대한스포츠의학회지

Freiberg disease, known as a Freiberg infraction, is an uncommon disorder of the second metatarsal head of the foot. Conservative treatment is recommended as initial management to relieve symptoms and minimize epiphyseal deformity. However, due to the rarity of this disorder, there have been few reports of long-term clinical and radiologic follow-ups of Freiberg disease treated with conservative treatment. We report Freiberg disease treated with conservative management including modification of shoe and insole. A 24-year-old woman presented with right forefoot pain. In plain radiography, the sunken appearance of the metatarsal head and periarticular spurring was observed. The articular cartilage was intact in magnetic resonance imaging (MRI), corresponding to Smillie’s stage 3 and Thompson’s type 2. We prescribed carbon fiber insert, customed semirigid insole with metatarsal dome and rocker-bottom shoe to relieve pressure under the metatarsal heads. Freiberg disease maintained a well-tolerable condition during 2-year follow-up period without further progression in MRI.

Association between N-Terminal Prohormone Brain Natriuretic Peptide and Decreased Skeletal Muscle Mass in a Healthy Adult Population: A Cross-Sectional Study

Background@#Although an inverse association between the N-terminal prohormone brain natriuretic peptide (NT-proBNP) and obesity exists, only few major studies have assessed the association between NT-proBNP levels and skeletal muscle mass in asymptomatic healthy adults. Therefore, this cross-sectional study was conducted. @*Methods@#We assessed participants who underwent health examinations at Kangbuk Samsung Hospital in South Korea from January 2012 to December 2019. Appendicular skeletal muscle mass was measured using a bioelectrical impedance analyzer, and the skeletal muscle mass index (SMI) was calculated. Participants were divided into the control, mildly low skeletal muscle mass (LMM) (−2 standard deviation [SD] < SMI ≤−1 [SD]), and severely LMM groups (SD ≤−2) based on their SMI. The association between elevated NT-proBNP level (≥125 pg/mL) and skeletal muscle mass was assessed using multivariable logistic regression analysis with adjustment for confounding factors. @*Results@#This study enrolled 15,013 participants (mean age, 37.52±9.52; men, 54.24%; control, n=12,827; mildly LMM, n=1,998; severely LMM, n=188). Prevalence of elevated NT-proBNP was higher in mildly and severely LMM groups than in the control group (control, 1.19%; mildly LMM, 1.4%; severely LMM, 4.26%; P=0.001). The adjusted odds ratio (OR) of elevated NT-proBNP was significantly higher in severely LMM (OR, 2.87; 95% confidence interval [CI], 1.3 to 6.37) than in control (OR, 1.00; reference) or mildly LMM groups (OR, 1.24; 95% CI, 0.81 to 1.89). @*Conclusion@#Our results showed that NT-proBNP elevation were more prevalent in participants with LMM. In addition, our study showed an association between skeletal muscle mass and NT-proBNP level in a relatively young and healthy adult population.

Natural Course of Swallowing Recovery and Associated Factors in Post-Ischemic Stroke Dysphagia / 대한연하장애학회지

Objective@#To identify factors associated with swallowing recovery in patients with dysphagia after ischemic stroke. @*Methods@#Patients admitted to Kangbuk Samsung Hospital from 2011 to 2019 for first acute ischemic stroke and dysphagia, as confirmed by a videofluoroscopic swallowing study (VFSS), were enrolled in this retrospective study. Patients whose Dysphagia Outcome and Severity Scale (DOSS) level was ＜6 as determined by VFSS were monitored in a dysphagia clinic and additional VFSS was performed periodically until one year after stroke. Follow-up was discontinued when the DOSS level reached 6 or 7. The main study outcomes were full recovery and tube removal rate. Cox regression analysis was used to identify prognostic factors of dysphagia. The Kaplan-Meier method was used to generate curves of the proportions of patients that achieved full recovery. @*Results@#One hundred and thirteen patients were enrolled. Multivariate analysis showed that only initial DOSS was significantly associated with swallowing recovery (13.0% for non-oral feeding vs. 35.6 % for a modified diet). @*Conclusion@#Initial swallowing status (as determined by VFSS findings) is strongly associated with swallowing recovery in post-ischemic stroke patients. Assessments of dysphagia are important for predicting dysphagia recovery and planning management strategies.

Association between Elevated Plasma Homocysteine and Low Skeletal Muscle Mass in Asymptomatic Adults

Background@#Homocysteine has been drawing attention with a closed linkage with skeletal muscle. However, the association of hyperhomocysteinemia with decreased skeletal muscle mass remains unclear. We aimed to investigate the association of hyperhomocysteinemia with low skeletal muscle mass (LMM) in asymptomatic adults. @*Methods@#This was a cross-sectional study of 114,583 community-dwelling adults without cancer, stroke, or cardiovascular diseases who underwent measurements of plasma homocysteine and body composition analysis from 2012 to 2018. Hyperhomocysteinemia was defined as >15 μmol/L. Skeletal muscle mass index (SMI) was calculated based on appendicular muscle mass (kg)/height (m)2. Participants were classified into three groups based on SMI: “normal,” “mildly low,” and “severely low.” @*Results@#The prevalence of hyperhomocysteinemia was the highest in subjects with severely LMM (12.9%), followed by those with mildly LMM (9.8%), and those with normal muscle mass (8.5%) (P for trend <0.001). In a multivariable logistic regression model, hyperhomocysteinemia was significantly associated with having a mildly LMM (odds ratio [OR], 1.305; 95% confidence interval [CI], 1.224 to 1.392) and severely LMM (OR, 1.958; 95% CI, 1.667 to 2.286), respectively. One unit increment of log-transformed homocysteine was associated with 1.360 and 2.169 times higher risk of having mildly LMM and severely LMM, respectively. @*Conclusion@#We demonstrated that elevated homocysteine has an independent association with LMM in asymptomatic adults, supporting that hyperhomocysteinemia itself can be a risk for decline in skeletal musculature.

Acute Onset Hip Pain after Excessive Walking Diagnosed with Skeletal Muscle Metastasis

Skeletal muscle metastasis of gastric cancer is extremely rare and is associated with various symptoms. Here, we report on a 60-year-old woman with right hip pain after excessive walking. Two years earlier, the patient had been treated for advanced gastric cancer (surgery, adjuvant chemotherapy). Upon magnetic resonance imaging, diffuse muscle swelling and high signal intensity were observed in T2-weighted images of the right hip muscle. However, the FDG uptake in the right gluteal muscles was not obviously increased. Pathological examination of muscle biopsy revealed metastatic adenocarcinoma of stomach origin. The patient was treated with chemotherapy, and the swelling and pain in the right hip are progressively improving.

Rapidly Destructive Arthrosis of Knee Following Treatment of Crizotinib in a Patient with Non-Small-Cell Lung Cancer

Rapidly destructive arthrosis is a rare syndrome characterized by narrowing of the joint space and rapid joint destruction within 6∼12 months. A 62-year-old woman with anaplastic lymphoma kinase rearranged non-small-cell lung cancer presented with both knee pain and varus deformity. She was treated with crizotinib 500 mg/day for more than 2 years, with partial tumor response. Initial plain radiography showed Kellgren and Lawrence (K-L) grade 1. After 10 months, varus deformity was worsened and plain radiography aggravated to K-L grade 4 despite conservative treatment including activity modification.Diffuse synovitis with massive joint effusion and destruction of anterior cruciate ligament, medial meniscus, medial collateral ligament, and lateral collateral ligament were shown in magnetic resonance imaging. The patient was diagnosed with rapidly destructive arthrosis of knee and underwent a both total knee arthroplasty.

Acute Onset Hip Pain after Excessive Walking Diagnosed with Skeletal Muscle Metastasis

Skeletal muscle metastasis of gastric cancer is extremely rare and is associated with various symptoms. Here, we report on a 60-year-old woman with right hip pain after excessive walking. Two years earlier, the patient had been treated for advanced gastric cancer (surgery, adjuvant chemotherapy). Upon magnetic resonance imaging, diffuse muscle swelling and high signal intensity were observed in T2-weighted images of the right hip muscle. However, the FDG uptake in the right gluteal muscles was not obviously increased. Pathological examination of muscle biopsy revealed metastatic adenocarcinoma of stomach origin. The patient was treated with chemotherapy, and the swelling and pain in the right hip are progressively improving.

Rapidly Destructive Arthrosis of Knee Following Treatment of Crizotinib in a Patient with Non-Small-Cell Lung Cancer

Rapidly destructive arthrosis is a rare syndrome characterized by narrowing of the joint space and rapid joint destruction within 6∼12 months. A 62-year-old woman with anaplastic lymphoma kinase rearranged non-small-cell lung cancer presented with both knee pain and varus deformity. She was treated with crizotinib 500 mg/day for more than 2 years, with partial tumor response. Initial plain radiography showed Kellgren and Lawrence (K-L) grade 1. After 10 months, varus deformity was worsened and plain radiography aggravated to K-L grade 4 despite conservative treatment including activity modification.Diffuse synovitis with massive joint effusion and destruction of anterior cruciate ligament, medial meniscus, medial collateral ligament, and lateral collateral ligament were shown in magnetic resonance imaging. The patient was diagnosed with rapidly destructive arthrosis of knee and underwent a both total knee arthroplasty.

A Subcalcaneal Bursitis Developed after Execessive Walking Exercise

Plantar heel pain is a common clinical problem in foot and ankle clinics. Typically, several conditions such as plantar fasciitis, fat pad atrophy, and calcaneal fracture may lead to plantar heel pain. However, subcalcaneal bursitis occurred between plantar fascia and plantar fat pad has rarely been described as a cause of plantar heel pain. To our knowledge, subcalcaneal bursitis has been reported only once, but there was no mention of preceding factors. We firstly present a case of subcalcaneal bursitis occurred after excessive walking exercise known as “Nordic walking” and successfully managed with conservative treatments that relieve impact on plantar heel.

Spinal Accessory Neuropathy Secondary to Diffuse Large B-Cell Lymphoma

Spinal accessory neuropathy (SAN) is commonly caused by an iatrogenic procedure, and that caused by tumors is very rare. We present a case of a 49-year-old man suffering from weakness in the right trapezius and sternocleidomastoid muscle. An electrophysiology study confirmed proximal SAN. Fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) revealed a diffuse large B-cell lymphoma compressing the right spinal accessory nerve. Ultrasonography showed definite atrophy on the trapezius and sternocleidomastoid muscles. In addition, post-chemotherapy FDG-PET/CT showed increased FDG uptake in the right upper trapezius, suggestive of denervation. This is the first report of SAN caused by direct compression by a diffuse large B-cell lymphoma, comprehensively assessed by an electrophysiology study, ultrasonography, and FDG-PET/CT.

Chronic Intractable Calcific Lateral Epicondylopathy Treated with Ultrasound-Guided Barbotage Combined with Extracorporeal Shock-Wave Therapy

Lateral epicondylopathy represents pain in the lateral (radial aspect) of the elbow caused by degeneration in the common extensor tendon. Calcium deposit frequently developes in lateral epicondylopathy, with the prevalence up to 46%. There are considerable debates on its treatment protocols for lateral epicondylopathy so far, likewise, the effective treatment method for calcific lateral epicondylopathy has not been established. We report here a case of chronic intractable calcific lateral epicondylopathy treated with ultrasound-guided barbotage and focused type extracorporeal shock wave therapy (ESWT). To our knowledge, this is the first report of calcific lateral epicondylopathy treated by ultrasound-guided barbotage combined with ESWT.

Quantitative Analysis of Swallowing Function Between Dysphagia Patients and Healthy Subjects Using High-Resolution Manometry

OBJECTIVE: To compare swallowing function between healthy subjects and patients with pharyngeal dysphagia using high resolution manometry (HRM) and to evaluate the usefulness of HRM for detecting pharyngeal dysphagia. METHODS: Seventy-five patients with dysphagia and 28 healthy subjects were included in this study. Diagnosis of dysphagia was confirmed by a videofluoroscopy. HRM was performed to measure pressure and timing information at the velopharynx (VP), tongue base (TB), and upper esophageal sphincter (UES). HRM parameters were compared between dysphagia and healthy groups. Optimal threshold values of significant HRM parameters for dysphagia were determined. RESULTS: VP maximal pressure, TB maximal pressure, UES relaxation duration, and UES resting pressure were lower in the dysphagia group than those in healthy group. UES minimal pressure was higher in dysphagia group than in the healthy group. Receiver operating characteristic (ROC) analyses were conducted to validate optimal threshold values for significant HRM parameters to identify patients with pharyngeal dysphagia. With maximal VP pressure at a threshold value of 144.0 mmHg, dysphagia was identified with 96.4% sensitivity and 74.7% specificity. With maximal TB pressure at a threshold value of 158.0 mmHg, dysphagia was identified with 96.4% sensitivity and 77.3% specificity. At a threshold value of 2.0 mmHg for UES minimal pressure, dysphagia was diagnosed at 74.7% sensitivity and 60.7% specificity. Lastly, UES relaxation duration of <0.58 seconds had 85.7% sensitivity and 65.3% specificity, and UES resting pressure of <75.0 mmHg had 89.3% sensitivity and 90.7% specificity for identifying dysphagia. CONCLUSION: We present evidence that HRM could be a useful evaluation tool for detecting pharyngeal dysphagia.

Failed Deglutitive Upper Esophageal Sphincter Relaxation Is a Risk Factor for Aspiration in Stroke Patients with Oropharyngeal Dysphagia

BACKGROUND/AIMS: We attempted to examine the relationship between abnormal findings on high-resolution manometry (HRM) and videofluoroscopic swallowing study (VFSS) of the pharynx and upper esophageal sphincter (UES), and to identify the risk factors for aspiration. METHODS: We performed VFSS and HRM on the same day in 36 ischemic stroke patients (mean age, 67.5 years) with dysphagia. Pressure (basal, median intra bolus, and nadir), relaxation time interval of the UES, and mesopharyngeal and hypopharyngeal contractility (as a contractile integral) were examined using HRM. The parameters of VFSS were vallecular residue, pyriform sinus residue, vallecular overflow, penetration, and aspiration. The association between the parameters of VFSS and HRM was analyzed by the Student's t test. RESULTS: Three (8.3%) and 4 (11.1%) stroke patients with dysphagia had pyriform sinus residue and vallecular sinus residue, respectively, and 5 (13.8%) patients showed aspiration. Mesopharyngeal and hypopharyngeal contractile integrals in patients with residue in the pyriform sinus were significantly lower than those in patients without residue in the pyriform sinus (P < 0.05). Relaxation time intervals in patients with aspiration were significantly shorter than those in patients without aspiration (P < 0.05), and multivariate regression analysis revealed a shorter relaxation time interval as the main risk factor for aspiration (OR, 0.03; 95% CI, 0.01–0.65; P < 0.05). CONCLUSIONS: Manometric measurements of the pharynx and UES were well correlated with abnormal findings in the VFSS, and a shorter relaxation time interval of the UES during deglutition is an important parameter for the development of aspiration.

Long-Term Outcome and Factors Affecting Prognosis of Extracorporeal Shockwave Therapy for Chronic Refractory Achilles Tendinopathy

OBJECTIVE: To investigate the factors affecting prognosis of extracorporeal shockwave therapy (ESWT) for chronic refractory Achilles tendinopathy (AT). METHODS: Thirty-six patients (48 consecutive feet) with chronic AT (>6 months) and who underwent ESWT for ‘poor’ or ‘fair’ grade in Roles-Maudsley Score (RMS) after unsuccessful conservative treatment were included in the present study. A maximum of 12 sessions of ESWT were conducted until treatment success: RMS reached ‘good’ or ‘excellent’. Termination of ESWT for no response, or ‘poor’ or ‘fair’ grade was regarded as treatment failure. Immediate outcome, long-term outcome (telephone interview after mean 26 months), and factors affecting treatment success were analyzed. RESULTS: Numeric Rating Scale was significantly decreased at immediate and long-term follow-up. Success rate was 71.1% and 90.3%, respectively. Univariate logistic regression identified that immediate treatment success was associated with retrocalcaneal enthesophyte on X-ray (odds ratio [OR], 0.06; 95% confidence interval [CI], 0.01–0.28), pretreatment abnormal ultrasonography echogenicity within Achilles tendon (OR, 18.89; 95% CI, 2.08–171.96), mean duration of ‘post-treatment soreness’ (OR, 0.55; 95% CI, 0.33–0.94), and duration of ‘post-treatment soreness after first ESWT’ (OR, 0.06; 95% CI, 0.01–0.34). The duration of ‘post-treatment soreness after first ESWT’ was found to be the only factor associated with long-term success (OR, 0.32; 95% CI, 0.10–0.99). CONCLUSION: ESWT appears to be effective in achieving long-term success in chronic refractory AT. Immediate success was associated with absence of retrocalcaneal enthesophyte on X-ray, presence of pretreatment abnormal ultrasonography echogenicity, shorter mean duration of ‘post-treatment soreness’, and shorter duration of ‘post-treatment soreness after first ESWT’. The shorter duration of ‘post-treatment soreness after first ESWT’ was identified as the only positive prognostic parameter in achieving long-term success.

Comparison of Diffusion Tensor Tractography and Motor Evoked Potentials for the Estimation of Clinical Status in Subacute Stroke

OBJECTIVE: To compare diffusion tensor tractography (DTT) and motor evoked potentials (MEPs) for estimation of clinical status in patients in the subacute stage of stroke. METHODS: Patients with hemiplegia due to stroke who were evaluated using both DTT and MEPs between May 2012 and April 2015 were recruited. Clinical assessments investigated upper extremity motor and functional status. Motor status was evaluated using Medical Research Council grading and the Fugl-Meyer Assessment of upper limb and hand (FMA-U and FMA-H). Functional status was measured using the Modified Barthel Index (MBI). Patients were classified into subgroups according to DTT findings, MEP presence, fractional anisotropy (FA) value, FA ratio (rFA), and central motor conduction time (CMCT). Correlations of clinical assessments with DTT parameters and MEPs were estimated. RESULTS: Fifty-five patients with hemiplegia were recruited. In motor assessments (FMA-U), MEPs had the highest sensitivity and negative predictive value (NPV) as well as the second highest specificity and positive predictive value (PPV). CMCT showed the highest specificity and PPV. Regarding functional status (MBI), FA showed the highest sensitivity and NPV, whereas CMCT had the highest specificity and PPV. Correlation analysis showed that the resting motor threshold (RMT) ratio was strongly associated with motor status of the upper limb, and MEP parameters were not associated with MBI. CONCLUSION: DTT and MEPs could be suitable complementary modalities for analyzing the motor and functional status of patients in the subacute stage of stroke. The RMT ratio was strongly correlated with motor status.

Effects of Repetitive Transcranial Magnetic Stimulation on Behavioral Recovery during Early Stage of Traumatic Brain Injury in Rats

Repetitive transcranial magnetic stimulation (rTMS) is a promising technique that modulates neural networks. However, there were few studies evaluating the effects of rTMS in traumatic brain injury (TBI). Herein, we assessed the effectiveness of rTMS on behavioral recovery and metabolic changes using brain magnetic resonance spectroscopy (MRS) in a rat model of TBI. We also evaluated the safety of rTMS by measuring brain swelling with brain magnetic resonance imaging (MRI). Twenty male Sprague-Dawley rats underwent lateral fluid percussion and were randomly assigned to the sham (n=10) or the rTMS (n=10) group. rTMS was applied on the fourth day after TBI and consisted of 10 daily sessions for 2 weeks with 10 Hz frequency (total pulses=3,000). Although the rTMS group showed an anti-apoptotic effect around the peri-lesional area, functional improvements were not significantly different between the two groups. Additionally, rTMS did not modulate brain metabolites in MRS, nor was there any change of brain lesion or edema after magnetic stimulation. These data suggest that rTMS did not have beneficial effects on motor recovery during early stages of TBI, although an anti-apoptosis was observed in the peri-lesional area.

Long-Term Outcome of Low-Energy Extracorporeal Shock Wave Therapy for Plantar Fasciitis: Comparative Analysis According to Ultrasonographic Findings

OBJECTIVE: To investigate the long-term effect of low-energy extracorporeal shock wave therapy (ESWT) for plantar fasciitis (PF) according to ultrasonography (US) findings. METHODS: Thirty feet of 25 patients with clinical diagnosis of PF were enrolled and divided into two groups (Apparent-US and Uncertain-US) according to US findings, such as plantar fascia thickening or hypoechogenicity. Inclusion criteria were symptom duration >6 months and a fair or poor grade in Roles-Maudsley score (RMS). ESWT (0.10 mJ/mm2, 600 shocks) was given once a week for 6 weeks. Numeric rating scale (NRS) and RMS were evaluated prior to each ESWT session, at short-term follow-up (one week after all ESWT sessions) and long-term follow-up telephone interview (mean 24 months after ESWT). Good and excellent grade in RMS were considered as treatment success. RESULTS: Repeated measure ANOVA demonstrated that NRS significantly decreased with time after ESWT up to the long-term follow-up (time effect, p<0.001) without group-time interaction (p=0.641), indicating that ESWT equally decreased pain in both groups. Overall success rate was 63.3% (short-term follow-up) and 80.0% (long-term follow-up). In comparative analysis between groups, success rate of Apparent-US and Uncertain-US at short-term follow-up was 61.9% and 66.7%, respectively, and 85.7% and 66.7%, respectively, at long-term follow-up. CONCLUSION: If other causes of heel pain are ruled out through meticulous physical examination and ultrasonography, low-energy ESWT in PF seems to be beneficial regardless of US findings. In terms of success rate, however, long-term outcome of Apparent-US appears to be superior to Uncertain-US.

Suppression of in vitro murine T cell proliferation by human adipose tissue-derived mesenchymal stem cells is dependent mainly on cyclooxygenase-2 expression / 대한해부학회지

Mesenchymal stem cells (MSCs) of human origin have been frequently applied to experimental animal models to evaluate their immunomodulatory functions. MSCs are known to be activated by cytokines from T cells, predominantly by interferon-gamma (IFN-gamma), in conjunction with other cytokines such as tumor necrosis factor-alpha (TNF-alpha) and interlukin-1beta. Because IFN-gamma is not cross-reactive between human and mouse species, the manner in which human MSCs administered in experimental animals are activated and stimulated to function has been questioned. In the present study, we established MSCs from human adipose tissue. They successfully suppressed the proliferation of not only human peripheral blood mononuclear cells but also mouse splenic T cells. When these human MSCs were stimulated with a culture supernatant of mouse T cells or recombinant murine TNF-alpha, they expressed cyclooxygenase-2 (COX-2), but not indoleamine 2,3-dioxygenase. The dominant role of COX-2 in suppressing mouse T cell proliferation was validated by the addition of COX-2 inhibitor in the co-culture, wherein the suppressed proliferation was almost completely recovered. In conclusion, human MSCs in a murine environment were activated, at least in part, by TNF-alpha and mainly used COX-2 as a tool for the suppression of in vitro T cell proliferation. These results should be considered when interpreting results for human MSCs in experimental animals.

Vitamin C acts indirectly to modulate isotype switching in mouse B cells / 대한해부학회지

Vitamin C, one of essential micronutrients, has been reported to modulate the humoral immune responses in some mammals. We investigated whether vitamin C might modulate this response in mice by directly affecting B cells. Splenic B cells were isolated and activated by CD40- and B cell receptor-ligation in vitro. The cells were cultured with a pretreatment of vitamin C from 0 to 1 mM of concentrations. Vitamin C slightly increased apoptosis of B cells dose-dependently and behaved as an antioxidant. We found that in vivo administration of vitamin C by intraperitoneal injection affected isotype switching as previously reported: the titer of antigen-specific IgG1 antibody was decreased, while that of IgG2a was unaffected. Somewhat different from those observed in vivo, in vitro exposure to vitamin C slightly decreased isotype switching to IgG1 and increased isotype switching to IgG2a. Pretreatment with vitamin C in the safe range did not affect either proliferation of cultured B cells or the expression of CD80 and CD86 in those cells. Taken together, in vivo results suggest that vitamin C acts to modulate isotype switching in the mouse. However, because of our in vitro results, we suggest that the modulation exerted by vitamin C in vivo is by indirectly affecting B cells, perhaps by directly influencing other immune cells such as dendritic cells.

Clinical characteristics and courses of congenital muscular torticollis / 소아과

PURPOSE: Congenital muscular torticollis (CMT), a common musculoskeletal disorder in infants, is characterized by the rotation and flexion deformity of the neck caused by sternocleidomastoid muscle shortening. We investigated the clinical courses and perinatal risk factors of CMT. METHODS: Less than 6-month-old patients (98; M:F = 60:38) diagnosed with CMT between February 2007 and August 2008 were classified into 2 clinical subgroups, namely, SMT (sternocleidomastoid tumor) and POST (postural torticollis). All the patients were physically and neurologically examined prospectively and their cervical X-rays and ultrasonographies were obtained. Their medical histories about perinatal problems were recorded. Of the 98 patients, 45 with normal range of motion were taught passive physical exercises and 43 were referred to the Department of Rehabilitation for undergoing manual stretching therapy. RESULTS: The mean age at initial assessment was 2.2 months (SMT: 1.4+/-1.0, POST: 2.7+/-1.6). SMT presented earlier than POST. All ophthalmologic examinations and cervical X-rays were normal. SMT was associated with higher incidence of caput succedaneum and cephalhematoma. POST was highly associated with plagiocephaly. Mean duration of rehabilitative physical therapy was 3.7 months (SMT: 4.6+/-2.5, POST: 2.6+/-1.9). POST resolved earlier than SMT. Of the 88 patients with follow-up, 87 had total resolution and only 1 had residual torticollis. CONCLUSION: All the patients received early treatment with passive stretching exercises. CMT was associated with perinatal problems and had various risk factors such as obstetrical problems.