infantile postural asymmetry ( far better known as congenital muscular torticollis ) is 
 characterised predominantly by asymmetric movement patterns , such as trunk convexity and 
 unilateral restriction in head turning1,2,3 .
to 
 direct the focus on the trunk , the designation  infantile postural asymmetry 
the expected cause of infantile postural asymmetry is an intrauterine - acquired 
 asymmetric fixation , possibly modified by mechanisms throughout birth4 , 5 .
the prevalence of 
 this idiopathic form of infantile postural asymmetry is estimated to be 1525%6,7,8 .
since 1992 infantile postural asymmetry and plagiocephaly have become more frequent2 , 4 due 
 to the launch of the back to sleep campaign to reduce the risk of sudden infant death .
the symptomatic form due to neuromuscular and skeletal disorders is 
 fairly rare1 , 9 .
infantile postural asymmetry occurs frequently with additional asymmetric features , such as 
 hip dislocation , subluxation of the atlanto - axial joint , shortening of the 
 sternocleidomastoid muscle , strabism and deformational plagiocephaly3 , 5 , 9 , 10 , 13 . to allow for unrestricted symmetric movements and to prevent a fixed torticollis , scoliosis 
 and head deformity ,
there are 
 different methods with are based largely on empirical evidence and supported by few studies ; 
 they include stretching , positioning , handling , physical , manual and microcurrent 
 therapy8 , 11,12,13,14 .
there is also a 
 randomised trial which supports the therapeutic efficacy of osteopathic treatment15 . in many countries
neurodevelopmental 
 treatment ( ndt ) and vojta therapy are used for the treatment of infantile asymmetry3 , 5 , 16 .
however , there have not yet been any 
 therapeutic trials in infants with postural asymmetry for these approaches . to evaluate the efficacy of vojta therapy versus ndt in infants with postural asymmetry , we 
 performed a randomised controlled trial ( rct ) using a standardised video - based asymmetry 
 scale2 , 17 .
this study was carried out from 2008 to 2012 at the centre of developmental neurology , 
 frankfurt , germany .
all local paediatricians were asked to refer infants with postural 
 asymmetry and a post - term age of six to eight weeks .
eligible for study participation were 
 otherwise healthy infants who had an asymmetry score of at least 12/24 points diagnosed by a 
 paediatrician , had not yet been treated for their asymmetry and had had a pregnancy duration 
 of at least 32 weeks2 .
in addition , their 
 parents had to provide written informed consent and had to have basic knowledge of the 
 german language .
infants with an extreme pelvic obliquity ( icd-10  m 95.5 ) , which does not 
 allow evaluation of the spine in the supine position , were excluded from the study . 

furthermore infants were excluded from this study if they had significant underlying 
 diseases or a treatment before or during the study according to other concepts .
the study protocol was approved by the ethical committee of the martin luther university 
 ( mlu ) halle - wittenberg and the hessen state chamber of physicians , germany ( approval number 
 mc 95/2008 ) .
a comparative study of vojta therapy against placebo was not allowed for ethical reasons 
 because vojta therapy is an officially recognized treatment modality for infant asymmetry in 
 germany and paid by health insurance .
after written informed consent was obtained and the caregivers agreed to publication , the 
 eligible infants were assigned to two groups using block randomisation .
the sealed and 
 sequentially numbered envelopes were not opened by the study coordinator until the family 
 came to the first therapy session .
infants of the first group were treated according to the vojta method , whereas infants in 
 the second group received elements of ndt , such as handling and positioning .
both groups 
 were treated for 45 minutes twice a week for eight weeks at the centre of developmental 
 neurology , frankfurt by experienced and certified vojta and ndt physiotherapists .
developed by vaclav vojta , the vojta method is well known as reflex locomotion and can be 
 divided into reflex crawling and reflex rolling ( phases 1 and 2 ) . by stimulating special 
 reflex points , the physiotherapist can trigger these motor patterns .
reflex crawling is 
 performed in a prone position , whereas reflex rolling is induced from a supine ( phase 1 ) and 
 side - lying ( phase 2 ) position . during this stimulation of motor patterns ,
the ndt group of infants received techniques opposing their preferred posture with the aim 
 of activating synergistic muscles .
parents were shown how to massage an infant to harmonise 
 muscular imbalance and how to initiate special positioning during sleep , thereby 
 antagonizing asymmetry .
they were also trained to increase the prone position time during 
 daytime ( 4  5 minutes ) .
further exercises in the ndt group comprised handling according to 
 the bobath concept , which includes recommendations for a specific positioning of the infant 
 during everyday procedures , such as washing , feeding , picking up and laying down , in 
 addition to the accommodation of the baby and the parental carrying20 .
the primary outcome was to evaluate the therapeutic effects of the two methods and to test 
 if vojta therapy might be superior to ndt in reducing infant postural asymmetry . before and eight weeks after intervention
, postural asymmetry was quantified using a 
 standardised video - based asymmetry scale developed by philippi et al.2 , 17 .
therefore a 
 tripod with the video camera was set up at the end of treatment mat , exactly two meters 
 above the infants . on the treatment mat ,
a cross was painted , in order to assess the 
 longitudinal axis ( spine ) and a horizontal axis ( shoulder girdle ) .
recording commenced with the infant s head being held for a brief 
 period of time in the middle supine position .
a head turn was then induced by presenting 
 noises , toys or the physiotherapist s face , and moving them from one side to the other . 

after at least two turns to each side , the infant was put in the prone position with its 
 head held for a brief time in the middle prone position , and the same procedures were 
 repeated2 .
that means , the four items 
 of this assessment comprise convexity of the trunk and restriction in head rotation in the 
 prone and supine position during a maximal head turn induced by optic and acoustic stimuli 
 to the right and left side of the infants .
the range of the scale is set with a maximum of 4 
  6 = 24 points for maximum asymmetry and a minimum of 4  1= 4 points for symmetry . for 
 each infant , this procedure was videotaped and analysed by three experienced and trained 
 physical therapists ( table 1table 1.characteristics of the physical therapistspt 1pt 2pt 3genderfemalefemalefemaleage ( years)433553experience from getting the physio license20
years12 years22 yearsreceive vojta certification2001 - --1999receive ndt certification199720081995other certificationcastillo moralessystemic family therapy ) , who were blinded to the therapeutic method used .
the three video scorers had 
 contact neither to the treating physical therapists nor to the parents throughout the whole 
 study .
they did not know if the video was recorded before or 
 after treatment and which treatment was used .
the treating physical therapist and the 
 parents were not blinded for the therapy method .
the secondary outcome was the compliance of the parents , which was ensured through two 
 appointments a week at the treatment centre and supervision of their manual therapy skills . 

the parents had to be present at 12 of the 16 possible appointments at the treatment centre 
 to avoid elimination from the study .
in addition , the frequency of therapy at home and the 
 behaviour of the infants during these treatments were evaluated with a structured parent 
 questionnaire .
questionnaire parents were ask if the crying of their infants affected the duration and 
 frequency of their exercises at home and if crying and behaviour changed over time .
the statistical analysis was performed with spss 18.0 and an 
 intention - to - treat - model used for the evaluation .
the main thesis is tested on a statistical 
 significance of 0.05 using a multivariate analysis of variance ( manova ) within all three 
 scorers over all four items .
an increase or decrease of four points ( out of 24 ) was 
 determined to be the minimum for clinical relevance .
the changes in an infant s behaviour were evaluated with the questionnaire through a 
 four - point likert scale every two weeks . a correlation analysis between therapy and 
 screaming behaviour
the 
 estimation of the number of subjects needed for this therapy study was performed with the 
 software nquery advisor and sas / iml . a previous study about osteopathy and infantile postural asymmetry was used as the 
 reference for the estimation15 .
the group 
 difference in the asymmetry reduction before and after treatment should be at least four 
 points on the asymmetry scale . based on a power of 80 , a significance level of 5% ,
an 
 estimated treatment effect of 4 points and a standard deviation ( sd ) of 3.5 points , 15 
 infants were needed for each group .
a list of block randomisation was created with a 
 computer - based random number generator at the institute of medical epidemiology , biometry 
 and informatics at mlu .
an independent person sent the order of allocation in closed , opaque 
 and numbered envelopes to the investigator , who opened them after receipt of parental 
 consent . because the envelopes were kept in a locked cabinet until opening , confidentiality 
 was ensured .
twenty - six infants exceeded maximal age of eight weeks during the 
 referral and decision process .
thirty - seven infants were found to be eligible and randomly 
 assigned to the two groups , 19 receiving vojta therapy and 18 receiving ndt ( fig .
consort  flow diagram : order of study randomisation was successfully performed as shown by similar baseline criteria in both 
 groups ( table 2table 2.baseline demographic and clinical characteristicscharacteristicsvojta therapy(n=19)ndt(n=18)mean ( sd ) age , weeks7.16 ( 0.77)7.61 ( 0.61)gender , male / female , n16 / 310 / 8mean ( sd ) growth , cm51.50 ( 3.4)50.38 ( 3.3)posture awake , nall positions54no prone position1414posture asleep , nsupine1712supine , side24prone02parental carrying , n<1 h / week2126 h / week221 h / day151224 h / day03plagiocephaly , n169twin birth , n13mean birthweight , g ( range)3,321 ( 2,3604,390)3,101 ( 1,5304,310)mean asymmetry score points ( sd)18.47 ( 1.72)18.35 ( 2.06)n : subjects ; sd : standard deviation ; h : hours ; cm : centimeter ; g : gram )
there 
 were no protocol violations , such as dropouts or change of group affiliation .
n : subjects ; sd : standard deviation ; h : hours ; cm : centimeter ; g : gram within an eight - week treatment either with vojta therapy or ndt , an average four - point 
 reduction of postural asymmetry was achieved . the mean difference ( pre - post ) between both 
 groups was 2.96 points ( 95% ci [ 5.01 ; 0.91 ] ) , a statistically significant improvement in 
 favour of vojta therapy ( p=0.025 ) ( fig .
2.total score difference ( tsc ) in the vojta and ndt group represented as box plots .
a 
 negative tsc represents an improvement , while a positive tsc indicates deterioration . 

total score difference ( tsc ) in the vojta and ndt group represented as box plots .
a 
 negative tsc represents an improvement , while a positive tsc indicates deterioration . 

a discordant value is marked by a circle in the vojta group , the asymmetry score dropped from 18.47 points ( sd 1.72 ) to 10.72 points 
 ( sd 2.77 ) ( 7.75 points 95%ci [ 6.43 ; 9.08 ] ) and in the ndt group from 18.35 points ( sd 
 2.06 ) to 13.56 points ( sd 3.53 ) ( 4.79 points 95%ci [ 3.12 ; 6.47 ] ) ( fig . 3fig .
3.manova regarding the difference in the primary outcome criteria before and after 
 treatment ( pre - post ) ) .
manova regarding the difference in the primary outcome criteria before and after 
 treatment ( pre - post ) the changes of the supine position contributed more to the results than those of the prone 
 position .
the mean changes were 1.18 points ( p<0.001 ; 95% ci [ 0.082 ; 0.840 ] ) in head rotation 
 supine , 0.81 points ( p=0.011 ; 95% ci [ 0.105 ; 0.921 ] ) in spinal convexity supine , 0.47 
 points ( p=0.094 ; 95% ci [ 0.107 ; 0.744 ] ) in head rotation prone and 0.50 points ( p=0.230 ; 
 95% ci [ 0.105 ; 0.610 ] ) spinal convexity prone . despite the recommendations of the physical therapists to treat their infants four times a 
 day
, parents in the vojta group treated their infants on average 2.21 times / day for 10.5 
 minutes .
they attended on average 15.63 from 16 possible appointments with their children at 
 the treatment centre .
parents in the ndt group treated their infants on average 2.44 
 times / day for 10.9 minutes .
thirty - four of 37 parents ( 91.9% ) reported similar or less frequent 
 crying of their infant after eight - week treatment , whereas three parents ( 8.1% ) noticed more 
 frequent crying ( one of the ndt group , two of the vojta group ) .
infantile postural asymmetry in seven - week - old infants both in the ndt group and the vojta 
 group showed clinically relevant improvement after an eight - week treatment interval 
 consisting both of home treatment carried out by the parents twice a day for 10 minutes on 
 average and the therapy at the treatment centre , which was performed twice a week for 30 
 minutes on average . with the same duration and frequency of treatment , there was 
 statistically significant improvement in the vojta group .
this study is the first rct to show the effects of vojta therapy and ndt on infantile 
 postural asymmetry .
the significant effect achieved through vojta therapy compared to ndt 
 may be explained by its more intensive muscle activation due to relatively precisely guided 
 movement responses to triggered reflexes .
in contrast , ndt allows for more variation of 
 muscle activation ; as a result , muscles which need activation may be missed because stronger 
 muscles take over the work of weaker ones
. a further strength of our study is that outcome was measured objectively by a standardised 
 video - based score evaluated by independent raters , who were blinded for treatment and 
 clinical data .
although infants cry during vojta treatment , the acceptance of the parents in this study 
 was good and did not influence compliance .
it is assumed that crying during vojta therapy is 
 more likely an expression of the infant s unwillingness to activate weak muscles rather than 
 an expression of pain .
this assumption is supported by the fact that crying stops as soon as 
 the training ceases and by the report of parents that crying caused by pain sounds 
 different .
parents who can not bear the baby s crying under vojta therapy obtained with ndt a 
 second , effective method but during the study period reached slightly less symmetry . 

compared with other measures8 , 10 , 11 , 14 , 15 both methods 
 show very good results . in physical therapy
usually parents do less home therapy than recommended ; this was also the 
 case in our study .
nevertheless , in our study physical therapy performed twice a day for ten 
 minutes by the parents was sufficient in order to be effective .
parents also have to perform 
 home therapy if they apply other recommended approaches for torticollis like stretching8 , 10 , 11 .
however , stretching is sometimes a 
 difficult experience for both parents and infants as it is often rather painful .
a novel 
 therapy , kinesiology tape14 , seems to be 
 a promising treatment option according to a first pre - post study .
it can not be proven in 
 the end that the natural course would not have achieved the same effect over time .
a further 
 limitation is the missing placebo group , which could not be implemented for ethical reasons . 
 from two historical study groups ( n=12 and n=16 ) of infants with postural asymmetry who were 

not be treated for 4 weeks at the age of 612 weeks , we know that there was a minimal change 
 of their postural asymmetry score (  1 point on average)15 .
this may indicate that initiating physical therapy is more 
 beneficial than waiting . in the treat - or - not - to - treat debate
, there are two further 
 important clinical aspects which might offer a good argument to treat those infants early . 

infants with fixed movement restriction in cervical rotation are limited in their 
 age - related participation because they can not explore the environment as they would like to 
 and need to . in untreated infants , torticollis and spine convexity
may become more fixed over time and 
 the risk of scoliosis and headaches increases . with early treatment
we have the chance to 
 relax the asymmetrically tensed - up spine muscles more easily and quickly ; later on , however , 
 the treatment of fixed torticollis , scoliosis and headache will be more extensive .
our study supports the beneficial effect of physical therapy on infants with infantile 
 postural asymmetry and indicates that physical therapy may be a good complement to 
 stretching and other treatments .
our data suggest that effectiveness can be attained by ten 
 minutes of home therapy twice a day and one 30-minute - treatment per week by the physical 
 therapist .
our results show that therapy compliance was comparable in ndt and vojta therapy ; 
 however , the total effect was greater in the vojta group .
this good result of physiotherapy measures in the treatment of infantile postural asymmetry 
 should now be examined with a greater numbers of participants , maybe in multicentre 
 studies .
this study was partially funded by physio germany ( german association of physical therapy 
  zvk e. v. ) .
this study was partially funded by physio germany ( german association of physical therapy 
  zvk e. v. ) .
 [ purpose ] physical therapy is an acknowledged and frequently applied method for infantile 
 postural asymmetry . 
 however , there is not yet sufficient evidence for its effectiveness . 
 
 [ subjects and methods ] in a randomised controlled trial , the effect of vojta therapy 
 versus neurodevelopmental treatment is assessed in infants with postural asymmetry . 
 65 
 infants with postural asymmetry were recruited . 
 37 infants aged six to eight weeks ( mean 
 7.38 ) were found to be eligible and randomly assigned to two groups , with 19 receiving 
 vojta and 18 neurodevelopmental treatment . using a standardised and blinded video - based 
 assessment , we documented restriction in head rotation and convexity of the spine in prone 
 and supine position before and after therapy . a reduction of at least four points ( range 
 of scale 20 points ) in postural asymmetry was regarded as a clinically relevant change . 
 
 [ results ] on average a four - point reduction was achieved in both groups within eight 
 weeks . a mean difference ( pre - post ) between the groups of 2.96 points in favour of vojta 
 therapy was observed . 
 [ conclusion ] while both neurodevelopmental treatment and vojta are 
 effective in the treatment of infantile postural asymmetry and comparably well applied by 
 the parents , therapeutic effectiveness is significant greater within the vojta group . 