Real versus Perceived Improvements of Helmet Molding Therapy for the Treatment of Plagiocephaly

Abstract

Sir: Since the inception of the Back to Sleep campaign in the early 1990s, there has been a well-documented drop in the incidence of sudden infant death syndrome.1 There has also been a concomitant, well-documented rise in the number of plagiocephaly cases.2 Helmet molding therapy with orthosis has become an accepted treatment for deformational plagiocephaly. No studies have compared changes in three-dimensional objective measures in a patient's head shape with subjectively observed outcome. In this study, we investigated the actual versus perceived improvements from helmet molding therapy for deformational plagiocephaly using three-dimensional laser head scans. During the initial clinic visit, parents of 61 deformational plagiocephaly patients were asked to rate their child's head shape and ear position on a scale of 1 to 10, with 1 being abnormal and 10 representing normal. After their child's helmet molding therapy, parents were again asked to rate their child's head shape and ear position. A matched cohort of 91 children who underwent helmet molding therapy for the treatment of deformational plagiocephaly were also identified. Patients' charts were reviewed and topographic laser head scans were acquired using a STARscanner (Orthomerica, Orlando, Fla.). Laser scans were analyzed for each patient before and after helmet molding therapy. Cranial vault asymmetry index was calculated from the oblique measurements on head scans. The results of this study are presented in Figures 1 and 2.Fig. 1.: Mean actual changes in cranial vault asymmetry index and ear offset as measured by topographic laser head scans. A cranial vault asymmetry index below 3.5 is generally indicative of normal symmetry.Fig. 2.: Parents were asked to rate their child's head shape and ear position before and after helmet molding therapy. Ratings were based on a scale of 1 to 10, with 1 representing abnormal and 10 representing normal.The STARscanner provides numerous measurements on head shape; however, the cranial vault asymmetry index was selected because it normalizes for head size, allowing for comparison of head shapes independent of changes in head size attributable to age.3 In this study, helmet molding therapy resulted in a mean change in the cranial vault asymmetry index of 2.4 percent and a posttherapy mean cranial vault asymmetry index of 4.8. Although this degree of change in head shape still corresponded with noticeable asymmetry, parents viewed these results positively. After helmet molding therapy, parents rated their child's head shape as 7.88 on a scale of 1 to 10, with 1 being abnormal and 10 representing normal. Before therapy, the mean parental rating was 2.99. However, the improvements in ear position that parents perceived (7.75 following molding compared with 3.75 before therapy) were similar in magnitude to the changes in head shape despite less impressive changes in actual ear offset. The actual change in ear offset measured on topographic scans was only 0.2 mm. Although measurable asymmetry remains following helmet therapy for the correction of posterior positional plagiocephaly, appreciable and statistically significant changes are observed. These changes are viewed as significant by parents, although the objective measurements appear minimal. These data can be used in combination with pre–helmet molding head scans to inform parents of expected changes from helmet orthosis. Future longitudinal prospective studies will need to address the true utility of helmet molding therapy as compared with lack of helmet orthosis in correction of posterior positional plagiocephaly. DISCLOSURE The authors have no financial interests to disclose. Evan B. Katzel, B.A. Peter F. Koltz, M.D. Hani Sbitany, M.D. Christine Emerson, N.P. John A. Girotto, M.D. Division of Plastic and Reconstructive Surgery Department of General Surgery University of Rochester Medical Center Rochester, N.Y.