Treatment Of Positional Plagiocephaly Research Articles

Concurrent Craniosynostosis and Positional Plagiocephaly: A Scoping Review

Background: Craniosynostosis and positional plagiocephaly (PP) both lead to deformities of the infant skull. In some cases, patients may present with concurrent craniosynostosis and PP. The forces exerted on the skull by both conditions can complicate and delay correct diagnosis and require adjustments to surgical planning. Objective: The purpose of this scoping review was to identify and analyze the existing peer-reviewed literature covering the diagnosis and treatment of concurrent craniosynostosis and PP. Design: In accordance with PRISMA guidelines, PubMed, MEDLINE, and EMBASE were searched for articles discussing concurrent diagnoses of craniosynostosis and PP. Results: Out of 633 articles discovered, 7 met inclusion criteria and discussed a cumulative total of 10 patients. The average age of referral to a craniofacial team was 17 ± 22.2 months. The most common reason for referral was craniofacial asymmetry (90%, n = 9). 40% presented with unilateral coronal synostosis (n = 4), 40% with lambdoid synostosis (n = 4), 10% with sagittal synostosis (n = 1), and 10% with metopic synostosis (n = 1). The most commonly reported clinical features were occipital flattening (90%, n = 9), ear displacement (80%, n = 8), and frontal bossing (30%, n = 3). Delayed or incorrect initial diagnosis was noted in 70% (n = 7) of patients. CT scan was the most commonly employed diagnostic tool, utilized in 100% of patients. 70% of patients (n = 7) underwent surgery at an average age of 6.75 ± 3 months. Two studies, accounting for 2 patients reported, noted altering their surgical technique to account for PP in addition to the synostotic suture. Conclusions: Coincident craniosynostosis and PP can pose a complicated diagnostic and therapeutic challenge. An in-depth understanding of the most reliable physical exam findings associated with each type of craniosynostosis combined with PP will facilitate accurate diagnosis. Consideration of the concurrent forces on the skull created by craniosynostosis and PP aid in the design of a tailored surgical plan.

Helmet therapy for positional cranial deformations; a 5-year follow-up study

The aim of this study was to assess the long-term effects of helmet therapy in its use for positional cranial deformation, such as plagiocephaly and brachycephaly, by evaluating head shapes in children with a 5-year interval. These children were included at a neonatal age, with a deviating cranial shape classified as positional deformation, and received different forms of therapy, varying from none to physical and helmet therapy combined. Cranial shape was measured before and after therapy, using plagiocephalometry. Both positional plagiocephaly and positional brachycephaly decrease significantly in prevalence and severity over time (P = 0.031 and P < 0.001, respectively), with average relative reductions of 194.5% in ODDI (P = 0.001) and of 878.4% in CPI (P < 0.001). Although the decrease in ODDI and CPI did not significantly vary between treatment methods, ODDI is shown to significantly decrease in case of therapy opposed to no therapy, especially if treatment consists of both physical therapy and helmet therapy (P < 0.001). The long-term effects of therapy are therefore beneficial in the treatment of positional plagiocephaly and will increase the reduction in ODDI, especially in case of both physical and helmet therapy.

Diagnosis and treatment of positional plagiocephaly.

Positional plagiocephaly is increasing in infants. Positional plagiocephaly is an asymmetric deformation of skull due to various reasons; first birth, assisted labor, multiple pregnancy, prematurity, congenital muscular torticollis and position of head. Positional plagiocephaly can mostly be diagnosed clinically and by physical examinations. The simplest way to assess the severity of plagiocephaly is to use a diagonal caliper during physical examination, which measures the difference between the diagonal lengths on each side of the head. Plagiocephaly can be treated surgically or conservatively. Positional plagiocephaly, which is not accompanied by craniosynostosis, is treated conservatively. Conservative treatments involve a variety of treatments, such as change of positions, physiotherapy, massage therapy, and helmet therapy. Systematic approaches to clinical examination, diagnosis and treatment of positional plagiocephaly can be necessary and the age-appropriate treatment is recommended for patients with positional plagiocephaly.

A new parameter for the management of positional plagiocephaly: the size of the anterior fontanelle matters.

The rate of positional plagiocephaly has increased since guidelines for the prevention of sudden infant death have led to the recommendation of positioning infants on their back during sleeping. Therapy includes repositioning, physiotherapy, and helmet therapy. To date, there is no consensus on the treatment of positional plagiocephaly. Therefore, it was the goal of this study to compare the results of physiotherapy and helmet therapy and to investigate if the size of the anterior fontanelle can be used as an additional parameter for the indication of the helmet therapy. We enrolled 98 infants with a diagonal difference of 7mm or more and plagiocephaly classified as Argenta II or more. Patients were grouped into infants with a small anterior fontanelle (< 25mm2) and infants with a large anterior fontanelle (≥ 25mm2). The patients were observed for at least 18months. Sixty-eight patients were treated with repositioning and physiotherapy, whereas 30 infants received helmet therapy. The remolding rate was significantly higher with the helmet therapy than with physiotherapy. In patients with a small fontanelle, a lower spontaneous remolding rate was seen pointing to their lower correction potential. Especially in these patients, plagiocephaly was reduced significantly more quickly with the helmet treatment than with physiotherapy, so that they may benefit from the helmet due to their otherwise reduced spontaneous remolding capacity. The helmet therapy led to a faster reduction of the asymmetry than physiotherapy in this study. In patients with a small anterior fontanelle and therefore lower remolding potential, the helmet treatment was more effective than physiotherapy.

Positional Skull Deformities.

Especially in the first 6 months of life, skull deformities manifesting as a uni- or bilateral flattening of the occiput often give rise to questions of differential diagnosis and potential treatment. In this review, the authors summarize the current understanding of risk factors for this condition, and the current state of the relevant diagnostic assessment and options for treatment. The recommendations given in this selective review of the literature are based on current studies and on existing guidelines on the prevention of sudden infant death, the recommendations of the German Society for Pediatric Neurology (Deutsche Gesellschaft für Neuropädiatrie), and the American guidelines on the treatment of positional plagiocephaly in infancy. Pre-, peri-, and postnatal risk factors can contribute to the development of positional skull deformities. These deformities can be diagnosed and classified on the basis of their clinical features, supplemented in unclear cases by ultrasonography of the cranial sutures. The putative relationship between positional skull deformities and developmental delay is currently debated. The main preventive and therapeutic measure is parent education to foster correct positioning habits (turning of the infant to the less favored side; prone positioning on occasion when awake) and beneficial stimulation of the infant (to promote lying on the less favored side). If the range of motion of the head is limited, physiotherapy is an effective additional measure. In severe or refractory cases, a skull orthosis (splint) may be useful. The parents of children with positional skull deformities should be comprehensively informed about the necessary preventive and therapeutic measures. Treatment should be initiated early and provided in graded fashion, according to the degree of severity of the problem. Parental concern about the deformity should not be allowed to lead to a rejection of the reasonable recommendation for a supine sleeping position.

The health belief model and factors associated with adherence to treatment recommendations for positional plagiocephaly.

OBJECTIVE This study aimed to examine factors associated with adherence to recommended treatment among pediatric patients with positional skull deformity by reviewing a single-institution experience (2007-2014) with the treatment of positional plagiocephaly. METHODS A retrospective chart review was conducted. Risk factors, treatment for positional head shape deformity, and parent-reported adherence were recorded. Univariate and multivariate analyses were used to assess the impact of patient clinical and demographic characteristics on adherence. RESULTS A total of 991 patients under age 12 months were evaluated for positional skull deformity at the Texas Children's Hospital Cranial Deformity Clinic between 2007 and 2014. According to an age- and risk factor-based treatment algorithm, patients were recommended for repositioning, physical therapy, or cranial orthosis therapy or crossover from repositioning/physical therapy into cranial orthosis therapy. The patients' average chronological age at presentation was 6.2 months; 69.3% were male. The majority were white (40.7%) or Hispanic (32.6%); 38.7% had commercial insurance and 37.9% had Medicaid. The most common initial recommended treatment was repositioning or physical therapy; 85.7% of patients were adherent to the initial recommended treatment. Univariate analysis showed differences in adherence rates among subgroups. Children's families with Medicaid were less likely to be adherent to treatment recommendations (adherence rate, 80.2%). Families with commercial insurance were more likely to be adherent to the recommended treatment (89.6%). Multivariate logistic regression confirmed that factors associated with parent-reported adherence to recommended treatment included primary insurance payer, diagnosis (plagiocephaly vs brachycephaly), and the nature of the recommended treatment. Families were less likely to be adherent if they had Medicaid, a child with a diagnosis of brachycephaly, or were initially recommended for cranial orthosis therapy than families with commercial insurance, a child with a diagnosis of plagiocephaly, or an initial recommendation for repositioning or physical therapy. Factors associated with treatment completion included corrected age, insurance, diagnosis, recommended treatment, and distance to provider from patient's residence. Patients with commercial insurance (OR 1.49, 95% CI 1.10-2.02, p = 0.009), those diagnosed with both brachycephaly and plagiocephaly (OR 2.26, 95% CI 1.31-3.90, p = 0.003), those recommended for treatment with cranial orthosis (OR 4.55, 95% CI = 3.24-6.38, p < 0.001), and those living in proximity to the provider (OR 1.40, 95% CI 1.00-1.96, p = 0.047) were more likely to complete treatment. CONCLUSIONS Insurance type, degree of head shape deformity, and types of recommended treatment appear to affect rates of adherence to recommended treatments for positional skull deformation.

Impact of severity and therapy onset on helmet therapy in positional plagiocephaly

Although helmet therapy is a widely established method in the treatment of positional plagiocephaly, therapeutic regimens remain contentious, especially regarding starting age. Hence, this study investigated the impact of starting age and severity on the effectiveness of helmet therapy. A total of 213 pediatric patients treated for positional plagiocephaly with an orthotic device were enrolled in this study. Pre- and post-treatment calvarial asymmetry was measured according to the Cranial Vault Asymmetry Index (CVAI) using 3D-Photogrammetry. Patients were classified by age at which treatment was started: Group 1 was comprised of patients younger than 24 weeks (n=82); Group 2, those aged 24-32 weeks (n=75); Group 3, those aged >32 weeks (n=56). Additionally, groups were categorized by severity (mild: CVAI 3-7%; moderate: CVAI 7-12%; severe: CVAI>12%). Mean initial CVAI was 9.8%, which reduced to 5.4% after helmet treatment. Group 1 (<24 weeks) showed the highest absolute and relative rate of correction. Within the groups, severity correlated positively with relative and absolute reduction of the asymmetry. A significant difference in the reduction of the CVAI depending on age was only seen in moderate and severe cases of plagiocephaly- but not in mild plagiocephaly. The present study confirms the effectiveness of helmet therapy for positional plagiocephaly. The use of an orthotic device is an appropriate treatment option particularly in infants with severe plagiocephaly and a start of helmet therapy before the age of 6 month is advisable.

Quantifying Positional Plagiocephaly

The treatment of positional plagiocephaly is controversial. A confounding factor is the lack of a proven clinically viable measure to quantify severity and change in plagiocephaly. The use of anthropometric measurements is one proposed method. In this study, the reliability and validity for this method of measurement were investigated. Two clinicians independently recorded caliper measurements of cranial vault asymmetry (CVA) for infants referred for plagiocephaly or torticollis, and an unbiased observer recorded visual analysis scores during the same visit. CVA scores were assigned into three predetermined severity categories (normal CVA < 3 mm, mild/moderate CVA <or= 12 mm, moderate/severe CVA > 12 mm). CVA measurements and visual analysis scores were recorded for 71 and 54 infants, respectively. Intrarater reliability was established (kappa = 0.98, kappa = 0.99), but inter-rater reliability was not (kappa = 0.42). In addition, the inter-rater reliability for the severity categories based upon these measures was poor (kappa = 0.28) and failed to correlate to the visual analysis (kappa = 0.31). Development of a stable and meaningful measurement system for the extent of plagiocephaly is needed to allow scientific studies of the natural history of plagiocephaly and effectiveness of interventions.

Treatment of craniofacial asymmetry with dynamic orthotic cranioplasty.

Dynamic Orthotic Cranioplasty (DOC) was developed to treat craniofacial deformities associated with positional plagiocephaly. This investigation describes the treatment of more than 750 patients with the DOC Band since 1988. All patients undergoing DOC treatment were fit with a custom fabricated orthosis made from a plaster impression taken from the infant's head. When the orthosis was applied, the corrective pressure was directed to hold growth at the calvarial prominences and redirect symmetrical growth. A detailed medical history was obtained and anthropometric measurements were taken at start, exit, 12, 18, and 24 months follow-up. This information was recorded in a database created in Microsoft Excel. Mean length of treatment was 4.3 months with an average entrance age of 6.9 months. Analysis of anthropometric data showed significant reduction in mean cranial vault, skull base, and facial asymmetries. Correction of the more difficult skull base was documented with computed tomography. Our anthropometric and clinical observations document complete or near complete correction of asymmetry for a wide variety of head shapes. Based on the results of this investigation, we are able to support the earlier claims of our pilot study, which concluded that DOC is effective in the treatment of positional plagiocephaly.

Treatment of Positional Plagiocephaly with Dynamic Orthotic Cranioplasty

Dynamic orthotic cranioplasty (DOC) was developed to treat asymmetrical head shape of a nonsynostotic origin, which is defined by the term positional plagiocephaly. These positional deformations have been found to correlate with a number of environmental factors. Infants with positional plagiocephaly may exhibit complex multistructural asymmetry affecting the cranial vault, face, and skull base, or expression may be local in nature. Between 1988 and 1993, we performed DOC on 124 infants with positional plagiocephaly. Through clinical, anthropometric, radiographic, and statistical evaluation, we found that DOC corrects positional deformation of the cranial vault, skull base, and upper face, with no evident relapse following treatment. The design and the global approach to deformation address a wide spectrum of abnormal head shapes. The procedure is dynamic and customized, and it does not rely on passive growth alone for improvement.

Commentaries on DOC Treatment of Positional Plagiocephaly

Commentaries on DOC Treatment of Positional Plagiocephaly