Long-term outcomes in treatment of deformational plagiocephaly and brachycephaly using helmet therapy and repositioning: a longitudinal cohort study

Use of orthotic helmets in children with positional plagiocephaly and brachycephaly: a systematic review

PURPOSE

This review aims to evaluate the scientific evidence on the efficacy and safety of cranial orthotic therapy (helmet therapy) in children under 12 months with moderate to severe posicional plagiocephaly and brachycephaly.

METHODS

A systematic review was performed in PubMed, EMBASE, and Cochrane databases. Additional searches were conducted in regulatory agency repositories for relevant notifications.

RESULTS

A total of 19 studies were included in the review, assessing various treatment modalities for PP. Repositioning therapy demonstrated effectiveness in reducing cranial asymmetry for mild to moderate cases, but several studies (class I and II evidence) indicated that it was less effective than both physical therapy and helmet use. Physical therapy, particularly manual therapy combined with caregiver counseling, showed superior outcomes for non-synostotic cranial asymmetry. Helmet therapy was consistently recommended for infants with moderate to severe deformities, with better outcomes when initiated during early infancy.

CONCLUSION

Helmet therapy is safe and effective for specific cases, especially moderate to severe PP or brachycephaly, with improved results when started early. However, available studies have methodological limitations, and the decision to use helmet therapy should be individualized, considering the severity of the deformity, patient age, and response to other treatments.

Customized 3D printed helmet in the treatment of metopic craniosynostosis in a 7-month-old infant, a case report

Introduction

Metopic craniosynostosis results in a deformed skull and hence, impacts brain growth and development. Surgery is usually applied to treat this trigonocephalic head malformation. Helmet therapy is also utilized in craniosynostosis treatment after the surgery. However, data on use of 3D printed helmets in treatment of metopic craniosynostosis is lacking. Most of the studies are published about molding helmets. Moreover, there is a lack of evidence on its clinical outcomes. Therefore, the aim of this study was to assess the use of a 3D printed helmet in treating a metopic craniosynostosis, after the endoscopy-assisted craniotomy surgical intervention.

Case description

A 7-month-old infant who was diagnosed with metopic craniosynostosis was referred from the neurosurgeon for a custom-made 3D printed helmet, after a surgical intervention. A certified orthotist has performed further assessment, scanning, designing, and printing a customized 3D printed helmet. Thereafter, fitting and delivery were successfully completed. Patient has come for two follow-up appointments, at 2 and 5 months.

Results

Five months after the initial fitting, the head shape correction and reduction of deformity were noticed through anthropometric measures. The cranial vault asymmetrical index (CVAI) decreased from 7% to 2% and the cranial vault asymmetry (CVA) reduced from 7 mm to 3 mm.

Conclusion

This case report illustrates the utilization of 3D printing technology in the treatment of metopic craniosynostosis. 3D printed helmets may offer an appropriate option for treating selective infants with metopic craniosynostosis. Thus, would introduce the 3D helmet as a following intervention for such cases after the endoscopy-assisted craniotomy surgical intervention. Further studies with a higher number of cases are compulsory to assess the effectiveness of treating metopic craniosynostosis by 3D printed helmets instead of molding helmets.

Two-Dimensional and Three-Dimensional Changes in Deformational Head Shapes During Repositioning Therapy and Cranial Remolding Treatment

Backgrounds/Objectives: The surge in deformational head shapes (DHSs) over the past 30 years has led to increased interest in comparing the treatment options of Repositioning Therapy (RT) and a Cranial Remolding Orthosis (CRO). This study investigates the amount and rate of 2D and 3D correction in infants with DHSs during these treatments. Methods: A total of 34 infants with DHSs were enrolled (RT group, n = 18; CRO group, n = 16). Infants were discharged after achieving correction or reaching 12 months of age. Two-dimensional scan/caliper measurements and three-dimensional scan measurements were collected at treatment initiation and conclusion (or 12 months of age). Results: Asymmetric infants in the RT group averaged a 2dCVAI reduction of 3.59 ± 1.57 and 3dCVAI correction of 12.17 ± 13.02 versus 4.44 ± 2.99 and 21.72 ± 15.36 correction in the CRO group (2d p = 0.6656; 3d p = 0.1417). Disproportionate infants in the RT group averaged a 2dCI reduction of 3.13% ± 2.57% and 3dCI reduction of 24.53 ± 24.01 while the CRO group averaged 5.21% ± 2.78% and 55.98 ± 25.77 (2d p = 0.0383*; 3d p = 0.0254*). Asymmetrical RT mean 2dCVAI weekly change was 0.21 ± 0.15 while CRO was 0.23 ± 0.17 (p = 0.7796). The 3dCVAI weekly change was 1.05 ± 1.55 in the RT group versus 1.17 ± 0.95 in the CRO group (p = 0.4328). Disproportionate RT mean 2dCI weekly change was 0.12 ± 0.11 while CRO was 0.23 ± 0.11 (p = 0.0440*). The 3dCI weekly change was 0.87 ± 0.91 in the RT group versus 3.02 ± 2.16 in the CRO group (p = 0.0143*). Conclusions: Results indicate that CRO treatment achieves greater total correction and rate of correction. Statistical significance was found in the treatment of disproportional DHSs, but further investigation is needed with a larger sample size.

The Caregiver Burden of Helmet Therapy following Endoscopic Strip Craniectomy: A Phenomenological Qualitative Study

INTRODUCTION

This cohort study aimed to elucidate the caregiver burden of helmet therapy (HT), following endoscopic strip craniectomy (ESC) to treat craniosynostosis, in an effort to inform clinicians and future caregivers navigating this therapeutic option.

METHODS

Fourteen caregivers of children with positional plagiocephaly (6) and craniosynostosis treated by ESC (8) undergoing HT at a single center were recruited via convenience sampling. Using a phenomenological qualitative approach, semi-structured interviews were conducted to understand the experience of HT for caregivers. Data collection and analysis were iterative and conducted until thematic saturation was reached.

RESULTS

Emerging themes revealed five domains of caregiver burden: emotional, cognitive, physical, psychosocial, and financial. No caregiver felt the therapy was too burdensome to complete. Caregivers of both groups also expressed positive aspects of HT related to support from the team, the noninvasive nature of treatment, and the outcomes of therapy. Furthermore, caregivers report overall satisfaction with the process, stating willingness to repeat the treatment with subsequent children if required.

CONCLUSION

HT is associated with five major domains of caregiver burden; however, none of the caregivers regret choosing this treatment option, nor was the burden high enough to encourage treatment cessation. This study will inform future prospective analyses that will quantify real-time caregiver burden throughout HT.

Endoscopy-Assisted Craniosynostosis Surgery without Postoperative Helmet Molding Therapy

OBJECTIVE

Endoscopy-assisted craniosynostosis surgery (EACS) yields excellent surgical outcomes by minimizing blood loss, operative time, and hospital stays. Postoperative helmet therapy (PHT), commonly employed for head shape correction, involves frequent adjustments, potential complications, and high costs. Given the rising cost of helmet therapy, reduced insurance coverage, and limited availability in low- and middle-income countries, understanding success rates without helmet use is crucial. The present study analyses the anthropometric results of the first EACS series without PHT.

METHODS

A retrospective analysis of a single-center series involving 90 consecutive patients who underwent EACS without PHT from 2012 to 2022 was conducted, with a follow-up exceeding 3 years. The study exclusively included patients with nonsyndromic isolated sagittal synostosis, with 33 meeting the criteria. Craniometric measurements were obtained from preoperative, 1-year postoperative, and the latest computed tomography scans. For isolated sagittal synostosis cases, the cephalic index (CI) was calculated (CI >75 for excellent results, CI 70-75 for good results, and <70 for poor results). Collected data encompassed patient sex, age, and follow-up time.

RESULTS

The mean age was 84.8 ± 45.3 days (2.79 ± 1.49 months) within a range of 3-172 days. The preoperative mean CI was 68 ± 42, increasing to 76 ± 6 1 year postoperatively (mean difference +8 ± 6.3; P = 0.0001). Seventy-one percent of patients achieved excellent results, 23% good (CI = 70-75), and 6% poor. Reintervention was unnecessary.

CONCLUSIONS

EACS without PHT demonstrates favorable anthropometric results, cost reduction, and simplified postoperative management.

Positional Skull Deformities and Neurodevelopmental Delay: Study on 449 Infants

OBJECTIVE

Provide data on a cross-sectional study of neurodevelopmental delays (NDD) in patients with positional skull deformities (PSD), based on severity and gender, in early childhood.

METHODS

Neurodevelopment of 449 patients with PSD, with an age range of 3 to 59 months, was assessed with Battelle Developmental Inventory (BDI) tests during and after their cranial orthotic treatment. Data obtained were compared with the anthropometric measurements taken the same day the test was made, and results were grouped by diagnosis and severity, segmented by age group, and split by gender.

RESULTS

From 3983 patients with PSD and simple craniosynostosis, 526 accepted to participate and took a total of 1261 BDI tests. Premature patients, patients with neurological diseases or congenital malformations, and tests taken when PSD had been corrected were excluded. The resulting study group was 449 children (123 girls and 326 boys) and 972 BDI tests. Ninety-five percent of tests presented significant NDD (median value, expressed in months) in one or more BDI domains; male patients present larger NDD than do female patients; largest delays were found in brachycephaly and plagiocephaly combined (-7 mo at age range 48-59 mo), scaphocephaly (-3.5 mo at age range 12-17 mo), plagiocephaly (-3.2 mo at age range 12-17 mo). No significant NDD were found in the receptive or cognitive domains.

CONCLUSION

When evaluating PSD, BDI tests, or similar, as well as mixed PSD classification should be considered. Patients with PSD should be monitored by a coordinated set of medical specialists.

A Randomized Controlled Trial of Osteopathic Manipulative Therapy to Reduce Cranial Asymmetries in Young Infants with Nonsynostotic Plagiocephaly

OBJECTIVE

This study aimed to compare the efficacy of osteopathic manipulative therapy (OMTh) versus light touch therapy (LTT) in reducing cranial asymmetries in infants with nonsynostotic plagiocephaly (NSP).

STUDY DESIGN

A prospective, parallel-group, single-center, LTT-controlled randomized clinical trial was conducted in the Department of Neonatology of Sant'Anna Hospital in Turin, Italy, from September 6, 2016 to February 20, 2020. We enrolled infants of 1 to 6 months of age with NSP, who were then randomly assigned to the study group (repositioning therapy plus six sessions of OMTh) or the control group (repositioning therapy plus six sessions of LTT). The outcome was the reduction of the oblique diameter difference index (ODDI) score <104%, which was assessed at the end of the intervention protocol (at 3 months) and at 1 year of age.

RESULTS

A total of 96 infants were randomized, 48 in the OMTh group and 48 in the LTT group, with mean ages of 3.1 versus 3.2 months, and baseline ODDI score of 110.2 versus 108.7%. In the OMTh group, a significant reduction of the ODDI score <104%, compared with the LTT group, was observed in the intension-to-treat (ITT) and per-protocol (PP) analyses. The ITT analysis revealed an ODDI score <104% in the OMTh group at 3 months (risk difference: 0.41; 95% confidence interval [CI]: 0.25-0.53; p < 0.001) and at the follow-up at 1 year of age (risk difference: 0.47; 95% CI: 0.31-0.64; p < 0.001). The PP analysis at 3 months reported a risk difference of 0.44 (95% CI: 0.27-0.60; p < 0.001), and at 1 year of age, a risk difference of 0.54 (95% CI: 0.36-0.72; p < 0.001).

CONCLUSION

In infants with NSP, a course of six OMTh sessions significantly reduced cranial asymmetries at both the 3-month and 1-year follow-up assessments, compared with LTT. This study is registered with ClinicalTrial.gov (identifier: NCT03970395; www.

CLINICALTRIALS

gov ).

KEY POINTS

· OMTh plus repositioning therapy significantly decreased the risk and severity of NSP compared with LTT.. · OMTh reduced mild and moderate cranial asymmetries.. · The role of OMTh in severe cranial asymmetries should be investigated in a multicenter trial..

Significant Factors in Cranial Remolding Orthotic Treatment of Asymmetrical Brachycephaly

This retrospective chart review focuses on determining the most effective time to begin cranial remolding orthosis (CRO) treatment for infants with asymmetrical brachycephaly. Subjects with asymmetrical brachycephaly started CRO treatment between 3 and 18 months of age. These infants had a cranial vault asymmetry index (CVAI) ≥ 3.5 and a cranial index (CI) ≥ 90. Subjects were excluded if they had any comorbidities affecting growth, dropped out of treatment, were lost to follow-up, or were noncompliant. Factors which were found to statistically influence treatment outcomes were subject initial age, initial CVAI, and initial CI. Overall, younger subjects were more likely to achieve a corrected head shape. The presence of prematurity or torticollis had statistically nonsignificant effects on the success of treatment. Initial CI was found to be a stronger predictor than initial CVAI as to which subjects achieved correction. The less severe the starting CI, the more likely the subject was to achieve full correction. The clinical understanding is that it requires more cranial growth to "round out" a full posterior skull flattening than an asymmetry. Based on the study results, infants with asymmetrical brachycephaly should be treated as early as possible to increase chances of achieving full correction of the deformity.

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

PURPOSE

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.

METHODS

We enrolled 98 infants with a diagonal difference of 7 mm 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 18 months. Sixty-eight patients were treated with repositioning and physiotherapy, whereas 30 infants received helmet therapy.

RESULTS

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.

CONCLUSION

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 cranial deformation in children: A plea for the efficacy of the cranial helmet in children

BACKGROUND

Cranial deformations have historically aroused the interest of people worldwide. One of the more debated points about positional plagiocephaly is the choice of the treatment. In this article, the senior author (CM) shares his experience on almost 30 years of use of the helmet molding therapy in children with deformation plagiocephaly.

METHODS AND POPULATION

We retrospectively and systematically reviewed the cases of 2188 patients (75% males and 25% females) presenting positional head deformity and treated between 1991 and 2013 with a cranial helmet. To assess the effectiveness of the helmet, we compared the cranial index in bilateral plagiocephaly and the Cranial Diagonals Difference (CDD) in unilateral plagiocephaly at the beginning and at the end of the treatment.

RESULTS

The cranial indexes ranged between 94.4% and 124.2% before the treatment and decreased significantly between 86.8% and 121.4% after the treatment (P<0.01). The CDD ranged between 0.3 cm and 4.5 cm with an average of 1.50±0.54 cm before the treatment and decreased significantly between 0.1 cm and 2.5 cm with an average of 0.72±0.37 cm after the treatment (P<0.01). For unilateral plagiocephaly, at the beginning of the treatment, 2.5% children presented a mild plagiocephaly, 19.6% a moderate plagiocephaly and 77.9% a severe plagiocephaly. At the end of the treatment, the deformation was classified as mild in 40.2% children, moderate in 44.3% children and severe in 15.5% children with significantly less children in the most severe subgroups (P<0.01) Facial symmetry pre-existed before the treatment in 13.7% of children. This rate was significantly increased at the end of the treatment to 66.7% (P<0.01). In only 8 cases (0.2%), the helmet therapy did not allow to obtain correct clinical results and a surgical posterior cranial remodeling was performed.

CONCLUSIONS

The results observed in this series confirms that cranial helmet is a simple and well tolerated alternative which bring satisfying results. Its success implies a good collaboration with parents and a management both by orthoptist, physiotherapist and doctor. Nevertheless, it remains many controversies in the literature concerning in particular long-term cosmetic and functional outcomes. A long-term multicentric prospective study could enable to remove doubts.

Treatment of Deformational Plagiocephaly With Physiotherapy

Non-synostotic plagiocephaly consists in an asymmetry of the skull due to mechanical forces applied in utero or postnatally: main differential diagnosis is with true synostotic asymmetry, which is caused by the premature closure of a suture. The correction of positional forms is mostly conservative, with 3 main strategies: counterpositioning, physiotherapy and helmet therapy. There is no synthesized evidence on which is the most effective. The Authors evaluate the modification of antropometric measurments before and after a pediatric physical therapy program in a sample of patients with non-synostotic skull asymmetry, in order to evaluate the improvements in the skull shape. The hypothesis being tested was that physical therapy alone could improve the antropometric measurments. The authors enrolled in this study 24 patients diagnosed of non-synostotic asymmetry, clinically and with ultrasound, referred to the Maxillo-facial Unit of Policlinico Umberto I, Rome, within 2013 and 2016. A standardized pediatric physical therapy intervention program was designed: it consisted in a combination of excercises and manipulative procedures to reduce positional preference, musculoskeletal disorders and cranial deformity. Infants received 16 sessions of physical therapy, of 40 minutes each, once a week, for four months. The Authors evaluate the variation of four anthropometric measurments, performed before and after the physical therapy program: Argenta scale, Oblique Diameter Difference Index (ODDI), Cranial Proportional Index (CPI) or Cephalic Ratio (CR), Cranial Vault Asymmetry Index (CVAI). Craniometric evaluations were extrapolated by standardized 2D digital photographs of frontal, sagittal and transverse planes, by the same physician to minimize bias. The management of positional cranial deformities is still controversially discussed and especially the effects of physiotherapy and osteopathy have been only marginally researched. Statistical analysis revealed the effectiveness of the protocol: all anthropometric measurements improved with a high rate, major in youngest children (P < 0.5) and in more severe first presentations (P < 0.05 or P < 0.01). The results suggest manipulative approach may improve the outcome in the long term follow up of cranial asymmetries.

Head Shape Retention Following Helmet Therapy for Deformational Plagiocephaly

BACKGROUND

The aim of the present study was to evaluate whether any change can be expected in the 6-month period after completing treatment with a molding helmet for deformational plagiocephaly. A retrospective review of helmeted patients from a deformational plagiocephaly clinic from May 2010 to June 2011.

METHODS

A total of 71 individuals with 6-month follow-up after completion of molding helmet treatment were identified. About 51 males and 20 females ranged in age from 2 to 10 months at initial treatment. The main outcome measure was the amount of change in head shape in the 6-month period following molding helmet therapy.

RESULTS

During the course of helmet treatment cephalic index and cranial vault asymmetry both decreased significantly (P < 0.001). Posthelmet follow-ups revealed a further decrease in cephalic index (P < 0.001). Although the cranial vault asymmetry decreased slightly between the final helmeting visit and the follow-up visit, this change was not statistically significant (P = 0.292). Controlling for other factors, continued normalization was not significantly related to helmeting duration.

CONCLUSION

Findings revealed both cephalic index and cranial vault asymmetry improved while in the helmet. During the 6 months following helmet treatment, cephalic index continued to improve; cranial vault asymmetry changed only insignificantly in this same period.

Molding Helmet Therapy for Deformational Brachycephaly

BACKGROUND

Molding helmet therapy is used for the treatment of infants with deformational brachycephaly (DB). There is a lack of rigorous outcome measures of helmet therapy in patients with DB using 3-dimensional (3D) imaging, with most reports rely on either subjective or 2-dimensional analyses. Furthermore, the longitudinal assessment of head shape improvement over the course of helmet therapy has not been documented. Our goal was to assess the outcome of molding helmet therapy using 3D surface imaging, and to document the pace of improvement during treatment.

METHODS

The head shape of 18 infants with DB who underwent orthotic molding helmet therapy was assessed. The 3D scans were obtained before treatment, during treatment, and at the end of treatment. First, we applied shape analysis techniques based on template deformation to obtain average (composite) heads of the 18 patients at the 3 time points of treatment (pretreatment, during, and posttreatment). In addition, we used 3D curvature analysis to quantify the degree of flatness at the same time points.

RESULTS

Molding helmet therapy started at 6.7 ± 0.9 months of age and lasted for 4.3 ± 0.8 months. The overall difference in the occipital contour between pretreatment and end of treatment was 6.3 ± 1.7 mm. Curvature analysis revealed that 15% of the back of the head had prehelmet marked flatness (mean curvature <5/m), which decreased to 9% at 2.5 months into treatment and 7% at the end of treatment.

CONCLUSION

Over 65% of the head shape improvement occurred during the 2.5 months of molding helmet therapy.

Head orthosis therapy in positional plagiocephaly: longitudinal 3D-investigation of long-term outcomes, compared with untreated infants and with a control group

Background

As there are very few long-term studies on the effects of head orthosis on deformational plagiocephaly (DP), we investigated the outcomes of patients, including facial symmetry and dental occlusion.

Methods

Forty-five infants with DP [cranial vault asymmetry index (CVAI) > 3.5 per cent] were divided into two groups: one treated with head orthosis (32 infants) and another without (13 infants). Another group without head asymmetry (CVAI ≤ 3.5 per cent) served as control. Using 3D-stereophotogrammetry, cranial asymmetry was analysed using symmetry-related variables [CVAI, posterior cranial asymmetry index (PCAI), and ear offset]. Data acquisition was performed before (T1) and at the end of treatment (T2), and at the age of 4 years (T3) for the treated group and at T1 and T3 for the remaining groups. Parameters of facial symmetry and dental occlusion were assessed at T3 for infants with DP.

Results

Symmetry-related variables (∆T1-T3) improved significantly more in the treated than the control group, whereas these parameters did not differ significantly between the untreated and control group. Comparing the treated and untreated groups between T1 and T3, the reduction in the asymmetry at the treated group was significantly higher for the CVAI and PCAI. In follow-up, the untreated group showed higher incidences of facial asymmetries than the treated group. Seventy-five per cent of all lateral crossbites found in patients with DP were contralateral to the posterior flattening.

Limitations

Due to ethical reasons, the investigation is a non-randomized study. Parameters of facial symmetry were only assed for the treated and untreated groups.

Conclusion

Head orthosis therapy in patients with DP leads to significantly better long-term outcomes. Facial asymmetries are more frequent in patients with DP who do not receive this treatment.

Assessing calvarial vault constriction associated with helmet therapy in deformational plagiocephaly

OBJECTIVE Deformational plagiocephaly and/or brachycephaly (DPB) is a cranial flattening frequently treated in pediatric craniofacial centers. The standard of care for DPB involves patient positioning or helmet therapy. Orthotic therapy successfully reduces cranial asymmetry, but there is concern over whether the orthotics have the potential to restrict cranial growth. Previous research addressing helmet safety was limited by lack of volume measurements and serial data. The purpose of this study was to directly compare head growth data in patients with DPB between those who underwent helmet therapy and those who received repositioning therapy. METHODS This retrospective cohort study analyzed pre- and posttherapy 3D photographs of 57 patients with DPB who had helmet therapy and a control group of 57 patients with DPB who underwent repositioning therapy. The authors determined the change in cranial vault volume and cranial circumference between each patient's photographs using 3D photogrammetry. They also computed a cubic volume calculated by multiplying anterior-posterior diameter, biparietal diameter, and height. Linear regressions were used to quantify effects of age and therapy type on these quantities. RESULTS A comparison of the following variables between the two groups yielded nonsignificant results: age at the beginning (p = 0.861) and end (p = 0.539) of therapy, therapy duration (p = 0.161), and the ratio of males to females (p = 0.689). There was no significant difference between patients who underwent helmeting versus positioning therapy with respect to change in either volume calculation or head circumference z-score (p ≥ 0.545). Pretherapy photograph age was a significant predictor of cranial growth (p ≤ 0.001), but therapy type was not predictive of the change in the study measurements (p ≤ 0.210). CONCLUSIONS The authors found no evidence that helmet therapy was associated with cranial constriction in the study population of patients with DPB. These results strengthen previous research supporting helmet safety and should allow health care providers and families to choose the appropriate therapy without concern for potential negative effects on cranial growth.