An assistive device for the treatment of positional plagiocephaly

UCSQ Method Applied on 3D Photogrammetry: Non-Invasive Objective Differentiation Between Synostotic and Positional Plagiocephaly

OBJECTIVE

Objective differentiation between unilateral coronal synostosis (UCS) and positional posterior plagiocephaly (PPP) based on 3D photogrammetry according to Utrecht Cranial Shape Quantificator (UCSQ).

DESIGN

Retrospective study.

SETTING

Primary craniofacial center.

PATIENTS, PARTICIPANTS

Thirty-two unoperated patients (17 UCS; 15 PPP) (age < 1 year).

INTERVENTIONS

Extraction of variables from sinusoid curves derived using UCSQ: asymmetry ratio forehead and occiput peak, ratio of gradient forehead and occiput peak, location forehead and occiput peak.

MAIN OUTCOME MEASURE(S)

Variables, derived using 3D photogrammetry, were analyzed for differentiation between UCS and PPP.

RESULTS

Frontal peak was shifted to the right side of the head in left-sided UCS (mean x-value 207 [192-220]), and right-sided PPP (mean x-value 210 [200-216]), and to the left in right-sided UCS (mean x-value 161 [156-166]), and left-sided PPP (mean x-value 150 [144-154]). Occipital peak was significantly shifted to the right side of the head in left-sided PPP (mean x-value 338 [336-340]) and to the left in right-sided PPP (mean x-value 23 [14-32]). Mean x-value of occipital peak was 9 (354-30) in left- and 2 (350-12) in right-sided UCS. Calculated ratio of gradient of the frontal peak is, in combination with the calculated asymmetry ratio of the frontal peak, a distinctive finding.

CONCLUSIONS

UCSQ objectively captures shape of synostotic and positional plagiocephaly using 3D photogrammetry, we therefore developed a suitable method to objectively differentiate UCS from PPP using radiation-free methods.

Comparison of molding helmet therapy versus natural course in twins with nonsynostotic head deformation

This observational study aims to compare the effectiveness of helmet therapy versus natural course in twin siblings suffering from nonsynostotic head deformations. A retrospective analysis of all twin couples treated with helmet therapy between March 2009 and May 2017 at an orthopedic hospital was conducted. Inclusion criteria were me if only one twin received helmet therapy. The other twin acted as control. A classification for different head shapes was used. A total of 61 twin couples was included. Change in outcome parameters of helmet therapy and natural course differed significantly: cranial vault asymmetry (CVA) -0.66 cm vs. -0.04 cm, cranial vault asymmetry index (CVAI) -5.35% vs. -0.51% (both p < 0.001), cephalic index (CI) -3.10% vs. -1.91% (p = 0.006). Helmet therapy showed a success rate (CI < 90% and CVAI ≤7% or better) of 63.6% vs. 21.1% in children with natural course (p = 0.002). Within the limitations of the study it seems that the results of this retrospective, single-center study confirm that helmet therapy to be a reliable treatment for mild to severe positional head deformation.

Outcome analysis of molding helmet therapy using a classification for differentiation between plagiocephaly, brachycephaly and combination of both

PURPOSE

The incidence of positional head deformation has increased during the last decades. Helmet therapy has been proved to be a reliable method for the treatment of nonsynostotic skull deformities. Until today, a simple classification to differentiate between different head shapes has not been established.

MATERIALS AND METHODS

We suggest a classification system to group patients with plagiocephaly, brachycephaly, and a combination of both, using two simple values: cranial vault asymmetry (CVA), and cephalic index (CI). We further analyzed a study population of 1050 children treated with molding helmets to identify prognostic variables for better outcome within our proposed classification.

RESULTS

In all, 736 patients were male (70.10%) and 314 patients were female (29.90%). Mean improvement of cranial vault asymmetry index (CVAI) ranged from 2.94% to 7.08% (CVA 0.37 cm-0.86 cm) in subgroups of patients defined by classification and severity of deformation. In patients with brachycephaly, CI improved from 4.17% to 8.22%. Duration of therapy differed from 21 weeks to 24 weeks. Children aged 6 months or less showed greater improvement and shorter duration of therapy compared to older patients. In addition to early onset of therapy, classification and severity of deformation were significantly associated with a reduction of the deformation under therapy. There were distinct differences in outcomes between different head shapes.

CONCLUSION

Helmet therapy should be initiated early. Our analysis suggests that the proposed classification correctly identifies patients whose deformation is reduced under therapy.

LEVEL OF EVIDENCE

III.

Quantification of Plagiocephaly and Brachycephaly in Infants Using a Digital Photographic Technique

Objectives

The aims of the study were: (1) to develop a technique to quantify plagiocephaly that is safe, accurate, objective, easy to use, well tolerated, and inexpensive; and (2) to compare this method with tracings from a flexicurve ruler.

Design

A case-control study of 31 case infants recruited from outpatient plagiocephaly clinics and 29 control infants recruited from other pediatric outpatient clinics.

Participants

Infants in the study had been diagnosed with nonsynostotic plagiocephaly or brachycephaly and were between 2 and 12 months old.

Interventions

Infants’ head shapes were measured using (a) digital photographs of a head circumference band and (b) a flexicurve ruler. Flexicurve tracings were scanned, and both the digital photos and the scanned flexicurve tracings were analyzed using a custom-written computer program.

Main Outcome Measures

The oblique cranial length ratio was used to quantify cranial asymmetry, and the cephalic index was used to quantify the degree of brachycephaly.

Results

The infants tolerated the photo technique better than the flexicurve. Also, mothers preferred the photo technique. There was less within-subject variance for the photos than for the flexicurve measurements. The results suggested that an oblique cranial length ratio of ≥ 106% can define plagiocephaly and that a cephalic index of ≥ 93% can define brachycephaly.

Conclusions

The photographic technique was better accepted and more repeatable than the flexicurve measuring system. We propose that “normal” head shape is indicated in infants with both an oblique cranial length ratio of less than 106% and a cephalic index of less than 93%.

Use of external orthotic helmet therapy in positional plagiocephaly

Positional plagiocephaly is the most common type of cranial asymmetry affecting infants. We aimed to investigate the effectiveness of helmet therapy compared to no helmet therapy in treating positional plagiocephaly in infants under the age of 1year. This retrospective review was conducted in an Australian paediatric hospital and included 171 patients recruited from outpatient clinics. Only 30 patients had positional plagiocephaly scores recorded at first and final consultations while 39 patients had diagonal measurements recorded at both visits. The mean age was 7.38months at initial consultation with a mean follow-up duration of 5.85months. Those who had helmet therapy had a significantly greater reduction in diagonal difference than those who did not use helmets (p=0.011). Therefore, there may be a role for helmet therapy in the treatment of severe positional plagiocephaly.

Efficacy of passive helmet therapy for deformational plagiocephaly: report of 1050 cases

OBJECT

There has been a tremendous increase in the incidence of deformational plagiocephaly in children throughout the world. Therapeutic options include observation, active counterpositioning, external orthotics, and surgery. The current treatment in the US is highly debated, but it typically includes external orthotic helmets in patients with moderate to severe plagiocephaly presenting between 4 and 10 months of age or in children with significant comorbidities limiting passive (no-pressure) therapy. The present study was designed to evaluate 3 key issues: 1) the accuracy of the Argenta classification in defining a progressive degree of severity, 2) identification of an upper age limit when treatment is no longer effective, and 3) the effectiveness of an off-the-shelf prefabricated helmet in correcting deformational plagiocephaly.

METHODS

An institutional review board-approved retrospective study was conducted of all patients at the authors' clinic in whom deformational plagiocephaly was assessed using the Argenta classification system over a 6-year period; the patients underwent helmet therapy, and a minimum of 3 clinic visits were recorded. Inclusion criteria consisted of an Argenta Type II-V plagiocephalic deformity. Patients' conditions were categorized both by severity of the deformity and by patients' age at presentation. Statistical analysis was conducted using survival analysis.

RESULTS

There were 1050 patients included in the study. Patients with Type III, IV, and V plagiocephaly required progressively longer for deformity correction to be achieved than patients with Type II plagiocephaly (53%, 75%, and 81% longer, respectively [p < 0.0001]). This finding verified that the Argenta stratification indicated a progressive severity of deformity. No statistically significant difference in the time to correction was noted among the different age categories, which suggests that the previously held upper time limit for correction may be inaccurate. An overall correction rate to Type I plagiocephaly of 81.6% was achieved irrespective of severity and degree of the original deformity. This suggests that an inexpensive off-the-shelf molding helmet is highly effective and that expensive custom-fitted orthoses may not be necessary. The patients in the older age group (> 12 months) did not have a statistically significant longer interval to correction than the patients in the youngest age group (< 3 months). The mean length of follow-up was 6.3 months.

CONCLUSIONS

Patients treated with passive helmet therapy in the older age group (> 12 months) had an improvement in skull shape within the same treatment interval as the patients in the younger age group (< 3 months). This study supports the use of passive helmet therapy for improvement in deformational plagiocephaly in infants from birth to 18 months of age and verifies the stratification of degree of deformity used in the Argenta classification system.

Treatment of deformational plagiocephaly and torticollis using a weight distribution ring: a report of three cases

Plagiocephaly, from the Greek 'plagios' (slanting) and 'kephale' (head), refers to a condition of an infant's head deformation by forces acting upon a malleable cranium. Marked plagiocephaly causes distress and stigma towards the baby and their family and has knock-on effects with craniofacial abnormalities, visual-field defects and delay in motor skills, and may also cause developmental difficulties. Current treatment methods have multiple drawbacks. This small, illustrated case series presents a novel, cost-effective, practical first-line treatment using a horseshoe-shaped gel head ring to redistribute pressure, allowing uniform growth and reshaping. Our early experience suggests that this method represents an effective treatment option with promising results so far.

Evidence-based care of the child with deformational plagiocephaly, part II: management

Non-synostotic deformational plagiocephaly (DP) is a common condition that affects as many as one in five infants in the first 2 months of life. The purpose of this article, the second in a two-part series, is to present a synthesis of the evidence related to management of deformational plagiocephaly and an evidence-based clinical decision tool for multidisciplinary management of DP. We systematically reviewed and graded the literature on management of DP from 2000 to 2011 based on level of evidence and quality. The evidence suggests that although many cases of DP will improve over time, conservative management strategies such as repositioning, physical therapy, and cranial molding devices can safely and effectively minimize the degree of skull asymmetry when implemented in the first year of life. Outcomes are best when the timing of diagnosis and severity of asymmetry guide decision making related to interventions and referrals for DP. Prevention and management of early signs of DP are best achieved in a primary care setting, with multidisciplinary management based on the needs of the child and the goals of the family.

Predictors of severity in deformational plagiocephaly

Multiple risk factors for deformational plagiocephaly (DP) have been reported. The purpose of this study was to establish the impact of these variables on the severity of this deformity. A prospective cohort study was performed. Parents completed a standardized questionnaire assessing potential risk factors for DP before assessment. Examination included measurement of transcranial difference (TCD; ie, difference in oblique cranial lengths), evaluation of head tilt, and rotational asymmetry. Pearson correlation coefficient, 1-way analysis of variance, and 2-sample t-test were used to quantify the relationship between identified risk factors and TCD. A total of 434 patients with DP were evaluated. Male-to-female ratio was 2:1; mean gestational age was 36.5 weeks. Deformational plagiocephaly was first appreciated at a mean infant age of 6 weeks. A preexisting diagnosis of torticollis was noted in fewer than 50%. Mean TCD was 11.2 mm. Head tilt was documented in 80% of infants, and mean head rotational asymmetry was 16.4 degrees. Deformational plagiocephaly was more severe in multiple birth pregnancies (P < 0.05), males (P < 0.05), infants with a favorite head position (P < 0.01), preexamination diagnosis of torticollis (P < 0.05), and infants with a head tilt (P < 0.05). Lower gestational age (P < 0.05) and greater head rotational asymmetry (P < 0.0001) were found to correlate with DP severity. This study suggests that the relationship between the severity of DP and certain risk factors can be quantified. The presence and degree of cervical imbalance correlate strongly with deformational cranial asymmetry.

Torticollis and plagiocephaly in infancy: Therapeutic strategies

BACKGROUND

Asymmetry in infancy is a diagnosis with a large spectrum of features, expressing an abnormal shape of parts of the body or unequal postures and movements, which might be structural and/or functional, with localized or generalized expression.

PURPOSE

The purpose of the present study is to highlight different therapeutic aspects of the most occurring asymmetries in infancy: congenital muscular torticollis, positional torticollis and plagiocephaly, based on best evidence in current literature.

RESULTS

A flow chart is presented showing different pathways in therapeutic strategies, such as physical therapy, orthotic devices (helmet treatment and Dynamic Orthotic Cranioplasty) and surgery.

CONCLUSION

It is concluded that there are different views towards management on torticollis and plagiocephaly. A systematic therapeutic management to evaluate these asymmetries is indicated. The presented therapeutic flow chart might serve as a basis in order to achieve uniformity in therapeutic thinking and performance.

The role of congenital muscular torticollis in the development of deformational plagiocephaly

BACKGROUND

Numerous risk factors have been associated with the development of deformational plagiocephaly, although the etiology remains unclear. Torticollis and sternocleidomastoid imbalance are implicated, but reporting is variable. The authors sought to determine the incidence of torticollis/sternocleidomastoid imbalance in deformational plagiocephaly.

METHODS

The authors prospectively evaluated 371 infants with cranial asymmetry between 2002 and 2003. Demographic data and medical history were recorded, and a questionnaire was administered. Cranial asymmetry and head rotation were assessed, and variables were statistically analyzed.

RESULTS

Two-hundred two patients were included. Mean age at initial evaluation was 6.1 months (range, 3 to 16 months). Sixty-eight percent (n = 138) were male; 74 percent (n = 149) were flat on the right occiput; 14 percent (n = 28) were from a multiple pregnancy (24 twins, four triplets); 27 percent (n = 54) were premature; and four percent (n = 8) were syndromic. Ninety-three percent (n = 188) of parents did not notice flattening at birth. Ninety-two percent (n = 186) recalled a preferential head position after birth, and in 95 percent of these infants (n = 177 of 186) this improved with age. Only 24 percent (n = 48) of infants had been previously diagnosed or treated for torticollis. Mean cranial asymmetry was 12.5 mm (range, 8 to 25 mm). Ninety-seven percent (n = 195) of infants had head rotational asymmetry of 15 degrees or greater, with more rotation to the flat side. The mean rotational difference was 24 degrees (range 0 to 60; SD 9.8). There was a negative correlation (p = 0.004) between age and head rotational asymmetry (i.e., younger patients exhibited greater asymmetry) and a positive correlation (p = 0.043) between cranial asymmetry and head rotational asymmetry.

CONCLUSIONS

The incidence of torticollis/sternocleidomastoid imbalance in deformational plagiocephaly is underreported. Because this condition improves rapidly during early infancy, the findings may be subtle and evidenced only by a history of preferential head rotation. The major cause of deformational plagiocephaly is limited head mobility in early infancy secondary to cervical imbalance.

Comparison of a modifiable cranial cup versus repositioning and cervical stretching for the early correction of deformational posterior plagiocephaly

BACKGROUND

Deformational occipital flattening is the most common cause of abnormal head shape. Current treatment calls for repositioning and cervical stretching in infants younger than 5 months. The authors assessed the effectiveness of a modifiable cranial cup compared to repositioning and cervical stretching to correct early deformational plagiocephaly.

METHODS

This nonrandomized, prospective clinical trial used historical controls. The treatment and control groups consisted of infants, younger than 4 months, referred for deformational posterior plagiocephaly. The control children were managed by repositioning and cervical stretching exercises. An adjustable concave cranial cup was used in the treated group. Infants were examined at the initial and final visits by a single examiner. Calvarial asymmetry was measured using a large cranial caliper. Active head rotation and degree of rotational asymmetry were estimated to the nearest 10 degrees.

RESULTS

There were no statistically significant differences between the control (n = 23) and treatment groups (n = 24) with respect to gestational age at birth, age at initial visit, initial head rotational asymmetry, initial transcranial difference, final head rotational asymmetry, and age at final evaluation. Mean time between initial and final evaluation was 56.3 days for the treatment group and 61.6 days for the control group. The mean transcranial difference decreased from 11.2 to 3.5 mm in the treatment group, and from 9.0 to 8.0 mm in the control group (p = 0.000).

CONCLUSION

The cranial cup, a modifiable concave resting surface, is significantly more effective than repositioning and physical therapy for correcting early deformational plagiocephaly.

Pitfalls for the pediatrician: positional molding or craniosynostosis?

Abnormal head morphology is common among infants and often leads parents to ask their pediatricians for guidance. While the vast majority of such children development and prevent adverse neurobehavioral sequelae secondary to increased intracranial pressure or impaired cerebral growth. The coordination of a multidisciplinary team in the setting of a center experienced in the management of craniosynostosis will assure the best possible results for each patient.

Plagiocephalometry: a non-invasive method to quantify asymmetry of the skull; a reliability study

Deformational plagiocephaly (DP) in newborns and very young children is a common problem in daily practice. The intrarater and interrater reliability of plagiocephalometry (PCM), a new, non-invasive, inexpensive instrument to assess and quantify the asymmetry of the skull, is evaluated at the outpatient Department of Physical Therapy of the Bernhoven Hospital at Veghel, The Netherlands. Using a thermoplastic material to mould the outline of the infant's skull, a reproduction of the skull shape is performed on paper, allowing for accurate cephalometric measurements. Fifty children (aged 0-24 months), with or without positional preference of the head, and with or without DP, were measured three times by two separate, experienced pediatric physical therapists. Intraclass correlation coefficients (ICC) regarding the measurements of the drawn lines were all above 0.92 (intrarater reliability) and 0.90 (interrater reliability). The ICCs of the plagiocephaly indicators ear deviation (ED), antero-sinistra-antero-dextra (ASAD), postero-dextra-postero-sinistra (PDPS) and oblique diameter difference (ODD) were 0.88, 0.57, 0.92 and 0.96, respectively, for the intrarater reliability and 0.90, 0.65, 0.94 and 0.96, respectively, for the interrater reliability. The ICCs of the two indices oblique diameter difference index (ODDI) and cranial proportional index (CPI) were 0.97 and 0.96, respectively, for the intrarater reliability and 0.95 and 0.92, respectively, for the interrater reliability. The limits of agreement according to Bland Altman, comprising 95% of the differences between two measurements (2 sd), were 4.3 mm (ED), 5.9 mm (ASAD), 3.0 mm (PDPS), 3.4 mm (ODD), 2.7% (ODDI) and 4.5% (CPI) for the intrarater reliability, and 3.7 mm (ED), 5.2 mm (ASAD), 2.4 mm (PDPS), 3.3 mm (ODD), 2.9% (ODDI) and 5.8% (CPI) for the interrater reliability.

CONCLUSION

We conclude that PCM is an easy-to-apply, non-invasive and reliable measurement instrument to assess skull asymmetry with good clinical accuracy and low application costs. PCM might serve as an instrument to be used in all levels of care for children with DP, and might provide information concerning the natural course of DP, as well as the assessment of the effects of conservative treatment strategies on DP.

A Pneumatic Orthotic Cranial Molding Helmet for Correcting Positional Plagiocephaly

The objective of this study was o determine the efficacy of a newly developed pneumatic orthotic cranial molding helmet for correcting positional plagiocephaly. The design was retrospective and the setting was a tertiary care center. Subjects were all patients in whom positional plagiocephaly has been diagnosed and who have been fitted by the Orthotics and Prosthetics Department for the helmet. Diagonal cranial lengths and widths were measured at each visit. Analysis included the calculation of the ratio change in oblique diameters compared with time, patient's age, and head circumference. Seventy-five patients met inclusion criteria (50 boys, 25 girls). Patients with pneumatic orthotic cranial molding helmet therapy had significantly improved outcomes as compared with pretreatment measurements (P < or = 0.0001). The helmet did not limit cranial growth as evidenced by significant normalization of the oblique measurement ratio when compared with increasing cranial circumference and age (P = 0.0003, P < or = 0.0001, respectively). The pneumatic orthotic cranial molding helmet successfully corrects positional plagiocephaly and does not hinder cranial growth.

Magnetic resonance imaging in the evaluation of infantile torticollis

This retrospective study assessed the use of magnetic resonance imaging (MRI) in 58 infants with infantile torticollis. Eighteen patients had nonmuscular causes of torticollis (group 1); MRI identified lesions in 16 patients. Of 40 patients with a diagnosis of congenital muscular torticollis (group 2), 28 had a normal MRI. Five patients had asymmetry of the sternocleidomastoid without noticeable signal changes. Seven patients showd evidence of fibromatosis colli. Asymmetry of the posterolateral skull consistent with plagiocephaly was common. Magnetic resonance imaging did not alter treatment of group 2. Findings of compartment syndrome of sternocleidomastoid were inconsistent. Magnetic resonance imaging is not recommended for asymptomatic patients with infantile torticollis.

The other side of 'back to sleep'

IN 1992 , THE AMERICAN Academy of Pediatrics (AAP) published the recommendation that “healthy infants, when being put down for sleep, be positioned on their side or back (p.1120),” with the goal of reducing sudden infant death syndrome (SIDS).1This guideline was later amended to recommend only the “back-to-sleep” position, although side positioning is still considered safer than prone.2Prior to this recommendation, the preferred position for sleeping infants in the U.S. was prone.

New insights into craniosynostosis

Craniosynostosis is a congenital developmental disorder involving premature fusion of cranial sutures, often associated with multiple neurological manifestations. The perspective of this group of disorders has changed dramatically in the new era of molecular genetics. In the last decade a large literature with new concepts in craniosynostosis has appeared. More than 100 syndromes associated with craniosynostosis have been described, and in about a dozen, the molecular defect has been identified. Pediatric neurologists are less aware than geneticists, neurosurgeons, and craniofacial surgeons of these changes. General concepts about craniosynostosis are here presented with updates of clinical and genetic aspects of well-defined syndromes such as Apert, Crouzon, Pfeiffer, Saethre-Chotzen. Evidence of their relationship with fibroblast growth factor receptors (FGFRs) 1, 2, and 3, and with causative genes such as TWIST has been documented. New and other less common syndromes also are discussed. The differences between positional and synostotic plagiocephaly are important, as well as the cause of nonsyndromic craniosynostosis. The prognosis and neurological outcome of patients, including "benign" forms of craniosynostosis, are other important aspects. Major advances have occurred in understanding pathogenesis, diagnosis, and treatment of craniosynostosis. The role of local dura mater and apoptosis; modalities of imaging such as prenatal ultrasound and three-dimensional and spiral CT have improved the accuracy in diagnosis, and the new approaches in surgical treatment involving efficient and less invasive methods, are evidence of these advances.