Treatment of Deformational Plagiocephaly

Dan Hasso, C.O.


Deformational plagio-cephaly or skull asymmetry, is a diagnosis that is presenting itself in many pediatric orthotic clinics. For many clinics this diagnosis is unfamiliar and a course of treatment is unknown. As treatment solutions are researched, many challenges arise. The first is understanding the screening process of a new referral source. The second is working with patients who do not present with deficits that Orthotists are accustomed to working with. The third is choosing or designing an orthotic solution that meets the needs of parents and families. Finally, the clinic must realize that the treatment produces subjective results whose value can only be judged by the family.

There are three types of plagio-cephaly. (Heng p.18) Compensa-tional and synostotic plagio-cephaly result in the sutures of the skull prematurely hardening. The effect is that a child's rapidly growing brain does not have room to expand. These two types of plagiocepahly are the result of mild, uneven pressures to the skull and are often associated with torticollis. All three types of plagiocephaly clinically present themselves the same. It is critical that all patients referred for treatment be examined by physicians trained in neuro surgery or cranio-facial specialties. These specialists will accurately diagnose the type of plagiocepahly and/or the presence of syndromes that would need further medical intervention. If the diagnosis is one of deformational plagiocephaly, the physician would then evaluate the severity of the deformity and the need for orthotic management. There are no studies that define the natural history of this condition and many feel that it will spontaneously correct itself. "Spontaneous resolution certainly would ... [take] a longer than the treatment period ... and could not have been guaranteed" (Clarren l979 p. 46)

Once the physician prescribes orthotic management, the Ortho-tist must familarize himself with the parent's fears about their child's condition and their expectations of orthotic management. These fears are different from those that an Orthotist usually encounters. They do not involve questions about walking, neurological impairment or compensating for weakened structures. The questions that these parents raise are ones of perception, comfort and acceptance. It is not that the parents of a cerebral palsy patient do not question perception, comfort and acceptance, it's that they gain reassurance in their decisions from their rehabilitation teams experience and when they see their child improving in function from the moment the orthosis is received. Parents of children with deformational plagiocephally are embarking on a journey into the unknown. There are no studies to reassure them of their decision and the results are only perceived as the treatment progresses. These parents must be assured that they are doing all that they can for their child and that orthotic management will maximize the path of correction.

When designing a system to correct deformational plagiocephaly, the orthotist must consider three factors. The device must contain and limit the growth of the prominent areas of the skull, it must allow the void or flattened areas to fill out and it must retain its position on the child's head. This device takes the form of a band or a helmet. The bands or helmets may be custom made or purchased prefabricated and custom fit. The ideal would begin treatment at about six months of age. (Claren 1981 p. 93). Eighty-five percent of the brain's growth is in the first year of life. (Heng p. 18). It is this growth that the helmet or band must harness. The orthosis harnesses this growth by being worn twenty-three hours per day until the child reaches one year of age or satisfactory correction is acheived. During the time when the orthosis is removed, the head must be carefully inspected for signs of excessive pressure. If these areas are identified, the orthotist must be seen immediately for adjustment. The family should be informed not to wear the orthosis if the child is running a fever and the child should be followed at least monthly to evaluate proper fit and corrections.

When evaluating the results of treatment the clinic should bear in mind that the results are subjective and should be mainly based on the family's interpretations. Clinical measurements can give some information but they are unreliable due to the lack of consistent landmarks. Of the 25 patients that I treated last year, 13 responded to a survey on the efficacy of the orthoses they were treated with.

  1. After orthotic management was explained to you, were your initial fears;
    • Mild (8)
    • Moderate (4)
    • Severe (1)
  2. Were your initial expectations from orthotic management;
    • Low(O)
    • Moderate (9)
    • High(4)
  3. Would you consider your child's acceptance of the orthosis;
    • Easier than expected (10)
    • As expected (0)
    • Harder than expected (3)
  4. Would you consider the course of treatment;
    • Easier then expected (7)
    • As expected (5)
    • Harder than expected (1)
  5. Would you consider the results of treatment;
    • Better than expected (4)
    • As expected (7)
    • Worse than expected (2)
  6. Would you put another child through this treatment?
    • Yes (12)
    • No(l)

The results of this survey indicate that orthotic management can have a positive effect on children with this condition. It also indicates that when parents are presented with the orthotic management plan, that they have a reasonable understanding for what the treatment will entail and what results it can produce. Finally it indicates that orthotic management may not be the best choice for all families and that the strongest efforts must be made to predict if the treatment will be a good option.

Scottish Rite Hospital, Atlanta GA.

References:
Clarren, Sterling, "Plagiocephaly and torticollis: Etiology, natural history and helmet treatment", The Journal of Pediatrics, Volume 96, Number 1, pp. 92-95, January 1981.
Clarren, S.K., Smith, D.W. and Hanson, J.W., "Helmet treatment for plagiocephaly and congenital muscular torticollis", The Journal of Pediatrics, volume 94, number 1, pp. 43-46, January 1979.
Heng, Mary, "The miracle of the mother network", Healthplex, Volume 10 Issue 1, pp. 17-19,1994.
Heng, Mary," Cassandra isn't a new member of the hockey team", Healthplex, Volume 9 Issue 2 pp. 20-21, 1993.
Ripley, C.E., Pomatto, J., Beals, S.P. Jojaniac, E.F., Manwaring, K.H. and Moss, S.D., "Treatment of positional plagiocephaly with dynamic orthotic cranioplasy, The Journal of Cranifacial Surgery, volume 5, number 3, pp. 150-159, July 1994.