Plagiocephaly Best Practice in Physiotherapy Jan 31 07

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Conservative Management of Infants with Positional Plagiocephaly: the

best evidence for physiotherapy practice

Prepared for Queen Alexandra Centre for Children’s Health

2400 Arbutus RoadVictoria, BC V! "V#

$anuar% &" 200#

Prepared by: Lynn Purves and Joan Glover

Preface

'he Queen Alexandra Centre’s ()idence Based Practice *roup +(BP* -as

established as part of a one %ear pilot pro.ect to de)elop a fra/e-or for ans-erin1 clinicall% rele)ant uestions for 3peech and an1ua1e

Patholo1ists, 5ccupational 'herapists and Ph%siotherapists based on the best

a)ailable research, and to appl% this fra/e-or to an initial set of the /ost

pressin1 clinical issues facin1 these staeholders6

'he 1oal is to de)elop a /odel for the collection and anal%sis of rele)ant

scientific literature, includin1 e)idence7based /edicine re)ie-s, clinical

1uidelines, and research articles, to deter/ine the best a)ailable treat/ent

options6

Queen Alexandra Centre’s ()idence Based Practice *roup includes8

• 3usan */itrosi, 3enior 5ccupational 'herapist

• Phil Har/uth, 3enior 3peech and an1ua1e Patholo1ist and

Coordinator of the 3-allo-in1 9isorders Clinic

•

%nn Pur)es, 3enior Ph%siotherapist and Coordinator of the !euro/uscular Clinic

• $oan *lo)er, Resource Ph%siotherapist, (arl% :nter)ention

Pro1ra/

• Victoria ;orb%7<uchs, Resource 5ccupational 'herapist,

(arl% :nter)ention Pro1ra/



'hans 1o to8

Corinne 9ulber1, Ph9 =PH, Research Consultant, V:HA

Cliff Cornish, V:HA ibrar%

Overview:

Pla1iocephal% /eans >se-ed head6? :t is a result of /echanical factors,

-hich, o)er ti/e, either in utero, at birth or postnatall%, alter the sull shape6

=ost often positional pla1iocephal% is perpetuated b% postnatal positionin1

of the infant on the sa/e part of his head e)er% ni1ht so that a flattened spot

de)elops6 'his flat spot tends to -orsen as the head tends to /ore easil%

co/e to rest on the flattened spot6

'%picall% an infant -ith

pla1iocephal% -ill de)elop a

parallelo1ra/ shaped sull -ith

ipsilateral occipital flattenin1 and

frontal bossin16 'he ipsilateral ear

is anteriorl% placed6 'here is

contralateral occipital bossin16

'here /a% be chee, /andible and

e%e as%//etr%6 9ia1ra/ and

description fro/ osee +"6

'he >Bac to 3leep? ca/pai1n

-as initiated in "@@2 in the 636

and "@@& in Canada as

epide/iolo1ical studies had found

that infants -ho slept on their

sto/achs had an ""6# ti/es hi1her ris for sudden infant death s%ndro/e

+3:936 :n the 636 the pre)alence of prone infant sleepin1 decreased fro/

#0 in "@@2 to "06 in "@@#6 'he incidence 5f 3:93 -as reduced fro/

26DE"000 in "@D to "E"000 in "@@6 'he incidence of pla1iocephal% has

increased fro/ "E&00 to "ED0 bet-een "@#4 and "@@D+2



Pla1iocephal% has been a fairl% ne- reason for referral to ph%siotherap% at

QACCH, onl% occurrin1 o)er the past & to 4 %ears, but -ith a 1raduall%

increasin1 rate of referral to ph%siotherap%6 Ph%siotherapists in the (arl%

:nter)ention Pro1ra//e ha)e been seein1 infor/ation re1ardin1 best

conser)ati)e /ana1e/ent of these clients, as it is a ne- condition to /ost of us6

Obectives:

'o re)ie- the e)idence for the best practice in the conser)ati)e

/ana1e/ent of infants -ith pla1iocephal%6

'o de)elop 1uidelines for ph%siotherap% /ana1e/ent of infants -ith

pla1iocephal% -ho are seen throu1h the (arl% :nter)ention Pro1ra/ at

Queen Alexandra Centre (nsure no-led1e transfer to clinicians at QACCH -orin1 -ith

infants -ith pla1iocephal%

Methods

9atabases -ere searched for searched for references related to pla1iocephal%

5R positional pla1iocephal% 5R nons%nostotic pla1iocephal% A!9

treat/ent 5R ph%siotherap% 5R hel/et therap% 5R /ana1e/ent6 'he

Cochrane 9atabase of 3%ste/atic Re)ie-s, 'he Cochrane Re1ister of Controlled 'rials and the 9atabase of Re)ie-s of (ffecti)eness -ere

searched first to find an% s%ste/atic re)ie-s of the literature related to

pla1iocephal%6 Pub =ed, =edline, P(9ro +Ph%siotherap% ()idence

9atabase and the ACP $ournal Club -ere subseuentl% searched for the

sa/e topics6 'he last iterature search -as conducted on !o) 200D6'-o

ph%siotherapists re)ie-ed the resultin1 abstracts of articles obtained and

separatel% chose those that /i1ht be pertinent to our uest6 :f there -as

disa1ree/ent, -e reuested and re)ie-ed the article6

C5!3(RVA':V( =A!A*(=(!'7'he best e)idence8



Bialocero-si et al +& conducted a s%ste/atic re)ie- of all research

reports related to conser)ati)e treat/ent of pla1iocephal% published bet-een

$anuar% "@& and 9ec 200&6 'his s%ste/atic re)ie- -as assessed b% &

independent raters fro/ the QACCH ()idence Based Practice 1roupF t-o

ph%siotherapists and one research consultant, usin1 the >ni)ersit% of *las1o-F Critical Appraisal Checlist for a 3%ste/atic Re)ie-? +4 'his

re)ie- scored "0E"0 in fulfillin1 the criteria of a 1ood s%ste/atic re)ie-

Bialocero-si et al conducted a ri1orous search of all research papers

related to pla1iocephal% and included those -hich used a uantitati)e

desi1n, in)esti1ated conser)ati)e /ana1e/ent of positional pla1iocephal%,

and ha)e reported results for children less than one %ear of a1e6 'he%

included "D studies in their re)ie-6 !one of these studies -ere rando/iGedcontrolled trials +le)el : le)el of e)idence but -ere rather case series or

co/parison 1roups, not rando/l% assi1ned +le)el ::: or :V6 'he% report

>considerable biases -ere present -ithin each stud%?6

'he% also assessed the ualit% of each stud% usin1 the criterion de)eloped b%

a- et al + and found poor to /oderate ualit% -ith an a)era1e score of

#E"D6 Please see tables at end of report for the author’s table presentin1 the

studies included

'he conser)ati)e treat/ents in)esti1ated included counter7positionin1, -ith

or -ithout ph%siotherap%, ph%siotherap%, and hel/et therap%6

Counter7positionin1 in)ol)es the acti)e repositionin1 of the child durin1

sleep and pla% to appl% pressure to the pro/inent areas of the sull and

reduce the forces on the flattened area6 Ph%siotherap% in)ol)ed stretchin1 of

the ti1ht cer)ical /usculature and pro/otion of positions to reduce forces on

the flattened area of the sull6 9uration, freuenc% and specific techniues

used -ere not described6 Hel/et therap% included d%na/ic orthotics and

headbands, -hich appl% pressure to abnor/al sull pro/inence and relief

-here sull 1ro-th is reuired6 'he% note that the findin1s of these studies

/ust be interpreted -ith caution due to the desi1ns and ualities of the

studies6



*raha/ and ucas su11est that counter positionin1 can be effecti)e in

infants -ith /ild pla1iocephal%6 Hel/et therap% /a% be effecti)e in

reducin1 pla1iocephal%, particularl% in infants -ith /oderate to se)ere

pla1iocephal%6

'here is so/e discrepanc% in the results of studies that co/pared counter

positionin1 E7 ph%siotherap% -ith hel/ettin16 =ullien and Vles concluded

hel/ets are /ore effecti)e because the% correct /ore rapidl%6 =oss and

$alaluddin concluded that counter positionin1 is as effecti)e as hel/ets6

'he /a.or -eaness of these studies has been the lac of control 1roups or

rando/iGation into 1roups6

'here /a% ha)e been so/e discrepancies bet-een studies87A1e at -hich treat/ent started

7Ho- pla1iocephal% -as assessed Edia1nosed

73e)erit%

7:nco/plete data on children lost to follo- up

7Accurac% and reliabilit% of outco/e /easures

3o/e of the conclusions the authors of this s%ste/atic present include8

Counter positionin1 7 ph%siotherap% or hel/et therap% /a% ha)e

beneficial results at reducin1 positional pla1iocephal%

'here is a need for a standard outco/e /easure -ith e)idence of

reliabilit% and )alidit% so that there can be confidence that the /a1nitude

of chan1e is 1reater than the /ar1in of error6

As pla1iocephal% is a cos/etic proble/, the outco/e /easure should

reflect the parent’s perception of cos/etic appearance6

'-o ualitati)e clinical trials re the conser)ati)e /ana1e/ent of

pla1iocephal% subseuent to Bialocero-si’s s%ste/atic re)ie- -ere found

in our literature search6 '-o ph%siotherapists e)aluated these later clinical

trials not been, usin1 the sa/e Critical Re)ie- <or/7Quantitati)e 3tudies



+ that -as used in their re)ie- as -ell as 1radin1 the e)els of ()idence

+D6

*raha/ et al +2 published a stud% in 200 that -as not included in the

Bialocero-si re)ie-6 'he% e)aluated 2@ babies referred for headas%//etr%6 "#D infants -ere treated -ith repositionin1, "@ -ith hel/ets

and &# -ith initial repositionin1 follo-ed b% hel/et therap%6 'he% report

that all infants -ith pla1iocephal% had so/e associated torticollis and -ere

treated -ith ph%siotherap%, not specificall% described, and follo-ed at

/onthl% inter)als6 Hel/et therap% -as used for infants D /onths or older

-ith cranial dia1onal difference of /ore that " c/ as this -as their pre)ious

standard of care6 'here -as not rando/ allocation to treat/ent 1roups in

these cases6 'he% state >/ost authors a1ree that if there is little i/pro)e/entin head shape in %oun1 infants bein1 treated -ith repositionin1 and

ph%siotherap%, orthotic therap% should be initiated -hile there is still enou1h

residual head 1ro-th to allo- for correction6?

'his stud% -as e)aluated b% t-o ph%siotherapists in the e)idence based

practice 1roup, usin1 the critical re)ie- for/ for uantitati)e studies,

de)eloped b% a- + and scored @E"D indicatin1 onl% /oderate ualit% of

the report, so conclusions /ust be interpreted -ith caution6 'his stud% -as

le)el ::: in le)els of e)idence6

*raha/ et al concluded that both repositionin1 and hel/et therap% -or

-hen used appropriatel% -ith nec ph%siotherap%6 'he% found that infants

treated -ith orthotics had a final sull shape closer to nor/al and that

orthotic therap% -as /ore effecti)e in reducin1 sull as%//etr% +D"

reduction co/pared to repositionin1 +2 reduction and that earl%

orthotics +before /onths -ere /ore effecti)e that later orthotics +after

/onths

'he% did note so/e of the li/itations of their stud% includin1 the lac of

rando/ assi1n/ent to stud% 1roups and the inabilit% to uantif% ho- s/all,

statisticall% si1nificant differences in outco/e /i1ht relate to parent

perception of cos/etic si1nificance6



:n /an% of the clinical trials included in the re)ie- b% Bialocero-si and

in the trial b% *raha/, the infants -ith /oderate to se)ere pla1iocephal%

-ere not rando/l% assi1ned to hel/ettin1 or repositionin1 1roups because

of the current standard practice at that centre that older, /ore se)ere babiesshould ha)e hel/et therap%6 :n se)eral studies so/e infants -ere initiall%

treated -ith counter positionin1 but /o)ed into an orthotics stud% 1roup if

i/pro)e/ent -as not sufficient6 :n these cases this is the result of clinical

experience at that tertiar% centres treatin1 pla1iocephal% +2, #,

*raha/ et al reco//end that if there is /ore than " c/6 difference in

dia1onal distances, /easured b% calipers, at D /onths of a1e, orthotic

therap% can be effecti)e6 +#

Also subseuent to the s%ste/atic re)ie- b% Bialocero-si8 Bruner et al

+ follo-ed D@ children -ith pla1iocephal% -ho under-ent soft shell

hel/et therap%6 3ull as%//etr% -as /easured usin1 co/puter

to/o1raph%, before therap% and D /onths after therap% be1an6 *enerall% the

infants -ore the hel/ets full ti/e for "2 -ees then at ni1ht onl%6 'he

a)era1e duration of treat/ent -as # /onths6 5nl% &4 infants co/pleted the

stud%6 of these sub.ects -ere co/pliant -ith hel/et therap% and in the

co/pliant patients, a &D to &@ reduction in cranial as%//etr% -as

found6 He concludes that hel/et therap% is effecti)e and cost effecti)e at

reducin1 cranial as%//etr%6 Althou1h Bruner et al used a /ore ad)anced

/easure/ent, co/puter to/o1raph%, -hich is less liel% to ha)e error or

bias that the /anual /easure/ents used in other studies, al/ost half of the

sub.ects -ere lost to follo- up -ith no reasons 1i)en and results -ere not

reported on the 4 sub.ects -ho co/pleted the trial but -ere .ud1ed to ha)e

poor co/pliance -ith hel/et therap%6

'his stud% -as e)aluated b% t-o ph%siotherapists in the e)idence based

practice 1roup, usin1 the critical re)ie- for/ for uantitati)e studies,

de)eloped b% a- + and scored E"D indicatin1 onl% poor to /oderate

ualit% of stud% desi1n and le)el :V le)el of e)idence, so results /ust be

interpreted -ith caution6



o)eda% +# reported that infants -ho fail to sho- i/pro)e/ent -ith

conser)ati)e /ana1e/ent are potential candidates for cranial /oldin1

orthotics6 'he orthotics tae ad)anta1e of the fact that of sull 1ro-th

occurs durin1 the first %ear of life6 He concluded, > A co/bination of the t-o/ana1e/ent re1i/ens could be the /ost effecti)e /ana1e/ent of

pla1iocephal%6?

'he A/erican Acade/% of Pediatrics, clinical 1uidelines on the pre)ention

and /ana1e/ent of positional sull defor/ities in infants +@ cites the

conflictin1 results fro/ different studies co/parin1 repositionin1 and nec

exercises and hel/et therap% and concludes that the use of hel/ets see/s to

be beneficial pri/aril% -hen there has been a lac of response to /echanicalad.ust/ents and exercise6

Clinical !otes re counter positionin1

*raha/ et al +2 e/phasiGed the need to position infants &E4 turned to the

side, -ith the head restin1 on the occipital pro/inence and that it is

i/portant that parents be -arned not to si/pl% position the child on the side

of their head, as it does not correct cranial as%//etr% and the child is in

dan1er of rollin1 to prone6 'he% reco//end the use of positionin1 de)ices

that allo- a bab% to be positioned in the I turn6 Je are li/ited in our

practice as this is contrar% to the reco//endations of the Canadian

Paediatric 3ociet% -ho reco//end that products to /aintain the sleep

position not be used and that soft beddin1 such as pillo-s, co/forters,

bu/per pads and la/bsin or si/ilar products is ept out of the sleep

en)iron/ent6 =ost authors e/phasiGe the need to position the infant so that

/attress pressures shift to the non7flattened aspect of the occipital sull, not

side l%in16

3e)eral authors /ention that counter positionin1 /a% be less effecti)e after

about D /onths of a1e because a t%pical infant is acti)el% /o)in1 enou1h

that it is difficult to /aintain pressure on the non7flattened occiput6



:n o)eda% and de Chalain’s stud% +# care1i)ers are told to ne)er allo- the

infant to sleep on the flat spot on his head6 Roo/s are to be rearran1ed so

that >interest? is not on the flat side +attention to doors, -indo-, /obiles,

coloured ob.ects6 'he position of the car seat in the car /a% reuire

/odification6 !ursin1 and carr%in1 positions /a% also be ad.usted6 Acti)ehead turnin1 acti)ities -ere incorporated into pla%6 o)eda% and Chalain

-ere )er% specific about all of these instructions to care1i)ers and -ere also

a/on1 the studies included in Bialocero-si’s re)ie- that found counter

positionin1 had a sli1htl% better outco/e than hel/et therap% althou1h the

/ana1e/ent period -as approxi/atel% & ti/es lon1er6

*raha/ et al +2 also stron1l% reco//ended earl%, super)ised tu//%7ti/e

to pro/ote nec ran1e of /otion and prone sill de)elop/ent as -ell ascorrectin1 positional preference6

Clinical notes re hel/ettin18

o)eda% +# reported se)eral concerns that arose durin1 hel/ettin18

7Proper fit -as difficult and the% often had to be /odified /an% ti/es

7Hel/ets beca/e hot and s-eat% and caused so/e heat rashes

7At ti/es there -as sin in.ur% o)er pressure points

75lder infants could undo the chinstrap and re/o)e hel/et

7Brach%cephalic children -ere /ore difficult to hel/et as the hel/et

tended to slip

73o/e infants did not accept the hel/et and beca/e distressed6 'his

-as /ore co//on in older infants

73o/e care1i)ers -ere e/barrassed b% the hel/et6

=an% authors /ention the cost of hel/ets bein1 a si1nificant factor in

the decision to pro)ide hel/ettin1, particularl% -hen the stud% outco/es do

not clearl% fa)our hel/ets o)er counter positionin1 and exercise +@

*raha/ co/pared the results of infants -ho started hel/et therap%

before /onths -ith those -ho be1an -hen /ore than /onths and found



that the final as%//etr% -as 1reater and the percenta1e of chan1e -as less

in the older 1roup +2)s6 D

'eich1raeber also noted that in infants -ith brach%cephal%, hel/et

therap% -as less effecti)e because of the difficult% fittin1 it so that it doesn’tshift6 suall% the occiput is a strate1ic pro/inence for anchorin1 the

orthotic6 +"0

'eich1raeber also found no statisticall% si1nificant difference in the

results of hel/ettin1 based on a1e of infants -ho all be1an hel/et therap%

before one %ear of a1e6 +"0

A335C:A'(9 '5R':C5:3

osee +" reported associated contralateral torticollis in & to 20 of children

-ith pla1iocephal%6

o)eda% +# reported that torticollis is associated -ith D4 to 4 of infants

-ho de)elop positional pla1iocephal%6 He too notes that con1enital 3C=

ti1htness /a% be a factor in the de)elop/ent of torticollis, but /a% also be

secondar% to persistent positional preference6

Persin1 +@ notes that torticollis coexistin1 -ith pla1iocephal% /a% be the

conseuence of he/orrha1e and subseuent scarrin1 -ithin the stern7cleido7

/astoid /uscle +3C= or that it /a% be /uscle shortenin1 caused b%

persistent unidirectional positionin1 and li/ited nec /otion6

*raha/ +2 reported that all infants -ith positional pla1iocephal% had so/e

de1ree of associated torticollis6 All of the infants in their stud% recei)ed

ph%siotherap%, -hether the% -ere in the counter positionin1 or hel/et

therap% 1roup6

Van Vli//eren +"" differentiates bet-een con1enital /uscular torticollis

-ith unilateral contracture of 3C= and positional torticollis due to persistent

positional preference6 He also re)ie-s specific ph%siotherap% procedures for





the% -ere not specificall% clinical trials of conser)ati)e treat/ent6 'his

includes infor/ation on8

!atural histor% of Pla1iocephal%

:ncidence and deter/inants of pla1iocephal%

3i/ple assess/ent of pla1iocephal% +/ethods -ithin our scope of practiceEtechnolo1icall% a)ailable to us

Associated proble/s such as )isual and neurode)elop/ental dela%s

'his infor/ation has been included if the infor/ation included /i1ht

influence practice at Queen Alexandra Centre6

:!C:9(!C(

'here are )ar%in1 esti/ates of the ne- incidence of pla1iocephal%6 Persin1

+@ notes a six7fold increase in the incidence since "@@2, -hen bac to sleep

-as introduced in the 636 *raha/ su11ests an incidence of " in D06 A

prospecti)e stud% in the !etherlands +"4 of o)er #000 ne-borns found the

incidence of positional preference to be 626

5f these children 4 de/onstrated as%//etric flattenin1 of the occiput,

2" of the forehead at the second assess/ent bet-een a1e 2 and & +264 of

all children

:t has been su11ested b% Hutchinson +" that the actual pre)alence is

unno-n but that as a result of increased a-areness it is bein1 reco1niGed

/ore freuentl%

9('(R=:!A!'3

osee et al +" re)ie-ed so/e of the reported de/o1raphics fro/ different

centres8

7Predo/inatel% /ale +D0 to#0

7Predo/inantl% ri1ht sided +# to#0

7:ncreased incidence in -hite children +@ -hite, 2 African

A/erican, 2 Hispanic6 +He su11ests this /a% be because >Bac to 3leep?

-as /ore readil% e/braced b% the -hite population

7:ncreased incidence is associated -ith /ultiparit% + to "264

7Possibl% incidence associated -ith pre/aturit% +0 to "6D



Jhen Hutchinson et al +"D co/pared "00 infants -ith pla1iocephal% -ith

@4 /atched controls the% found the% -ere /ore liel% /ale, pre/ature, not

to ha)e head position )aried, not to ha)e spent /ore than /inutes a da% in

prone and sleep in supine6 'he% -ere /ore liel% to be percei)ed b% their /other as less acti)e, to ha)e a de)elop/ental dela% and to ha)e de)eloped

a preferred head orientation b% D -ees of a1e6

Boore/an et al +"4 found a hi1her pre)alence of positional preference in

first7born children, /ales, and infants born after breech deli)er% or

pre/aturel%6 'he% also found increased incidence in infants -ho -ere

al-a%s bottle fed -ith either the left or ri1ht hand6

PR(V(!':5!8

=ost authors stress the i/portance of pre)ention in reducin1 this >ne-

epide/ic? of pla1iocephal% +","","4,","D,"#,2#,2 All a1ree that

pre)entati)e counselin1 to parents of ne-borns should include the

i/portance of alternatin1 head position and encoura1in1 tu//% ti/e for

pla% for /ore than /inutes a da% -hen the infant is a-ae and obser)ed

=an% include chan1in1 orientation to outside acti)it% +e616 Chan1in1 -hich

end of the crib the infants head is at and /ini/iGin1 ti/e in car seats

+unless in a )ehicle or other seats such as bounc% seats and encoura1in1

upri1ht cuddle ti/e +@,"#,"4

:t should be noted that so/e earl% -or on pla1iocephal%, at ti/es,

reco//ended side l%in1 to sleep ho-e)er as of 200& the A/erican

Acade/% of Pediatrics no lon1er reco1niGed side l%in1 as a safe sleep

position6 Hutchinson +"D reports that supine sleepin1 in the %oun1 infant is

D ti/es safer than prone sleepin1 and t-ice as safe as side sleepin1

concernin1 3:93 incidence6

!A'RA H:3'5RK8



o)eda% reported that /an% health professionals tell parents of infants -ith

pla1iocephal% that it -ill dissipate -ith ti/e and thou1h this /a% happen

occasionall%, for the /a.orit% of children there -ill be so/e per/anent

residual defor/ation6 'his /a% be /ild or ca/oufla1ed b% hair6 +#

*raha/ reported that the defor/it% persisted in al/ost "E& of cases -hen

reexa/ined at a1e 2 to &6+2

osee et al report that in their clinical experience, si1nificant as%//etr% at D

/onths of a1e does not self correct -ithout treat/ent6 +"

Boere7Boonea/p et al +"4, in a prospecti)e stud% of o)er #000 ne-borns,

found positional preference in 62 of infants6 5f those 264 still had so/eflattenin1 of the sull or restricted ran1e of /otion bet-een a1es 2 to &

Hutchinson al +" follo-ed 200 nor/al infants recruited at birth and found

the hi1hest pre)alence of positional pla1iocephal% at 4 /onths of a1e +"@6

5)erall, 2@6 of infants de/onstrated pla1iocephal% or brachiocephal% at

so/e sta1e durin1 the follo- up, /ostl% occurrin1 at D -ees and 4 /onths

follo- ups6 =ost cases i/pro)ed -ith ti/e so that pre)alence -as & at 2

%ears of a1e6

A33(33=(!'8 'he A/erican Acade/% of Pediatricians reco//ends that

the assess/ent of pla1iocephal% reuires inspection fro/ se)eral an1les6 +@

:t is necessar% to loo do-n at the top of the head and note8

Position of ears

Position of chees

5ccipital flattenin1Ebossin1

<rontalEparietal bossin1

<ro/ face on one should note8

Head tilt

Contralateral facial flattenin1

'hen obser)e acti)e ran1e of /otion of the nec6



=ost authors include the abo)e inspection criteria in the assess/ent of

pla1iocephal%6 Hutchinson +" specified the need to test passi)e nec

rotation in supine at ne-born and 4 /onths of a1e, then fro/ D /onths he

obser)ed acti)e nec rotation -ith the child )isuall% follo-in1 a to% -hile

seated on =other’s lap6Cranial 'echnolo1ies offers an assess/ent for/, -hich allo-s a fra/e-or

for the assess/ent of all but the nec /o)e/ents, reco//ended abo)e6

:n prospecti)e studies in the !etherlands +"4 assess/ent for the presence

of /uscular torticollis, scoliosis, li/ited hip abduction or ano/alies of the

feet +club feet pes adductus -ere included in their inspection6

=ost authors tal about the i/portance of parent perception of cos/etic

se)erit% of pla1iocephal% as part of the assess/ent procedure and

assess/ent of effecti)eness of treat/ent6 +&,2,""

:t is be%ond the scope of ph%siotherap% to dia1nose s%nostosisF ho-e)er,

ph%siotherapists treatin1 infants -ith pla1iocephal% should be alert to the

possibilit% of la/boidal s%nostosis6 :n la/boidal s%nostosis the pattern of

occipital flattenin1 and ipsilateral frontal bossin1 is the sa/e as in positional

pla1iocephal% thou1h frontal bossin1 is less6 :n la/boidal s%nostosis,

ho-e)er the ear on the side of the flattened occiput is t%picall% posterior and

inferior6 'he posterior basal sull /a% be tilted and the /astoid pro/inent6

<acial as%//etr% tends to be /ini/al +@6 An% concern re pre/ature fusion

or abnor/alit% of an% of the sutures should be referred bac to the child’s

ph%sician6



9ia1ra/ of positional pla1iocephal% differentiated fro/ la/boidal

s%nostosis8 fro/ osee +"

Quantitati)e assess/ent of pla1iocephal% is an area of concern in the

literature, particularl% in the clinical trials6 +& 'here is no standard toolaccepted6 3o/e authors reco//end co/puted to/o1raph% techniues but

these ha)e been criticiGed because of cost, exposure to radiation, and riss

fro/ anaesthetic +#

Hutchinson et al +" ha)e de)eloped a head shape /easurin1 techniue,

Heads p, -hich in)ol)es an elastic head circu/ference band, -ith slidin1

/arers for ears and nose -hich is di1itall% photo1raphed fro/ abo)e

=ortenson and 3teinbo +" conducted a stud% to in)esti1ate the reliabilit%

and )alidit% of anthropo/etric /easure/ents usin1 calipers6 5ne exa/iner

-as able to establish intra7rater reliabilit%6 'he other -as not6 'he% -ere not

able to establish inter7rater reliabilit%, nor -ere the% able to correlate their

nu/erical /easure/ents of cranial )ault as%//etr% -ith their )isual



anal%sis of se)erit% +/ild, /oderate and se)ere6 'hese authors uestion

-hether cranial )ault as%//etr%, thou1h the best /easure of cranial

as%//etr%, is the /ost si1nificant /easure/ent in uantif%in1 outco/e that

is rele)ant6 Pla1iocephal% is predo/inantl% a cos/etic concern, so there /a%

be assess/ents that are /ore /eanin1ful cos/eticall%F for exa/ple face,side and bac )ie-s /a% be /ore i/portant, perceptuall%, than top do-n6

o)eda% +# de)eloped an assess/ent /ethod, usin1 an artist’s flexicur)e to

obtain a circu/ferential head tracin1, -hich the% used to calculate a cranial

)ault as%//etr% index6 'he% calculated their relati)e error as bein1 ±

A335C:A'(9 PR5B(=3

Van Vli//eren +"" reports that localiGed as%//etr%, such as pla1iocephal%

and torticollis, /a% be associated -ith /ore 1eneraliGed as%//etr%,

includin1 head and face, scoliosis, rib ca1e /oldin1, pel)ic obliuit% as -ell

as hip and foot as%//etr%6 o)eda% reports that con1enital hip dislocation,

scoliosis, 3C= tu/ours and pro/inent ears /a% be associated -ith

pla1iocephal%

osee reported conflictin1 data re1ardin1 craniofacial chan1es affectin1 .a-

function, )isual disturbances +strabis/us and asti1/atis/, neurolo1ical

de)elop/ent and possibl% auditor% function6

3iato-si et al +@ perfor/ed )isual field testin1 on 40 children -ith

positional pla1iocephal%6 'he% found & of these children had constriction

of one or /ore )isual fields6 'his is statisticall% different fro/ pre)iousl%

established nor/ati)e data6 'he% found that lateralit% of field defect -as not

related to the side of flattenin16 'here -as a correlation bet-een se)erit% of

)isual defect and se)erit% of pla1iocephal% but it -as not statisticall%

si1nificant6

A335C:A'(9 9(V(5P=(!'A PR5B(=3



3e)eral articles discussed the possibilit% of associated neurode)elop/ental

proble/s -ith children -ith defor/ational pla1iocephal% +9P6 =iller et al

+20 report that /ales -ith pla1iocephal% at birth are a hi1h7ris 1roup for

subtle de)elop/ental dela%6 Panchal et al, +2" in co/parin1 Ba%le% scoresat /onths of a 1roup of infants -ith 9P -ith expected scores, that there

-as a hi1her incidence of de)elop/ental dela%6 ;ordestani et al, +22 in an

associated stud% to Panchal, reported that infants -ith 9P -ho had

de)elop/ental dela% also had confoundin1 factors6 !one of the articles

re)ie-ed sho-ed stron1 e)idence +lo- scores in critical re)ie-6 Collet et al

+2&, in a re)ie- article, -hich includes the abo)e authors, su//ariGes the

issue -ith the state/ent that >these studies tentati)el% su11est that 9P is

associated -ith increased ris for de)elop/ental dela%8 ho-e)er a causalassociation should not be presu/ed6 Althou1h there /a% be ad)erse effects

resultin1 fro/ brain de)elop/ent in an as%//etric sull, it is also plausible

that 9P is /erel% a /arer for other conditions that i/pede de)elop/ent6?

He su11ests further -ell7controlled research to stud% the effect of sull

defor/ation on brain de)elop/ent, the effect of brain de)elop/ent +or C!3

patholo1% on sull shape, and the effect of positionin1 li/itations on both

9P and /otor de)elop/ent6

B:B:5*RAPHK8

"osee $(, =ason AC6, 9efor/ational pla1iocephal%8 dia1nosis,

pre)ention, and treat/ent6 Clin6 Plast6 3ur16, 200 $anF &2+"8 &7D4,L

2*raha/ $= $r, *o/eG =, Halber1 A, (arl 9, ;reutG/an $', Cui $, *uo

M6, =ana1e/ent of defor/ational pla1iocephal%8 repositionin1 )ersus

orthotic therap%6 $ Pediatr6 <eb 200F "4D +28 27D26

& Bialocero-si A(, Vladusic 3, Ho-ell 3=6, Conser)ati)e

inter)entions for positional pla1iocephal%8 a s%ste/atic re)ie-6 9e) =ed

Child !eurol6 Au1 200F 4# +8 D&7#06

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15636765&query_hl=0&itool=pubmed_docsum










4 5x/an A9, Coo 9$, *u%att *H6 Critical Appraisal Checlist for a

3%ste/atic Re)ie-, sers’ *uide to the =edical iterature6 V:6 6Ho- to use

an o)er)ie-6 $A=A "@@48 2#28 "&D#7"&#"

a- =, 3te-art 9, Pollic. !, etts , Bosch $, Jest/orland =, +"@@Critical Re)ie- <or/7Quantitati)e 3tudies +=c=aster ni)ersit%6

Accessed on --- =a% 200D

D a- =, 3te-art 9, Pollic. !, etts , Bosch $, Jest/orland =, +"@@

Critical Re)ie- <or/7Qualitati)e 3tudies +=c=aster ni)ersit%6 Accessed

on --- =a% 200D

# o)eda% BP, de Chalain 'B6 Acti)e counterpositionin1 or orthotic de)iceto treat positional pla1iocephal%N $ Craniofac 3ur16 200" $ulF "2 +48 &07"&6

Bruner 'J, 9a)id R, *a1e H9, Ar1enta C6 5b.ecti)e outco/e

anal%sis of soft shell hel/et therap% in the treat/ent of defor/ational

pla1iocephal%6 $ Craniofac6 3ur16 2004 $ulF " +48 D4&706

@ Persin1 $, $a/es H, 3-anson $, ;att-inel $F A/erican Acade/% of

Pediatrics Co//ittee on Practice and A/bulator% =edicine, 3ection on

Plastic 3ur1er% and 3ection on !eurolo1ical 3ur1er%6

Pre)ention and /ana1e/ent of positional sull defor/ities in infants6

A/erican Acade/% of Pediatrics Co//ittee on Practice and A/bulator%

=edicine, 3ection on Plastic 3ur1er% and 3ection on !eurolo1ical 3ur1er%6

Pediatrics6 200& $ulF ""28 "@@72026

"0 'eich1raeber $<, Ault $;, Bau/1artner $, Jaller A, =essers/ith =,

*ateno $, Bra)enac B, Mia $ +2002 9efor/ational Posterior Pla1iocephal%8

9ia1nosis and 'reat/entF Cleft Palate7Craniofacial $ournal, !o)e/ber

2002, Volu/e &@, !o D, pp .n27D

"" Van Vli//eren A, Helders P$, )an Adriche/ !, (n1elbert RH6

'orticollis and pla1iocephal% in infanc%8 therapeutic strate1ies6















Pediatric Rehabil6 200D $an7=arF@+"8407D6

"2 *olden ;, Beals 3, itlefield ', Po/atto $6 3ternocleido/astoid

i/balance Versus Con1enital =uscular 'orticollis8 'heir Relationship to

Positional pla1iocephal%6 Cleft Palate7Craniofacial $ournal, =a% "@@@,Vol6&D !o &6 Pp2D72D"

"& 9e Chalain '=, Par 36, 'orticollis associated -ith positional

pla1iocephal%8 a 1ro-in1 epide/ic6

$ Craniofacial 3ur16 200 =a%F "D+&8 4""7

"4 Boore7Boonea/p, inden7;uiper , ida '8 Positional Preference in

:nfants and <ollo-7p After '-o Kears8 Pediatrics, <eb 200", Vol6 "0# !o2

" Hutchinson , Hutchinson , 'ho/pson $, =itchell (, Pla1iocephal%

and Brach%cephal% in the <irst '-o Kears of ife8 A prospecti)e Cohort

3tud%, Pediatrics Vol6 ""4 o64 5ct 2004, pp@#07@0

"D Hutchinson , 'ho/pson $ and =itchell (, 9eter/inants of

!ons%nostotic Pla1iocephal%8 A Case Control 3tud%8 Pediatrics, Vol6""2

no64 5ct 200& pp6 e&"D7&22

"# A/erican Acade/% of Pediatrics 'as <orce on 3udden :nfant 9eath

3%ndro/e6 'he chan1in1 concept of sudden infant death s%ndro/e8

dia1nostic codin1 shifts, contro)ersies re1ardin1 the sleepin1 en)iron/ent,

and ne- )ariables to consider in reducin1 ris6

Pediatrics6 200 !o)F ""D+8 "2476 (pub 200 5ct "06

" =ortenson P, 3teinbo P8 Quantif%in1 Positional Pla1iocephal%8

Reliabilit% and Validit% of Anthropo/etric =easure/ents, $ournal of

Craniofacial 3ur1er%, =a% 200D, )ol6"#, nu/ber&, pp4"&74"@

"@ 3iato-si R=, <ortne% AC, !aGir 3A, Cannon 3, Panchal $, <rancel

P, <euer J, Ah/ad J6 Visual field defects in defor/ational posterior

pla1iocephal%6 $ AAP536 200 $unF @ +&8 2#476













20=iller R:, Clarren 3 ;6, on17ter/ de)elop/ental outco/es in patients

-ith defor/ational pla1iocephal%6 Pediatrics6 2000 <ebF "0+28 (2D6

2" Panchal $, A/irshe%bani H, *ur-itch R, Coo V, <rancel P, !eas B,

e)ine !6 !eurode)elop/ent in children -ith sin1le7suture cranios%nostosis

and pla1iocephal% -ithout s%nostosis6, Plast Reconstr 3ur16 200"

!o)F"0+D8"4@27F discussion "4@@7006

22 ;ordestani R;, Panchal $6 !eurode)elop/ent dela%s in children -ith

defor/ational pla1iocephal%6 Plast Reconstr 3ur16 200D 3epF ""+&807@

2& Collett B, Brei1er 9, ;in1 9, Cunnin1ha/ =, 3peltG =6

!eurode)elop/ental i/plications of Odefor/ationalO pla1iocephal%6

$ 9e) Beha) Pediatr6 200 5ctF 2D+8 &#@7@

24 $oint 3tate/ent8 Canadian <oundation for the 3tud% of :nfant 9eaths, the

Canadian :nstitute of Child Health, the Canadian Paediatric 3ociet% and

Health Canada, Re)ision in Pro1ress 2004, Accessed on

---6cps6caE(n1lishEstate/entsE:PEcps@70"6ht/, $an & 200#






http://www.cps.ca/English/statements/IP/cps98-01.htm






http://www.cps.ca/English/statements/IP/cps98-01.htm



'AB( " fro/ s%ste/atic re)ie- bt Bialero-si et al



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Plagiocephaly Best Practice in Physiotherapy Jan 31 07