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Clinical Evaluation Processes and Procedures for the Orthotic Treatment of Infants With Deformational Plagiocephaly

Deanna Fish, MS, CPO


Early identification of cranial deformation during the first 3 months is critical for effective treatment to promote the development of a symmetric and proportional head shape in young infants. 1 Repositioning efforts can have a significant and positive effect on the overall head shape if started early enough and performed with diligence by the caregivers. When treated early, mild deformations respond favorably to changes in supported positioning during playing, feeding, and sleeping. Improvements to moderate and severe deformations might not be as significant, and further cranial remolding with a custom orthosis could be indicated.

Insurance companies require anthropometric measurements and letters of medical necessity to document degrees of severity in determining the basis for coverage. Unfortunately, no standard of clinical care exists for the evaluation and treatment of these infants, 2,3 and such a void in the medical literature leaves many infants without the possibility of effective treatment during the critical window of opportunity presented in the first year of life. Criteria for the clinical differentiation of synostotic and deformational plagiocephaly are also necessary to distinguish surgical cases from those that can be managed with more conservative efforts such as therapy and/or orthotic treatment programs. 4

The focus of this presentation is to report clinical evaluation processes and procedures used to identify infants with asymmetric and/or disproportionate head shapes who would benefit from an orthotic treatment program. Additionally, infants with developmental delay or congenital muscular torticollis who would benefit from therapy programs should be identified and referred for further evaluation. A multidisciplinary team approach best serves the child and family by addressing the physical, psychosocial, and emotional aspects of craniofacial deformation. 2,5,6

PATIENT HISTORY

A thorough background of both prenatal and postnatal factors is important in establishing the most likely pathogenesis of the plagiocephalic condition. Demographic factors such as gender, age, ethnic background, and familial traits are documented. Maternal factors and prenatal events provide additional insight into the possibility of early fetal constraint and in utero molding. Altered craniofacial contouring can be noted secondary to complications during the delivery process or assisted births (ie, forceps, suction, and so on). Premature infants present with extremely soft cranial plates and deformation can occur quickly; term infants are also susceptible to cranial deformation as a result of sustained supine positioning, congenital muscular torticollis, and other factors. Table 1 contains a Patient Information Sheet designed to gather pertinent information from the parents as it relates to the orthotic evaluation and treatment of the infant diagnosed with deformational plagiocephaly. 7–14

VISUAL EXAMINATION

A subjective visual examination of the infant's face and cranium should be performed from various perspectives. 2,15–17 Facial asymmetry and distortion are observed from a frontal view with variations in eye alignment, epicanthal folds, nose and chin orientation, fullness of the cheeks, head tilt, and ear alignment being noted. Side views reveal significant occipital distortion and frontal bossing. A posterior view reveals areas of hair loss, alignment of the ears and skull base, and some indication of congenital muscular torticollis, neck weakness, neck malalignment, or other anomalies. Finally, an aerial view overlooking the top of the head is often the most telling in terms of severity of the deformation. From this perspective, occipital flattening and bossing, frontal flattening and bossing, proportional width and length of the skull, and ear misalignment can be identified. It is important to view the head from all angles to develop proper appreciation of the deformation and relative relationships of the viscerocranium and neurocranium. Specific clinical features for distinguishing deformational plagiocephaly from synostotic plagiocephaly have been discussed by many sources. 4,13,16,18,19

MANUAL EXAMINATION

Palpation of the lambdoid, sagittal, coronal, and frontal sutures is performed to help rule out craniosynostosis and verify the patency of the cranial sutures. Sagittal and metopic synostoses produce ridges that are easily seen and palpated. Coronal and lambdoid synostoses are less likely to produce palpable ridging 13 and, therefore, the examiner must rely even more on the entire physical examination. The relative size of the anterior fontanelle provides some indication of remaining skull growth.

Neck musculature is evaluated for small fibrous masses associated with congenital muscular torticollis. Passive range of motion is assessed and active range of motion is evaluated by distracting the infant with visual stimuli from one extreme of their visual field to the other. Neck tightness or weakness can be tentatively identified by an asymmetric range of motion or by lack of dissociation between the neck and trunk rotation. Any cervical spine anomalies or developmental asymmetry are noted as well. Referral to physical therapy for further evaluation and treatment should be made for infants with neck involvement or developmental delay and/or asymmetry.

CLINICAL MEASUREMENTS

Numerous and complex craniofacial measurements have been reported in the literature. 1,2,8,12,19–25 The goal of the clinical evaluation is to provide a baseline of craniofacial morphology that is consistent, efficient, and reproducible over time. The most common measurements used during the clinical evaluation of deformational plagiocephaly are shown in Figure 1 , Figure 2 , Figure 3 , and Figure 4 . Littlefield et al. 12 reported the most signifi- cant measurements for documentation of plagiocephalic head shapes to be the cranial vault, skull base, and upper face measurements. Additional measurements are used as necessary to further define the deformation and the relationship of the neurocranium to the viscerocranium. 19

Like with clinical photographs, consistency and accuracy of anthropometric measures are extremely important. The experienced measurer will produce more reliable measurements than the novice, 2 because time and experience enhance precision on a moving and possibly uncooperative infant. 20 Basic tools include a set of handheld calipers for facial measurements, extended calipers or what is commonly referred to as a mediolateral (M-L) gauge for skull measurements, and a standard tape measure.

Documentation of craniofacial deformation should be performed at initial evaluation and end of treatment, and is recommended every 4 to 6 weeks throughout the duration of the treatment program. Criteria for insurance coverage are often determined by the degree of severity as quantified by anthropometric measures. Comparison of before and after treatment measures provides evidence of the efficacy of the nonsurgical treatment program.

CAREGIVER EDUCATION AND INSTRUCTIONS

During the initial evaluation, a significant amount of time is spent relaying information to the caregiver and answering questions about the infant's condition. Caregivers are provided with recommendations for repositioning, which is most effective during the first 3 months. 2,16,29,31 Suggestions include: 1) rearranging the furniture in the nursery to encourage opposite head rotation, 2) alternating the infant's head from one side of the crib to the other each night, 3) limiting time in carriers and swings, 4) supervising tummy time, 5) focusing play activities to challenge the infant's active range of motion of the neck, and 6) creating feeding positions that limit forces to the back of the infant's head. Many different types of supportive pillows and cushions are available to enhance the repositioning protocols.

SUMMARY AND PROPOSED TREATMENT PLAN

Clinicians must work to educate caregivers and other healthcare professionals on preventive measures that will reduce the likelihood and/or severity of cranial deformations. Early identification of cranial asymmetry and disproportion is best treated with aggressive and consistent repositioning and/or therapy programs when there is no evidence of synostotic involvement. Follow-up examinations by 3 to 4 months of age should show considerable improvement in overall head shape if repositioning and/or therapy are to be effective. Moderate to severe cranial asymmetry or disproportion noted at 3 to 4 months of age warrants consideration for a cranial remolding orthosis. The earlier the orthotic intervention is introduced, the more significant the changes to the shape of the infant skull. Ultimately, medical team members working together can significantly reduce the progression and severity of these deformities and provide effective treatment for those not responding sufficiently to repositioning and changes in parenting practices.

Correspondence to: Deanna Fish, MS, CPO, Orthomerica Products, Inc., 1508 West Elm Hill Circle, Taylorsville, UT 84123; e-mail: dfish@orthomerica.com .


DEANNA FISH, MS, CPO, is affiliated with Orthomerica Products, Inc., Taylorsville, UT.

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