Orthotic Treatment of Deformational Plagiocephaly, Brachycephaly, and Scaphocephaly


Table of Contents


SECTION 7: ORTHOTIC TREATMENT PROTOCOLS FOR PLAGIOCEPHALY


This article provides an overview of treatment protocols based on review of the related literature and results from a nationwide survey of select orthotic facilities. The following topics are addressed:

  1. Purpose and Use of Cranial Remolding Orthoses
  2. Length of Treatment
  3. Wearing Schedules
  4. Fittings and Follow-Up
  5. Variables Affecting Outcomes
  6. Multiple Orthoses
  7. Contraindications for Orthotic Treatment

Purpose and Use of Cranial Orthosis


The goal of a cranial remolding orthosis is to inhibit growth in some areas of an infant's skull and enable growth in others, thus improving cranial symmetry and/or proportion. Orthoses could also prevent infants from lying on the skull's flattened area, thus inhibiting further deformity.

Length of treatment


Treatment time is variable from 6 weeks to 6 months depending on age at onset of treatment, type of deformity, severity of the deformity, compliance, and treatment of existing torticollis.

Age of onset of treatment

 
  • The consensus is that onset of treatment between 4-8 months of age is ideal for optimal outcomes
  • The overall accepted range of ages for treatment is 3-18 months
  • Treatment at 3 months of age is not contraindicated, however, clinicians choosing to do so may face the challenges of requiring two orthoses to complete the treatment due to small initial circumference and rapid growth, and/or address fitting issues related to lack of head control.
  • Treatment of patients greater than or equal to 12 months of age yields a decreased chance of achieving optimal correction, probable extended treatment duration, and increased probability of child attempting to remove the orthosis.
  • The earlier an infant presents for treatment, the increased likelihood of capturing periods of rapid brain growth, resulting in a significant increase in the correction achieved.
  • Consensus is that age at onset of treatment is directly correlated to length of treatment.

Type of Deformity

 

Plagiocephaly (oblique): Consensus is that this shape has the best potential for correction and orthosis is the least difficult to fit.

Brachycephaly (short, wide): Consensus is that it is more difficult to fit and less likely to attain full correction.

Scaphocephaly (long, narrow): Consensus is that this type has decreased correction potential. It is difficult to fully determine outcomes due to large variations in orthoses, clinicians, and modifying styles.

Severity at onset of treatment

 

The consensus is that the greater the severity, the greater the length of treatment (i.e. a young, severe patient will have a potentially better outcome than an older, severe patient). The more severe the plagiocephaly, the greater the likelihood for need of > 1 orthosis to complete the treatment

Treatment of existing torticollis

 

If torticollis is unresolved, clinicians could increase the duration of cranial remolding orthosis treatment by 2 to 4 weeks as a prophylactic measure.

Wearing Schedules


Caregiver education should include break in period, average wearing schedule, skin care, proper donning and doffing techniques, prevention of rashes, extenuating circumstances for removal of orthosis, and goals for termination of treatment.

Initial Wearing Period

 

Consensus indicates that initial wearing period varies widely ranging from no ramping up period (orthosis worn 23 hours on first day) to a gradual seven day ramping up wear schedule.

Average Wearing Schedule

 

Patients typically wear the orthosis 22-23 hours per day for the duration of the treatment with removal for bathing and hygiene. This is based upon the concept that correction occurs via redirection of natural head growth. Since it is unknown what the exact time of growth is, full time wear captures growth to the fullest potential.

When to discontinue orthotic use

 

Typically, termination of the orthotic treatment program is recommended, without weaning, when head shape falls within normal limits. If unresolved torticollis exists or if sleeping patterns are poor (same side as flatness), use is continued for an additional 2-4 weeks.

Fit and Follow-Up


Fit

 
  • Design of orthosis allows for growth
  • Maintenance of good suspension (< 1 cm of movement)
  • Trimlines around eyes, ears and occiput are as low and streamlined as possible
  • Accommodate for trapezius muscle if head tilt (due to torticollis) is present
  • Rotation controlled with points of contact

Follow-Up

 

Follow-up every 1-3 weeks is dependent on infant's age and family need.

Multiple Orthoses


  • A second orthosis is rarely required but may be used in cases of increased severity, extenuating circumstance (infant with multiple health issues), or a very young infant (< 3 months)
  • Criteria for use of a second orthosis include the following: Ill fitting orthosis after multiple attempts to adjust, age/severity indicators with a willingness to continue by the family, postoperative adjunct/ preventative measures.

Contraindications


Summary of Variables Affecting Outcomes:


  1. Age at onset of treatment
  2. Type of deformity
  3. Severity of deformity at onset of treatment
  4. Compliance

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