In July 2013, the Journal of Pediatrics published a study entitled, “The Incidence of Positional Plagiocephaly”. 440 healthy full term infants were evaluated, and the incidence of Plagiocephaly in infants at 7-12 weeks was reported to be 46.6%. With such a high incidence, I thought it would be helpful to provide a comprehensive picture of the most up to date literature on the efficacy of different Plagiocephaly treatments.
Positional Plagiocephaly is a condition characterized by changes in skull shape and symmetry. It typically occurs in infants and results from mechanical factors, which, when applied over a period of time in utero, during the birthing process or postnatally, alter the shape of the skull. Some infants may have noticeable skull shape deformity at birth that resolves itself in the early postnatal period. Therefore, Positional Plagiocephaly refers specifically to infants with changes in skull shape, who are older than six weeks of age. These children present with open cranial sutures that appear within normal limits, with no craniosynostosis noted.
Plagiocephaly ranges in both location and severity, from bilateral flattening of the posterior cranium, to unilateral occipital flattening and various degrees of ipsilateral forehead bossing. Because of changes in skull shape and symmetry, this disorder often causes families to seek treatment to address cosmetic concerns and reduce asymmetry.
In a 2002 study, Bridges and Chambers explained, “Positional Plagiocephaly does not appear to be associated with long-term physical or cognitive problems“. When treatment is recommended, conservative interventions are advocated, which includes parental education, counter-positioning, Physical Therapy and helmet/orthosis. Counter-positioning as defined by studies by Moss and Loveday, “involve active repositioning of the child during sleep and play, to apply pressure to the prominent areas of the skull and allow flattened areas of the skull to remodel“.
Physical Therapy may also include positioning, active and passive range of motion of restricted cervical musculature and promotion of variety of developmental positions for play, thereby reducing forces on the flattened areas of the skull.
A New York Times article entitled, “Helmets Do Little to Help Moderate Infant Skull Flattening“, reports that “roughly one baby in five will develop a skull deformation caused by lying in the supine position“. This article highlights the March 2014 British Medical Journal (BMJ) publication which investigated the effectiveness of helmet therapy for Positional Plagiocephaly compared with the natural course of the condition in infants 5-6 months of age. This was a randomized trial with a sample size of 84 children who were born full-term with no other pre-existing conditions (no diagnosis of Torticollis, Craniosynostosis, or dysmorphic features). 42 children received helmet orthosis and 42 children did not. The primary outcome was change in skull shape from baseline. Secondary outcomes were ear deviation, facial asymmetry, occipital lift and motor development in the infant, quality of life (infant and parent measures), as well as parental satisfaction and anxiety. The results indicated the Plagiocephaly and Brachycephaly change score from 5 months of age to 24 months of age was almost equivalent in both groups. Additionally, the numbers of infants showing full recovery were comparable in both groups. No significant differences were found of the additional clinical outcomes, parent related outcomes, and motor development. The conclusion:
“Based on the equal effectiveness of helmet therapy and skull deformation following its natural course, high prevalence of side effects, and high costs associated with helmet therapy, we discourage the use of a helmet as a standard treatment for healthy infants with moderate to severe skull deformation.”
In 2011, the American Academy of Pediatrics (AAP) issued an updated policy statement in which the recommendations for prevention and management of positional skull deformities include:
- Active Exercise Including Tummy Time
- Careful Monitoring
The AAP recommends the use of cranial orthoses to be reserved for severe deformities, but highlighted that conservative management is stressed as the primary intervention before more invasive treatments are even considered. Lead author Dr. James Laughlin stated in response to the 2014 BMJ study, “There are definitely cases of infants with mild to moderate skull deformation who are treated with helmet therapy, and this study confirms and reaffirms that this is not necessary…not doing helmet therapy will give you the same results as doing helmet therapy which is expensive and can be stressful for the family.”
Effectiveness of Conservative Intervention
In 2005, the Journal of Developmental Medicine and Child Neurology published a systematic review aimed at synthesizing the current research to determine the effectiveness of conservative interventions for infants with Positional Plagiocephaly. Sixteen papers met their inclusion criteria. The consistent finding was that “counter-positioning with Physical Therapy or helmet therapy may reduce skill deformity“.
Within this review, six studies supported the use of counter-positioning with Physical Therapy to reduce skull asymmetries. One study embraced the use of counter-positiong alone to effectively treat infants with mild Plagiocephaly. Five studies found benefit for helmet orthotics in reducing skull asymmetries, particularly in infants with moderate to severe Plagiocephaly.
Two studies, one by Moss and one by Jalaluddin, concluded that counter-positioning with Physical Therapy is as effective as helmet therapy. Two other studies by Mulliken and Vles concluded that helmets were more effective than counterpositioning because they ‘correct’ the issue more rapidly than other conservative interventions.
I think it is only fair to point out that in all five studies which justified use of helmet orthotic over other treatment methods, the authors had affiliations with orthotic companies, which as we can assume may have biased results.
Repositioning vs. Helmet Therapy
Another study published by the Journal of Pediatrics in 2005 evaluated 176 infants treated with repositioning, 159 treated with helmets, and 37 treated with initial repositioning followed by helmet therapy when treatment failed. The results indicate that infants treated with repositioning, the mean percentage decrease in cranial diagonal difference (a measurement to assess head symmetry) for the orthotic group was 61% compared to 52% for the repositioning group. A few flaws in this study, the first being the repositioning group length of therapy was 3.5 months while the helmet group had longer treatment period, 4.2 months. Each group should have been allotted the same time frame to determine relative benefit of treatment. Also this study only compared “repositioning” to orthotic use. The repositioning was performed by parents who were followed at monthly intervals to monitor progress and encourage compliance. The specific protocols are not explained. I would love to see a similar study done comparing Physical Therapy intervention (with a defined protocol) to the helmet orthotic intervention!
This study also evaluated the effect of age on helmet treatment, comparing outcomes of 44 children who began treatment at 8 months or older, compared to 115 infants who started treatment at age of 8 months or older (mean age = 5.8 months). In older infants the percentage decrease in cranial diagonal difference was 51% vs 65% in the younger group. Again the flaw is that the treatment length was longer in the younger group and the sample size much smaller in the older group. But in general we can reasonably state, the earlier the intervention is initiated, the better the outcomes are for children.
Increased Incidence of Plagiocephaly
Many authors have spent time explaining the potential rationale for the increase in incidence of Plagiocephaly as of late. This diagnosis has become more common since the American Academy of Pediatrics‘ 1992 “Back to Sleep” campaign, which advises parents to place infants to sleep on their backs in order to prevent Sudden Infant Death Syndrome (SIDS).
A large majority of children with Plagiocephaly also are diagnosed with Torticollis. Proper Physical Therapy intervention for Torticollis often resolves the craniofacial asymmetry or Plagiocephaly. By removing the muscular restriction causing the child to present with limited range of motion of head/neck and positional preference, the child will more freely change positions and promote redistribution of external forces causing the plagiocephaly. Promotion of tummy time encourages motor skill development, as well as head and neck range of motion, offloading pressures on skull and help to remodel the child’s head shape.
One of the overarching themes found in each of the research papers reviewed was the importance of early diagnosis and intervention.
A 2008 study from the Archives of Pediatric & Adolescent Medicine, proposed that identifying positional preference as early as 7 weeks and treating with a 4-month standardized Physical Therapy program, “significantly reduced the prevalence of severe deformational plagiocephaly compared with usual care.”
Torticollis and Plagiocephaly
When a child is diagnosed with Torticollis and Plagiocephaly, both Cheng et al and Emery et al explain, “If initiated by 3 months, conservative treatment of Torticollis with Physical Therapy is very effective, resulting in full passive range of motion and no facial asymmetry.”
Graham et al describe, “After age 12 months, efficacy of orthotic treatment significant decreases. Delays in initiating corrective treatment until later infancy may lead to incomplete or ineffective correction…so early diagnosis and treatment is essential.”
Since current evidence suggests that Positional Plagiocephaly is a cosmetic concern more than a medical one, more importance should be placed on functional outcomes rather than anatomic ones. Once the child develops adequate head control, full range of motion, is without physical limitations which may have led to or were caused by the underlying plagiocephaly, and the child can independently get in and out of developmental positions…where does our concern lay? Let’s take a different look at our outcomes, instead of head shape let’s spend more time addressing the child’s functional abilities.
The helmet orthotic may correct or at least attempt to correct the skull shape, but Physical Therapy strives to address the underlying cause of the Plagiocephaly, promotes healthy motor development and growth free of restrictions and limitations.
The goal of clinicians should shift from an anatomic to a more functional perspective. Viewing the child as a whole rather than a composite of individual parts can only help to improve outcomes!
For some great Tummy Time Tips and Tricks to help address head shape and prevent flattening, visit our post here!
For helpful equipment ideas to address Plagiocephaly and Torticollis visit our post here!
Learn more about Dinosaur Physical Therapy!
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