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Plagiocephaly and Torticollis: Causes and Effects on Alignment and Development

This is a term paper that is about, in laymen's terms, deals with the flattening of an infant's head.

A variety of developmental problems exist that could be interesting to research to gain more knowledge that would be beneficial in treating children. It is a con to isolate the resources to such a concentration on one subject. The negative aspect of focusing just on positional plagiocephaly and secondary muscular torticollis is that the two conditions have multiple causes and different versions of injury that may be attributed to more than just supine positional compression.

Positional head deformities are caused by external pressures placed on a quickly developing skull. The infant's head becomes deformed as the result of external modeling forces applied prenatally, postnatally or both. The increased use of car seats and carriers has been an attributing factor to positional plagiocephaly. Sleeping in the supine position and feedings always offered from the same side correlate with a positional head deformity. Plagiocephaly occurs first and predisposes other forms of neck imbalance. Torticollis may occur in association with plagiocephaly; each condition exacerbates the other or, successful treatment of one demands recognition and then treatment of the other condition. Plagiocephaly associated torticollis; the onset is immediate and appears to be related to the infant adopting a favored sleeping position usually lying supine with the head turned to one side. Ipsilateral sternocleidomastoid (SCM) muscle shortens resting in a torticollis position because the head rotates and tilts initiating the side preference and the occiput flattens correspondingly. Risk Factors for plagiocephaly and torticollis include but are not limited to intrauterine development, prematurity, multiple births, congenital anomalies, neurological injury, tumors, cervical defects, muscular, bony, and restrictive condition development. The key to the successful management of infants with deformational plagiocephaly is to prevent the occurrence of injury, however early diagnosis and treatment is extremely important.

The infant's head shape and neck range of motion must be assessed first as a newborn and again evaluated at two months. Approximately one out of 300 healthy birth infants have a noticeable flattening of the head, asymmetry of the skull base and face, or both. Plagiocephalic deformity may be perpetuated or worsened by gravitational forces, so the supine position creates a higher likelihood for deformation. Early recognition of positional head deformity is crucial with the rapid growth of an infant's skull. Deformational plagiocephaly has been described as a parallelogram shaped head when looking from a vertex view or when observed from a top down analysis of the skull. There is asymmetry that may cause deformation of the facial features when severe and an ipsilateral ear shift and a contralateral forehead flattening. Some degree of facial distortion is usually apparent, but it also may be minimal, however it becomes more noticeable when the infant is held up to a mirror. The mirror reflection can be checked for asymmetry without distraction of the babies' response.

Dysfunction of the neck musculature is almost a universal finding in patients with deformational plagiocephaly.6 Torticollis has some limitations of active rotation of their heads away from the flattened side of the occiput Neck dysfunction can be diagnosed by the rotating stool test, which can be used in children 3 months or older. Torticollis can effect vertical eye movements or strabismus secondary to the head tilt created by the SCM muscle shortening. The number of affected patients can be reduced by early screening, identifying patients at risk, educating parents about the importance of rotating infants, and supervised "tummy time".

The most important treatments for plagiocephaly and torticollis are prevention and awareness. Educating the infant's caregiver related to supervised tummy time and how it promotes development of the trunk musculature and improves both gross and fine motor skills is the first line of defense. Prone positioning while the infant is awake and being observed is crucial to prevent the development of flat spots on the occiput and to facilitate development of shoulder girdle strength, necessary for motor milestones. Encouraging and implementing a nightly alternating head position, changing the supine head position during sleep and periodically changing the orientation of the infant to outside activity can make all the difference. The preventative interventions are also part of the solution to reducing the plagiocephaly and torticollis in existing conditions.

Parents must be involved to make a difference in the infant's condition. All patients under the age of 18 months should be given active and passive neck stretching exercises as the first line of treatment. Most forms of intervention rely on redirecting symmetrical growth of the skull during the first year of life when 80% of growth occurs. Additionally, in the first 6 to 18 months of life there is an attempt to use remaining brain growth to redirect head shape. It is critical that parents be taught a home exercise program since physical therapy at one hour visits three times a week will be insufficient to make a difference in plagiocephaly and torticollis alone. A regiment that includes repetitive passive stretches of the affected SCM muscle and strengthening exercises for the contralateral side needs to be done regularly. In addition, positioning and handling skills will aid in resolution, allowing the infant to alter head orientation more freely. Neck exercises should be done with each diaper change, three repetitions of 10 second stretches of the SCM, upper trapezius, and the ipsilateral trunk muscles need to be performed. Caregivers must reposition their child frequently by alternating the arm in which the child is carried and fed. Parents can subsequently relieve pressure sites on the skull by rotating the position of toys in the crib, stroller, swing and car seat, which will in turn improve the range of motion of the neck. Parents need to approach feeding to the side opposite of the flattened area to encourage head turning and lengthening of the SCM muscle. A cranial orthoses, in addition to a stretching program, are a viable option to aid in the recovery from plagiocephaly and decrease the secondary torticollis. Significant improvements in overall symmetry are found with use of a cranial remolding orthosis.

Helmet therapy or an external orthotic device is an effective treatment option that has similar results to using repositioning and stretching. The theory is based on the mechanism that pressure from a rapidly growing brain against a concave surface should round flattened areas caused by earlier pressure against a flat surface. The best response for helmets occurs in the age range of 4-12 months because at the greater malleability of the young infant skull bone and the normalizing effect of the rapid growth of the brain.10 Using slight alterations in design, all cranial orthoses, bands and caps attempt to achieve a more normalized skull through strategically placed forces and directing new growth. The orthosis may need to be kept on for approximately 20 hours out of the day. Therapeutic physical adjustments of the orthosis is necessary to correct for positional changes. Also, a cervical collar can be used to block lateral flexion to the involved side to decrease range of motion deficits. When conservative treatment has been exhausted, surgery is a viable option.

The earlier the treatment begins for plagiocephaly and torticollis, the greater the likelihood of a successful outcome. Immediately after diagnosis, the majority of the literature suggests that conservative treatment should be started. This initial intervention suggests proper positioning, followed by a rigorous stretching program, both implemented by the parents. It has been identified that 95 percent of congenital muscular torticollis resolves within 1 year with manual stretching. A cranial orthoses or helmet therapy has also been used with positive results with patients under 3 months of age. However, 25 percent of the 3 to 6 months old infants, 70 percent of 6-18 month old infants and 100 percent of the older children required surgery. Surgical management of torticollis is rare. Therefore, a craniofacial surgeon should only be considered if there is a progression of the condition or a lack of improvement following a trial of mechanical adjustments. There were long-term problems noted related to subtle cerebral dysfunction during the school-age years involving language disorders, learning disability, and attention deficits in this population. This may be due to compression in certain areas of the brain that are manifested as the child grows into their deficits. Disruption of the head in the midline position through trauma or deformation such as torticollis can also affect the processing of sensory stimulation and lead to visual disturbances.5 The visual deficits if not resolved are the major reason torticollis is surgically corrected. Other factors should not be over-looked, psychosocial issues such as depression and self image problems may occur if the deformities are not corrected. Social interactions may be avoided by a child that looks different. For example, there may be fear avoidance of being singled out by their peers.

In conclusion, I agree with the rationale for prevention, care, assessment, and rehabilitation of plagiocephaly and torticollis as seen in the current literature. The inherent symmetrical brain growth and the skull's natural flexibility and plasticity in the early months create dynamic correction and improve cranial shape.5 The skull undergoes approximately 80 percent of its postnatal growth with the first year of life. Awareness of the condition and its causes may decrease the occurrence of positional plagiocephaly and torticollis. Currently, approximately 25 percent of parents never place their infants prone, even for play. It is essential to encourage prone playing and teach parents how to alter eating positions to diminish the side preference of their child. Stretching is the most effective intervention for a parent to perform regularly, however other options like the cranial orthosis exist. The majority of infants referred to neurosurgeons with occipital plagiocephaly can be successfully managed nonsurgically. My conclusions are supported by a sizeable amount of research that is available in reputable journals and online.

Several of my articles are from the Journal of Pediatrics and the American Academy of Pediatrics (AAP). These studies varied in the size of the subjects tested. There was a 15 year retrospective study of 82 infants with non-surgical interventions and 18 with surgery. A clinical report regarding guidance for rendering care by the AAP with recent citations was also available. There was a case study and a clinical report that were small sample subject sizes, however the information quoted in these articles was recent and noteworthy. There was not a preponderance of evidence with in the case study research given their prospective size. The clinical report and several other articles were funded by the company that made the cranial orthoses as were two other articles, which made me question if the papers were indeed unbiased. Luther had a population of 821 with muscular torticollis and stretching exercises, 90 percent had positive outcomes for non-surgical intervention. Another well written article by de Chalain had 159 infants from three out-patient facilities giving some diversity to the population. There were also a couple of articles such as BNI quarterly in 2001; that released a well researched management guide. However, an actual study was not performed. It seemed that there was more guideline and background information available than actual studies with large population sizes with good research formats that are unbiased. In quite a few articles the follow-up decreased the number of subjects analyzed by almost half of the total subjects available. Further research is needed to help identify prevention, assessment, and management of these conditions.

Future research is essential to evidence-based practice. It would be interesting to have a study of caregivers who are given information and prevention methods on positional plagiocephaly and torticollis. Research conducted prenatally will be followed-up at three months, six months and a year to identify how many of these children develop this condition in comparison to controls that do not receive training. There seemed to be a lot of studies that were created by the cranial orthosis companies. I believe to legitimize the use of these devices it is essential to have independent unbiased research comparing both stretching/ positioning and helmet use in the first year of life after diagnosis of positional plagiocephay and associated torticollis. There should be one group that only uses cranial orthoses, a second group that only uses stretching/positioning and a third group that is a combination of the two groups. Finally, I would like to see a population of positional plagiocephaly and secondary torticollis in the second year of life comparing the non-surgical interventions effectiveness. It seemed as though surgical intervention was the primary option during this time because of the decrease in brain and cranial growth. I would like a study to perform non-surgical interventions in the second year toddler. Similar studies with the use of all intervention strategies should be analyzed with larger subject samples and different patient demographics. A power analysis should be done to identify appropriate sample sizes for this population in future studies.

Works Cited

1) Academy of Pediatrics. (2002). While in Utero, One Twin More Likely to Develop Misshapen
Head. Pediatrics.140.1.

2) Biggs, Wendy S. MD. (2003). Diagnosis and Management of Positional Head Deformity.
American Family Physician.67.1953-60.

3) de Chalain TM and Parak S. (2004). Torticollis Associated with Positional Plagiocephaly: A Growing Epidemic. Journal of Orthotics and Prosthetics.16(4S).28-30.

4) Emery, C. (1994). The Determinants of Treatment Duration for Congenital Muscular Toticollis.
Pediatrics.74 (10).921-9.

5) Lima D. and Fish D. (2003) Acquiring Craniofacial Symmetry and Proportion Through
Repositioning, Therapy, and Cranial Remolding Orthoses. Journal of Orthotics amp; Prosthetics.15 (1S) 1-8.

6) Littlefield TR, Reiff JL, and Rekate HL. (2001) Diagnosis and Management of Deformational
Plagiocephaly. BNI Quarterly.17 (4).1-9.

7) Luther, Brenda L. (2002) Congenital Muscular Torticollis and Placiocephaly. National
Association of Orthopaedic Nurses.21 (3).21-29.

8) Miller RI and Sterling CK. (2000) Long-Term Developmental Outcomes in Patients with Deformational Plagiocephaly. Pediatrics.105 (2).E26-30.

9) National Institute of Neurological Disorders and Stroke, National Institute of Health. (Oct. 13, 2005). Dystonias. Retrieved November 22, 2005, from
.

10) Persing, John MD.etal. (2003) Prevention and Management of Positional Skull Deformities In Infants. Pediatrics.112.199-202.