Deformational Plagiocephaly: Recommendations for Future Research:

Comorbidities of deformational plagiocephaly in infancy: a scoping review protocol

INTRODUCTION

Deformational plagiocephaly (DP) is one of the most common cranial shape disorders in infancy. It is characterised by unilateral flattening of the skull due to head preference to one side. The literature suggests that DP is associated with comorbidities such as developmental delay, but the nature and prevalence of the comorbid impairments are still unclear and controversial. Therefore, our scoping review (ScR) aims to explore systematically the extent and nature of literature by identifying, mapping and categorising the most relevant comorbidities of DP in children up to the age of 2 years.

METHODS AND ANALYSIS

This protocol is based on the framework outlined by Arksey and O'Malley. A systematic search will be conducted to identify relevant full text studies from 1992 to 2021 using the databases of Cochrane, MEDLINE, Google Scholar, EMBASE, PubMed and University of Nicosia EBSCO. Two independent reviewers will screen abstracts and full articles in parallel, using specific inclusion and exclusion criteria. Specifically, this review will consider studies investigating DP and relevant comorbidities in children up to the age of 2 years of life without craniosynostosis, torticollis and any other diagnosed neurodevelopmental deficiency.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for ScR Checklist will be considered for results' analysis and reporting. The results will be described in a narrative form in relation to the research question and in the context of the overall study purpose.

ETHICS AND DISSEMINATION

Research ethics approval is not required for this ScR since data will be retrieved from publicly available studies. Dissemination activities will include research findings' submission for publication in a relevant peer-reviewed journal and presentation of the results at relevant conferences.

REGISTRATION

Our protocol was registered prospectively with the Open Science Framework (https://osf.io/48am3/).

Orthotists' and physical therapists' perspectives on quality of care indicators for persons with custom ankle-foot orthoses

Purpose: To describe the priorities of orthotists and physical therapists about quality measurement themes, and the feasibility and utility of collecting data from persons using custom AFOs that could inform quality measure development.Materials and Methods: Online survey assessed respondents' perspectives and experiences. An Advisory Committee representing professional, organizational, and accreditor groups distributed survey invitations.Results: 461 orthotists and 153 physical therapists completed part or all of the survey; 60% rated 9 quality themes and 20 quality of care topics as extremely important, and 12 standard instruments as feasible and good to use for quality measurement. Patients were the preferred source of information for ease of scheduling, device weight, ease of donning and doffing, adherence to device use, beneficial effects, activity level and independence, and quality of life. Clinicians were the preferred source for material quality, device modifiability, and joint range of motion. Facility records were the preferred source for timeliness of device delivery and clinician follow-up. Respondents reported that gait speed and walking endurance were best obtained by patient performance.Conclusions: Results provide insight on the topics orthotists and physical therapists regard as priorities for defining healthcare quality for persons using custom ankle-foot orthoses and instruments for data collection.

Orthotic Management of Deformational Plagiocephaly: Consensus Clinical Standards of Care

Objective

To establish consensus on definitive, actionable standards for the management of deformational plagiocephaly.

Design

Three-stage Delphi Survey process based on best practice statements obtained through literature review.

Setting

Electronic survey delivery.

Participants

Review panel of 10 multidisciplinary subject matter experts (SMEs); survey panel of 30 cranial orthotists.

Results

Fifty-four best practice statements were accepted in four categories: diagnosis, presentation and severity, initiating treatment, and management principles.

Conclusions

Clinical practice can be guided en route to robust evidence as to the efficacy of various plagiocephaly management strategies, in pursuit of definitive standards.

Efficacy of passive helmet therapy for deformational plagiocephaly: report of 1050 cases

OBJECT

There has been a tremendous increase in the incidence of deformational plagiocephaly in children throughout the world. Therapeutic options include observation, active counterpositioning, external orthotics, and surgery. The current treatment in the US is highly debated, but it typically includes external orthotic helmets in patients with moderate to severe plagiocephaly presenting between 4 and 10 months of age or in children with significant comorbidities limiting passive (no-pressure) therapy. The present study was designed to evaluate 3 key issues: 1) the accuracy of the Argenta classification in defining a progressive degree of severity, 2) identification of an upper age limit when treatment is no longer effective, and 3) the effectiveness of an off-the-shelf prefabricated helmet in correcting deformational plagiocephaly.

METHODS

An institutional review board-approved retrospective study was conducted of all patients at the authors' clinic in whom deformational plagiocephaly was assessed using the Argenta classification system over a 6-year period; the patients underwent helmet therapy, and a minimum of 3 clinic visits were recorded. Inclusion criteria consisted of an Argenta Type II-V plagiocephalic deformity. Patients' conditions were categorized both by severity of the deformity and by patients' age at presentation. Statistical analysis was conducted using survival analysis.

RESULTS

There were 1050 patients included in the study. Patients with Type III, IV, and V plagiocephaly required progressively longer for deformity correction to be achieved than patients with Type II plagiocephaly (53%, 75%, and 81% longer, respectively [p < 0.0001]). This finding verified that the Argenta stratification indicated a progressive severity of deformity. No statistically significant difference in the time to correction was noted among the different age categories, which suggests that the previously held upper time limit for correction may be inaccurate. An overall correction rate to Type I plagiocephaly of 81.6% was achieved irrespective of severity and degree of the original deformity. This suggests that an inexpensive off-the-shelf molding helmet is highly effective and that expensive custom-fitted orthoses may not be necessary. The patients in the older age group (> 12 months) did not have a statistically significant longer interval to correction than the patients in the youngest age group (< 3 months). The mean length of follow-up was 6.3 months.

CONCLUSIONS

Patients treated with passive helmet therapy in the older age group (> 12 months) had an improvement in skull shape within the same treatment interval as the patients in the younger age group (< 3 months). This study supports the use of passive helmet therapy for improvement in deformational plagiocephaly in infants from birth to 18 months of age and verifies the stratification of degree of deformity used in the Argenta classification system.

The incidence of positional plagiocephaly: a cohort study

OBJECTIVE

The objective of this study was to estimate the incidence of positional plagiocephaly in infants 7 to 12 weeks of age who attend the 2-month well-child clinic in Calgary, Alberta, Canada.

METHODS

A prospective cohort design was used to recruit 440 healthy full-term infants (born at ≥37 weeks of gestation) who presented at 2-month well-child clinics for public health nursing services (eg, immunization) in the city of Calgary, Alberta. The study was completed in 4 community health centers (CHCs) from July to September 2010. The CHCs were selected based on their location, each CHC representing 1 quadrant of the city. Argenta's (2004) plagiocephaly assessment tool was used to identify the presence or absence of plagiocephaly.

RESULTS

Of the 440 infants assessed, 205 were observed to have some form of plagiocephaly. The incidence of plagiocephaly in infants at 7 to 12 weeks of age was estimated to be 46.6%. Of all infants with plagiocephaly, 63.2% were affected on the right side and 78.3% had a mild form.

CONCLUSIONS

To our knowledge, this is the first population-based study to investigate the incidence of positional plagiocephaly using 4 community-based data collection sites. Future studies are required to corroborate the findings of our study. Research is required to assess the incidence of plagiocephaly using Argenta's plagiocephaly assessment tool across more CHCs and to assess prevalence at different infant age groups. The utility of using Argenta's plagiocephaly assessment tool by public health nurses and/or family physicians needs to be established.

Helmet versus active repositioning for plagiocephaly: a three-dimensional analysis

BACKGROUND AND PURPOSE

Orthotic helmets and active repositioning are the most common treatments for deformational plagiocephaly (DP). Existing evidence is not sufficient to objectively inform decisions between these options. A three-dimensional (3D), whole-head asymmetry analysis was used to rigorously compare outcomes of these 2 treatment methods.

PATIENTS AND METHODS

Whole-head 3D surface scans of 70 infants with DP were captured before and after treatment by using stereophotogrammetric imaging technology. Helmeted (n=35) and nonhelmeted/actively repositioned (n=35) infants were matched for severity of initial deformity. Surfaces were spatially registered to a symmetric template, which was deformed to achieve detailed right-to-left point correspondence for every point on the head surface. A ratiometric asymmetry value was calculated for each point relative to its contralateral counterpart. Maximum and mean asymmetry values were determined. Change in mean and maximum asymmetry with treatment was the basis for group comparison.

RESULTS

The helmeted group had a larger reduction than the repositioned group in both maximum (4.0% vs 2.5%; P=.02) and mean asymmetry (0.9% vs 0.5%; P=.02). The greatest difference was localized to the occipital region.

CONCLUSIONS

Whole-head 3D asymmetry analysis is capable of rigorously quantifying the relative efficacy of the 2 common treatments of DP. Orthotic helmets provide statistically superior improvement in head symmetry compared with active repositioning immediately after therapy. Additional studies are needed to (1) establish the clinical significance of these quantitative differences in outcome, (2) define what constitutes pathologic head asymmetry, and (3) determine whether superiority of orthotic treatment lasts as the child matures.