Effectiveness of pediatric integrative manual therapy in cervical movement limitation in infants with positional plagiocephaly: a randomized controlled trial

BACKGROUND

Positional plagiocephaly (PP) is a cranial deformation frequent amongst children and consisting in a flattened and asymmetrical head shape. PP is associated with excessive time in supine and with congenital muscular torticollis (CMT). Few studies have evaluated the efficiency of a manual therapy approach in PP. The purpose of this parallel randomized controlled trial is to compare the effectiveness of adding a manual therapy approach to a caregiver education program focusing on active rotation range of motion (AROM) and neuromotor development in a PP pediatric sample.

METHODS

Thirty-four children with PP and less than 28 week-old were randomly distributed into two groups. AROM and neuromotor development with Alberta Infant Motor Scale (AIMS) were measured. The evaluation was performed by an examiner, blinded to the randomization of the subjects. A pediatric integrative manual therapy (PIMT) group received 10-sessions involving manual therapy and a caregiver education program. Manual therapy was addressed to the upper cervical spine to mobilize the occiput, atlas and axis. The caregiver educational program consisted in exercises to reduce the positional preference and to stimulate motor development. The control group received the caregiver education program exclusively. To compare intervention effectiveness across the groups, improvement indexes of AROM and AIMS were calculated using the difference of the final measurement values minus the baseline measurement values. If the distribution was normal, the improvement indexes were compared using the Student t-test for independent samples; if not, the Mann-Whitney U test was used. The effect size of the interventions was calculated using Cohen's d.

RESULTS

All randomized subjects were analysed. After the intervention, the PIMT group showed a significantly higher increase in rotation (29.68 ± 18.41°) than the control group (6.13 ± 17.69°) (p = 0.001). Both groups improved the neuromotor development but no statistically significant differences were found. No harm was reported during the study.

CONCLUSION

The PIMT intervention program was more effective in increasing AROM than using only a caregiver education program. The study has been retrospectively registered at clinicaltrials.gov, with identification number NCT03659032 . Registration date: September 1, 2018.

Motor Function in School-Aged Children With Positional Plagiocephaly or Brachycephaly

OBJECTIVE

To determine whether children with a history of positional plagiocephaly/brachycephaly (PPB) show persistent deficits in motor development.

METHODS

In a longitudinal cohort study, we completed follow-up assessments with 187 school-aged children with PPB and 149 participants without PPB who were originally enrolled in infancy. Primary outcomes were the Bruininks-Oseretsky Test of Motor Proficiency-Second Edition (BOT-2) composite scores.

RESULTS

Children with PPB scored lower than controls on the BOT-2. Stratified analyses indicated that differences were restricted to children who had moderate-severe PPB. No consistent differences were observed in children who had mild PPB.

CONCLUSION

Children who had moderate-severe PPB in infancy show persistent differences in motor function. We suggest close developmental monitoring and early intervention to address motor deficits.

Infant sleep position, head shape concerns, and sleep positioning devices

AIM

The Back To Sleep campaign has successfully promoted the use of the supine sleep position for infants, with a corresponding decrease in sudden infant death syndrome death rates around the world. The aim of this study was to survey current infant sleep position practices, concerns about plagiocephaly, and the use of sleep positioning devices.

METHODS

A postal survey of 400 mothers of infants aged 6 weeks to 4 months was carried out in Auckland, New Zealand.

RESULTS

Of the 278 (69.5%) respondents, the supine position was usually used in 64.8%, the prone position in 2.9%, with 32.3% using the side position or a combination of side and back positions. Approximately one-third had a concern about their infant's head shape, and 80% described practices to help prevent head deformation. Thirty per cent reported they had changed their infant's sleep position because of head shape concerns. A third of the mothers used some sort of positioning system to maintain the infant's sleep position.

CONCLUSIONS

Anxieties about plagiocephaly, aspiration of vomit, and poor quality sleep are the main concerns that parents have about sleeping their infants on their backs. Further education is needed to inform mothers about these issues and to alleviate their fears.

Soft-helmet skull remodeling in canine models: intracranial volume unchanged by compensatory skull growth

OBJECT

Habitual sleeping positions in infants can produce occipital plagiocephaly, which causes strabismus as well as skull and facial asymmetry. This condition can be managed using a hard helmet, but maintaining an infant in such a device is often intolerable. The authors studied whether the shape of a young canine skull could reform while inside a soft helmet and whether intracranial volume would be preserved by the compensatory growth of the skull.

METHODS

The authors tracked the head sizes of 14 1-week-old beagles who wore long, soft helmets (study group) and seven beagles who did not (control group). From these measurements, the intracranial volume in each beagle was calculated. All crania were also studied radiologically by using plain skull radiography, computerized tomography (CT), and magnetic resonance (MR) imaging. The crania of all 14 beagles who wore soft helmets quickly adapted, resulting in a narrow, long head only 2 weeks into the experiment. This configuration continued to develop throughout the 7-week experimental period. At 8 weeks of age, animals in the study group showed no significantly different alteration in calculated intracranial volumes (p > 0.05). It is interesting that the helmet-treated animals initially underwent a paradoxical increase in intracranial volume growth. No structural difference in their brains was evident from CT or MR imaging findings, nor was there any functional disability.

CONCLUSIONS

Intracranial volume can be preserved by the compensatory growth of the skull during successful remodeling of the developing skull achieved using a soft helmet.

Palpatory diagnosis of plagiocephaly

INTRODUCTION

The term plagiocephaly, from the Greek plagios (oblique) and kephalê (head), means distortion of the head, and refers clinically to cranial asymmetry. Cranial Osteopathy, since it was first proposed, has focussed upon the diagnosis and treatment of birth trauma and cranial asymmetries, and consequently specific therapy for plagiocephalic deformities has been described. Osteopathic manipulation also has been proposed as a treatment for torticollis, a condition associated with plagiocephaly. For these reasons, we decided to look at the mechanics of the occipital bone and the adjacent atlas and bones of the cranial base, in relation to functional plagiocephaly.

METHODS

The records of 649 children seen in an osteopathic practice in Lyon, France, were reviewed retrospectively, in compliance with the legal requirements of the Commission Nationale de l'Informatique et des Libertés (CRIL) and the Helsinki accord, for gender, age at presentation, birth history, obstetrical data (breech presentation, vacuum extraction, forceps delivery or Caesarean section), presenting complaint, side of posterior plagiocephaly, side of frontal plagiocephaly, torticollis, motion pattern of the occipital bone upon the atlas, and motion pattern of the spheno-occipital synchondrosis.

RESULTS

We found significant correlations between plagiocephaly (right/left) and primipara (P=0.024), use of forceps (P=0.055) and extractor suction (P=0.055). Correlations were also found between flattening of the occiput (right/left) and lateral strain of the spheno-occipital synchondrosis (P=0.002) and between plagiocephaly (right/left) and occipito-atlantal motion (P=0.000).

CONCLUSION

We found a significant correlation between the lateral strain pattern of the spheno-occipital synchondrosis and plagiocephaly and between rotational dysfunction of the occiput upon the atlas and the side of posterior plagiocephaly. We suggest that thorough neonatal osteopathic examination can identify individuals predisposed to develop posterior plagiocephaly.

Patterns of postural asymmetry in infants: a standardized video-based analysis

Cervical rotation deficit (CRD) and trunk convexity (TC) constitute the diagnosis of infantile postural asymmetry (IPA), which is often associated with further asymmetric features. However, very little data on the entire symptom complex are currently available. The aim of this study was to analyse the entire clinical spectrum of IPA based on a standardized video documentation. Forty-five infants (27 male) with an asymmetry score of > or = 12 points (scale: 4-24) at a median post-term age of 10 weeks (range: 6-16) were selected from two previously studies using predefined criteria. CRD and TC as reactive movements to an orienting head turn in the prone and supine position were assessed from video recordings by three independent observers. Plagiocephaly, oblique body position and asymmetric foot position were descriptively assessed by consent of the same observers. Hip dysplasia data were derived from sonography charts. The assessment of the reactive movements showed a "scoliosis" pattern in sox infants, a "torticollis" pattern in nine infants, a "mixed prone" pattern in 13 infants and a "mixed" pattern in 26 infants. Side agreement in the prone and supine position of TC and CRD was seen in 27 infants, with a left-sided convexity and left-sided head rotation deficit in two-thirds of the infants. Plagiocephaly was present in 27 infants, oblique body position in 13 infants, hip dysplasia in 4 infants and calcaneus foot in 11 infants. In conclusion, infantile asymmetry pattern analysis showed that morphological and functional anomalies are intricately linked and that infants with only a single apparent sign of asymmetry have actually a much more generalized disturbance.

Management of deformational plagiocephaly: repositioning versus orthotic therapy

OBJECTIVES

We compare positioning with orthotic therapy in 298 consecutive infants referred for correction of head asymmetry.

STUDY DESIGN

We evaluated 176 infants treated with repositioning, 159 treated with helmets, and 37 treated with initial repositioning followed by helmet therapy when treatment failed. We compared reductions in diagonal difference (RDD) between repositioning and cranial orthotic therapy. Helmets were routinely used for infants older than 6 months with DD >1 cm.

RESULTS

For infants treated with repositioning at a mean age of 4.8 months, the mean RDD was 0.55 cm (from an initial mean DD of 1.05 cm). For infants treated with cranial orthotics at a mean age of 6.6 months, the mean RDD was 0.71 cm (from an initial mean DD of 1.13 cm).

CONCLUSIONS

Infants treated with orthotics were older and required a longer length of treatment (4.2 vs 3.5 months). Infants treated with orthosis had a mean final DD closer to the DD in unaffected infants (0.3 +/- 0.1 cm), orthotic therapy was more effective than repositioning (61% decrease versus 52% decrease in DD), and early orthosis was significantly more effective than later orthosis (65% decrease versus 51% decrease in DD).

Deformational brachycephaly in supine-sleeping infants

OBJECTIVES

Medical dictionaries and anthropologic sources define brachycephaly as a cranial index (CI = width divided by length x 100%) greater than 81%. We examine the impact of supine sleeping on CI and compare orthotic treatment with repositioning.

STUDY DESIGN

We compared the effect of repositioning versus helmet therapy on CI in 193 infants referred for abnormal head shape.

RESULTS

Eighty percent of the infants had a pretreatment CI > 81%. Their initial mean CI at mean age 5.3 months was 89%, and after treatment, their mean CI was 87% (+/-2 SE = 0.9%) at mean age 9.0 months. For 92 infants with an initial CI at or above 90%, their initial mean CI of 96.1% was reduced to a mean of 91.9%.

CONCLUSIONS

Post-treatment CI was 86% to 88%, CI in neonates delivered by cesarean section was 80%, and CI in supine-sleeping Asian children was 85% to 91%, versus 78% to 83% for prone-sleeping American children. Repositioning was less effective than cranial orthotic therapy in correcting severe brachycephaly. We recommend varying the head position when putting infants to sleep.