The Orthotic Management of Infants with Deformational Plagiocephaly and Other Head Shape Deformities

1. The Orthotic Management of Infants with Deformational Plagiocephaly and Other Head Shape Deformities Orthomerica Products, Inc.

2. STARband Cranial Remolding Orthosis

3. COMMON HEAD SHAPE DEFORMITIES

4. Definition of Terms • Bossing: An area of prominence. • Occipital plagiocephaly: An area of flattening in the occipital region. • Frontal plagiocephaly: An area of flattening in the forehead or frontal region. • Facial asymmetry: Difference in the bony and soft tissue structures of the right side compared to the left side of the face.

5. Definition of Terms Deformational Plagiocephaly Brachycephaly Scaphocephaly

6. BRACHYCEPHALY • Bilateral occipital flattening or central flattening • Frontal bossing • High cranial vault • Width of head is greater than 85% of the length and may exceed 100% (cephalic ratio)

7. Deformational Brachycephaly

8. Deformational Plagiocephaly

9. Deformational Plagiocephaly • An asymmetrical molding of the head caused by external forces often accompanied by torticollis. • Incidence reported at birth: • 1 in 300 when torticollis is also present (Clarren) • 16% (4 weeks) Hutchison • 13% flattening and 11% other unusual head shape Peitsch

10. Scaphocephaly • Long, narrow head shape • Prevalent in infants with sagittal synostosis and NICU babies due to side-lying position • Width of head is less than 75% of the length • Infant’s neck muscles have difficult time extending the head due to head shape

11. Early Management of Torticollis • Child is in custom molded cranial orthosis. • Child pinned to the bed sheet in prone! • Rubber tubing attached to the orthosis and to the bed rail. • Torticollis resolved in 7-10 days, but babies didn’t tolerate the treatment.

12. Why don’t these skull deformities resolve like they used to? • Supine positioning at night. • Supine positioning all day in carriers, car seats, swings. • Infants who sleep supine roll later, so infants spend more time in supine before they are able to reposition themselves. • Neck tightness does not resolve because of limited positions during the day.

13. Why don’t these skull deformities resolve like they used to? • Increased incidence of multiple births. • Parents are busy and can’t reposition infants as often. • Less intrauterine space. • More pre-term babies survive whose heads are more fragile and susceptible to deformation.

14. Orthotic Treatment Components • Non-synostotic deformational plagiocephaly • Diagnosed with clinical observation. • X-ray, CT, and/or MRI MAY be used to rule out craniosynostosis • Uniform growth • Brain determines size and shape of cranium. • Maximum growth • Treatment is most effective when the head is actively growing. • 4-7 months is ideal timing. • Children can be treated up to 18 months. • Compliance • 23 hours per day.

15. The goal of the orthotic treatment program is to provide effective and progressive realignment of the skull.

16. Principals of Orthotic Intervention for Deformational Plagiocephaly • Provide total contact in the areas where growth is to be curbed. • Allow space in the areas where growth is desired. • There is a critical window of opportunity, specifically between 3-12 months of age, when the head is actively growing. • The symmetrical helmet creates a pathway for growth to occur.

17. How does the STARband improve the head shape of babies with deformational plagiocephaly? • A cast or scan is taken of the infant’s head and poured or carved to get a positive model. • The flattened areas are built up with plaster in the posterior-lateral quadrant to obtain symmetry. • The flattened frontal area is also built up with plaster to obtain symmetry. • Contact will be maintained over the prominent or bossed areas to deter growth in those areas.

18. How does the STARband improve the head shape of babies with brachycephaly? • Primary build-up on the positive mold will occur across the central occipital region to obtain improved proportions of the head. • The Cephalic Ratio of babies in 2006 is about 83-85%. • Cephalic Ratio + Width divided by Length of the head. • Contact is maintained over the frontal and parietal regions to deter growth.

19. How does the STARband improve the head shape of babies with scaphocephaly? • Scaphocephaly—mild, moderate or severe. • Primary build-up on the plaster mold will occur at the right and left parietal areas to obtain improved proportions of the head. Normally, the cranial width is approximately 80% of the cranial length. • Contact will be maintained over the frontal and posterior (bossed) regions to deter growth.

20. Patient Evaluation

21. Documentation: Visual Examination • Note areas of • Flattening • Bossing • Increased head height • Ear shift • Unusual side to side or anterior-posterior forehead slope

22. Visual Assessment • Note areas of bossing. • Note areas of flatness. • Ear alignment. • Facial asymmetry: • Eyes • Nose • Mouth • Cheeks

23. Evaluate the baby from every side.

24. The deformity may not be obvious in the frontal view.

25. After a three month trial of repositioning, who should be referred for a cranial remolding orthosis? Mild: 1 quadrant Involvement and minimal ear shift. (Refer for baseline measurements and monitor.) Mild-Moderate Moderate: 2 quadrant involvement and ear shift.(Refer for a cranial orthosis.) Severe: 3-4 quadrant involvement, ear shift, and facial involvement.(Refer for a cranial orthosis.) Mild Severe Moderate

26. STAR Cranial Remolding Orthoses STARlight Bi-Valve STARlight Side-Opening STARlight Cap STARband Bi-valved Clarren Helmet STARband

27. Moderate to severe head plagiocephaly • Moderate to severe brachycephaly • Continued post-operative remodeling for mild to severe head deformations • 1/2” liner allows adjustability over shunts

28. STARband General Information • Active orthosis—active on part of the orthotist and the baby’s growth. • Modified to full or partial symmetry. • Considerable adjustments available through removal of liner material. • Requires frequent follow-up for ongoing adjustments. • Requires basic skill/knowledge.

29. STARlight Side Opening Band • Proximal opening • Side opening band • Approximately 2/4” clear plastic shell • 1 1/2” Velcro strap and chafe closure • Indications: • Deformational Plagiocephaly • Deformational Symmetrical or Asymmetrical Brachycephaly

30. STARlight Bi-valve • Anterior and posterior shells • Approximately 1/4” clear plastic shell • Overlap design • Superior sliding mechanism • 1” Velcro strap and chafe closure • Indications: Post-op, Scaphy

31. STARlight Bi-valve • Moderate to severe plagiocephaly • Moderate to severe brachycephaly • Moderate to severe scaphocephaly • Continued post-operative remolding for mild to severe head deformation • Shunt can be monitored through clear plastic.

32. STARlight Bi-valve • Active orthotic treatment process. • Modified to full or partial symmetry. • Growth accommodation available through overlapping shells. • Plastic can be heated and stretched. • Design mechanism allows tri-planar adjustability. • Requires advanced skill/knowledge.

33. STARband Bi-valve • Deformational scaphycephaly. • Following surgery for craniosynostosis. • Trim lines can be modified to allow growth in specific areas. • Sliding top mechanism allows A-P control. • Orthotist can cut plastic out where growth is desired. Design developed by Orthomerica and Frank Vicari, Children’s Memorial Of Chicago.

34. Contraindications • Craniosynostosis • Contraindicated until the synostotic suture is removed. • STARband can be used post-operatively as an adjunct to surgery. • Hydrocephalus • Contraindicated until the volume is stabilized. • STARband can be used post-operatively with special care taken to prevent occlusion of the shunt. • Children younger than three months • Aggressive repositioning efforts are recommended. • Children older than eighteen months • Case by case assessment, minimal change expected.

35. Ruling out Craniosynostosis • A premature fusion of the cranial suture(s) resulting in disproportionate growth of the cranial bones and as a sequence the growth of the facial bones are also involved. • Cranial orthoses are contraindicated until the fusion is released. Post-operatively, the orthosis can be used as either a remolding or protective orthosis.

36. Hydrocephalus • Cranial orthoses are contraindicated with hydrocephalus unless it is controlled with a shunt. • The fluid may be shunted into the heart or the abdominal cavity.

37. Hydrocephalus is a contraindication for cranial remolding orthoses. Shunt is often visible through the skin.

38. Orthotic Management with the STARband Cranial Remolding Orthosis

39. Traditional method of taking an impression of the infant’s head • Preparation for casting with plaster wrap: • “Poncho” made of stockinette. • Helps to keep the baby warm and clean. • Caregiver also needs cover as they will be “helping”.

40. Traditional Casting Process • Casting with flexible fiberglass casting tape is faster and cleaner • Casting is accurate, safe and quick for the patient and parents • Changes are documented monthly with hand-measurements.

41. Finished cast!

42. Fitting • Orthotist trims helmet to fit patient • Break in instructions are provided • Wearing instructions are provided • One week follow-up appointment is scheduled

43. Modifications to STARbandTM Progressive Adjustments During the Orthotic Treatment Program Monthly appointments with others on a as needed basis

44. Frontal modifications • The orthotist removes material from the inside of the STARband about every two weeks to direct head growth into a more symmetrical and well proportioned shape. • Specialized equipment is needed for the fitting and follow up appointments.

45. Modifications cont. • Orthotist can heat and press out the plastic • Pads can be added for relief and rotation control

46. Who covers Helmets? • Medicaid • Aetna • Select Health • DMBA • Other plans are based on wether it is an exclusion or not • Each insurances have various requirements for authorization

47. Medicaid • Under one year of age • Diagonal difference >1.0 cm • Requires authorization prior to treatment • Brachycephaly & Scaphocephaly not currently not covered

48. Aetna • Older than 4 months • Younger than 12 months • Diagonal difference >.6cm • Requires authorization prior to treatment • Covers all three diagnoses • Brachycephaly >2 SD above the norm

49. IHC • Older than 4 months • Younger than 12 months • Diagonal difference >.6cm • 3 months positioning therapy • Requires authorization prior to treatment • Covers all three diagnoses • Brachycephaly >2 SD above the norm

50. DMBA • Diagonal difference >.6cm • Student plan requires authorization • Traditional DMBA plan does not require authorization • Covers all three diagnoses • Brachycephaly >2 SD above the norm