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The Orthotic Management of Infants with Deformational Plagiocephaly and Other Head Shape Deformities. Orthomerica Products, Inc. STARband Cranial Remolding Orthosis. COMMON HEAD SHAPE DEFORMITIES. Definition of Terms. Bossing: An area of prominence.
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The Orthotic Management of Infants with Deformational Plagiocephaly and Other Head Shape Deformities Orthomerica Products, Inc.
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.
Definition of Terms Deformational Plagiocephaly Brachycephaly Scaphocephaly
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)
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
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
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.
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.
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.
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.
The goal of the orthotic treatment program is to provide effective and progressive realignment of the skull.
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.
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.
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.
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.
Documentation: Visual Examination • Note areas of • Flattening • Bossing • Increased head height • Ear shift • Unusual side to side or anterior-posterior forehead slope
Visual Assessment • Note areas of bossing. • Note areas of flatness. • Ear alignment. • Facial asymmetry: • Eyes • Nose • Mouth • Cheeks
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
STAR Cranial Remolding Orthoses STARlight Bi-Valve STARlight Side-Opening STARlight Cap STARband Bi-valved Clarren Helmet STARband
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
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.
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
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
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.
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.
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.
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.
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.
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.
Hydrocephalus is a contraindication for cranial remolding orthoses. Shunt is often visible through the skin.
Orthotic Management with the STARband Cranial Remolding Orthosis
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”.
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.
Fitting • Orthotist trims helmet to fit patient • Break in instructions are provided • Wearing instructions are provided • One week follow-up appointment is scheduled
Modifications to STARbandTM Progressive Adjustments During the Orthotic Treatment Program Monthly appointments with others on a as needed basis
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.
Modifications cont. • Orthotist can heat and press out the plastic • Pads can be added for relief and rotation control
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
Medicaid • Under one year of age • Diagonal difference >1.0 cm • Requires authorization prior to treatment • Brachycephaly & Scaphocephaly not currently not covered
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
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
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