Transcript Cranial Remolding Orthoses for Positional Plagiocephaly and the

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
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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
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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 Brachycephaly
Deformational Plagiocephaly
Deformational Plagiocephaly
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An asymmetrical molding of
the head caused by
external forces often
accompanied by torticollis.
Incidence reported at birth:
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1 in 300 when torticollis is
also present (Clarren)
16% (4 weeks) Hutchison
13% flattening and 11%
other unusual head shape
Peitsch
Scaphocephaly
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Long, narrow head shape
Prevalent in infants with
sagittal synostosis and
NICU babies due to sidelying 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
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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?
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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?
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Increased incidence of
multiple births.
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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
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Non-synostotic deformational
plagiocephaly
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Maximum growth
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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.
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
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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
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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?
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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?
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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?
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Scaphocephaly—mild,
moderate or severe.
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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.
Patient Evaluation
Documentation: Visual Examination
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Note areas of
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Flattening
Bossing
Increased head height
Ear shift
Unusual side to side or
anterior-posterior
forehead slope
Visual Assessment
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Note areas of bossing.
Note areas of flatness.
Ear alignment.
Facial asymmetry:
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Eyes
Nose
Mouth
Cheeks
Evaluate the baby from every side.
The deformity may not be obvious in
the frontal view.
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
MildModerate
Severe
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.)
STAR Cranial Remolding Orthoses
STARlight Bi-Valve
STARband
STARlight Side-Opening
Clarren Helmet
STARlight Cap
STARband Bi-valved
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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
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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
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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
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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
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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
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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
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Design developed by Orthomerica and Frank Vicari,
Children’s Memorial Of Chicago.
Deformational scaphycephaly.
Following surgery for
craniosynostosis.
Trim lines can be modified to
allow growth in specific areas.
Sliding top mechanism allows AP control.
Orthotist can cut plastic out
where growth is desired.
Contraindications
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Craniosynostosis
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Contraindicated until the synostotic suture is removed.
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STARband can be used post-operatively as an adjunct to surgery.
Hydrocephalus
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Contraindicated until the volume is stabilized.
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STARband can be used post-operatively with special care taken to
prevent occlusion of the shunt.
Children younger than three months
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Aggressive repositioning efforts are recommended.
Children older than eighteen months
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Case by case assessment, minimal change expected.
Ruling out Craniosynostosis
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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
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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
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Preparation for casting
with plaster wrap:
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“Poncho” made of
stockinette.
Helps to keep the baby
warm and clean.
Caregiver also needs
cover as they will be
“helping”.
Traditional Casting Process
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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 handmeasurements.
Finished cast!
Fitting
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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
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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.
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Orthotist can heat
and press out the
plastic
Pads can be added
for relief and
rotation control
Who covers Helmets?
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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
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Under one year of age
Diagonal difference >1.0 cm
Requires authorization prior to treatment
Brachycephaly & Scaphocephaly not
currently not covered
Aetna
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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
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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
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Diagonal difference >.6cm
Student plan requires authorization
Traditional DMBA plan does not require
authorization
Covers all three diagnoses
Brachycephaly >2 SD above the norm
STARband Treatment
Outcomes
SPENCER
Improved Proportion and Symmetry.
Improvement in Cephalic Ratio and
Symmetry.
Normalization of Cranial Vault
Improved Frontal Appearance
Post-Operative Remolding
Pre-surgery
STARband Treatment
1 month post-op
Post-
Improvement of Posterior Symmetry
Improvement of Symmetry and
Proportion
4 MESES
Improvement in Cephalic Ratio
Thank you for your
attention!
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Northwest Orthotics
and Prosthetics
1675 N 200 W
Provo, Utah 84604
phone: 801-377-3433
fax: 801-377-4127