plagiocephaly and torticollis · 1 wk for: head shape/dysmorphism 2wk, 6wk, ... •prevalence is 1...
TRANSCRIPT
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Plagiocephaly and Torticollis
Mia E. Lang, MD, PhD, FRCPC
General Pediatrician, Co-Vice Dean Education
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Presenter: Mia Lang
• Speakers Bureau/Honoraria: N/A
• Consulting Fees: N/A
• Grants/Research Support: N/A
• Patents: N/A
• Other: N/A
• The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.
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Acknowledgments
Carolyn Shinbine, RN, BScN, Pediatric Head Shape Clinic, StolleryChildren’s Hospital
Dr. Keith Aronyk, pediatric neurosurgeon
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Objectives
1. Assess infants for plagiocephaly and torticollis at routine well child visits
2. Discuss infant repositioning techniques with caregivers
3. Identify indications for referral for plagiocephaly/torticollis
4. Explain rationale for various treatment modalities for plagiocephaly/torticollis
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Objective # 1
Assess infants for plagiocephaly and torticollis at routine well child visits:
- Overview of plagiocephaly
- History, risk factors
- Physical examination
- Differential: torticollis and craniosynostosis
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Definition of Positional Plagiocephaly
2 Types:
1. Positional occipital plagiocephaly:• unilateral flattening of parieto-occipital region• compensatory anterior shift of the ipsilateral ear• bulging of the ipsilateral forehead
2. Positional brachycephaly - different than brachycephaly craniosynostosis
• symmetric flattening of the occiput• foreshortened anterior-posterior dimensions of the skull• compensatory biparietal widening
https://www.youtube.com/watch?v=-VlPLoPqJxI
https://www.aappublications.org/news/2016/10/27/Plagiocephaly102016
Cranial Technologies. https://www.cranialtech.com
/how-to-assess/
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Positional Plagiocephaly, aka Deformational, non-synostotic plagiocephaly
0.3% pre Back-To-Sleep, post = 8.2%
Prevalence:
• 6 weeks: 16 - 22 %
• 4 months: 19.7 %
• 12 months: 6.8 %
• 2 years: 3.3 %
Bialocerkowski et al., 2008
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Risk Factors for Abnormal Head Shape
Prenatal:
- Male- Primip- Multiple birth
Perinatal:
- Obstetrical instrumentation- High birth weight- Prematurity- Large head circumference
Postnatal:- Supine position- Torticollis, restricted head movement- Bottle feeding without repositioning- Little “tummy time”- Development delay
Linz et al., 2017. Positional skull deformities
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Physical exam
1 wk for: head shape/dysmorphism
2wk, 6wk, 4m, 6m, +/-9m, 12m for:• General: dysmorphisms
• Growth: HC
• Head: suture lines, fontanelles, mastoid process, shape, forehead
• Neck: ROM, mass
• Eyes: shape, size, symmetry
• Ears: location, symmetry
• MSK: tone, development
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Differential
• Congenital muscular torticollis
• Unilateral lambdoid synostosis
• Unilateral coronal synostosis
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Congenital muscular torticollis aka “Wry Neck””
Incidence: 3.9% - 16%
3 Types:
1. postural: mild, normal ROM2. muscular: SCM tight and ROM limitations3. SCM mass: most severe type
Clinical Dx: https://www.youtube.com/watch?v=FHpZzb-L28U
• Head tilted towards affected side
• Chin turned to opposite side
• Palpable neck mass, shortened SCM
• Difficulty turning head
• Associations: DDH, brachial plexus injury
Kaplan et al., 2018; Sargent et al., 2019
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Craniosynostosis “premature fusion of cranial sutures”
• Prevalence is 1 in 2500• Overriding sutures• Eye and/or Ear asymmetry• Syndromic (rare) vs Non-Syndromic
• Non-Syndromic: most = 1 suture fused:
• sagittal (45%) > coronal > metopic > lambdoid
• M > F for sagittal
• F > M for coronal
Google images
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Types of Abnormal Head Shapes
Dempsey et al., 2019 Nonsyndromic Craniosynostosis
45%
25 %
20 % < 5 %
Image: Arlyng González-Vázquez, Scientific Reports, 2017
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http://www.bcchildrens.ca/neurosciences-site/Documents/BCCH034PlagiocephalyCliniciansGuideWeb1.pdf
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View from Above
Cranial Technologies. https://www.cranialtech.com/how-to-assess/
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Profile View
Cranial Technologies. https://www.cranialtech.com/how-to-assess/
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Frontal View
Cranial Technologies. https://www.cranialtech.com/how-to-assess/
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View from Below
Cranial Technologies. https://www.cranialtech.com/how-to-assess/
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Objectives # 2 and # 4
Discuss infant repositioning techniques with caregivers
Explain rationale for various treatment modalities for plagiocephaly/torticollis
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Prevention of Positional Plagiocephaly
• Avoidance of favourite side
• Bilateral stimuli
• Adequate tummy time: 10-15min TID
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https://www.aboutkidshealth.ca/article?contentid=24&language=english
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Plagiocephaly Treatment
• Surgical: for craniosynostosis
• Non-Surgical:
• Observation
• Repositioning
• Physiotherapy
• Moulding/Helmet Therapy
• Infant bed “positioning”pillows
• Chiropractic
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Repositioning
● Physiotherapy = Counterpositioning:■ Limit time in car-seat, bouncy chair, swings■ Alter focus of vision based on “clock” position: feeding, sleeping, tummy time, play-time, diaper
changes, car-seat■ Alter position of crib mobiles, source of light■ Adequate tummy-time
● Repositioning device: wrap, pillow
Klimo et al., 2016. systematic review from the Congress of Neurological Surgeons
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Helmet/Cranial Orthosis therapy
Advantages
• Slightly faster rate of improvement in skull shape
Disadvantages
• Cost ($1800 - $2800 )• Time• Contact dermatitis, pressure sores
Best age: 6 - 9 m old (capture aggressive brain growth)Indicators:
● severe plagiocephaly (Can Ped Society, 2018)
● persistent moderate to severe plagiocephaly (Congress of Neurological Surgeons,
2016)
1. after repositioning and/or physio;
2. presenting at an advanced age
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Cranial Orthotics- 23 h/day x 4 months- Orthotist visits Q2weeks
Traditional Helmet SnugKap
https://pediatricheadshape.com/snugkap/
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Torticollis Treatment: Torticollis does not spontaneously resolve
Best outcomes when treatment starts before 3m old
1st Line:a. Neck passive ROM: stretch tight SCMb. Neck and trunk active ROM: strengthen opposite side SCMc. Develop symmetrical movementd. Environmental adaptations: Repositioning techniquese. Caregiver education
Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy. Kaplan et al., 2018
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Torticollis Treatment▪ 2nd Line: (in descending order of evidence strength)
▪ Therapeutic Ultrasound
▪ Kinesiological taping
▪ Soft tissue mobilization
▪ Level V evidence:
▪ TOT Collar: Tubular Orthosis for Torticollis
▪ Torticollis “Support Kit”/Snuggin Go
No published evidence for cervical manipulation
Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy. Kaplan et al., 2018
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Objective # 3
Identify indications for referral for plagiocephaly/torticollis
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Image from AHS Head Shape Clinic Referral Form
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• Grande Prairie
• When:• plagio/brachycephaly• craniosynostosis referred
to Edmonton
• Who: PT (Pediatric Rehab)
• How:
• FAX: 780-530-1060
• email: [email protected]
Referral Process• AHS Head Shape Clinics
• When:• craniosynostosis, rapid macrocephaly (seen within 7-10 d)• torticollis, plagio/brachycephaly > 4 m old (seen within 8 wks)• Plagio/brachycephaly < 4 m old
• Who: Nurse Practioner for Neurosurg, RN/OT/PT
• How:
• Edmonton (Stollery) FAX: 780-407-6284, tel: 780-407-6393
• Calgary (AB Children’s) FAX: 403-476-7756, tel:403-955-7918
• Referral Forms on AHS Referral Directory
Pediatric Head Shape ClinicPrivate clinics, free initial assessment, cost for treatment
Different than AHS Head Shape Clinic
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Conclusions
Positional plagiocephaly:
- common, benign, but distressing to guardians- distinguish from craniosynostosis- prevention and repositioning- referral if: dysmorphic findings, craniosynostosis, plagio > 4m- monitor development
Torticollis:
- check neck ROM at routine baby checks- refer to AHS Head Shape Clinic