4Definition 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.
5Definition of Terms Deformational Plagiocephaly Brachycephaly Scaphocephaly
6BRACHYCEPHALY Bilateral occipital flattening or central flattening Frontal bossingHigh cranial vaultWidth of head is greater than 85% of the length and may exceed 100% (cephalic ratio)
9Deformational 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) Hutchison13% flattening and 11% other unusual head shape Peitsch
10Scaphocephaly Long, narrow head shape Prevalent in infants with sagittal synostosis and NICU babies due to side-lying positionWidth of head is less than 75% of the lengthInfant’s neck muscles have difficult time extending the head due to head shape
11Early 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.
12Why 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.
13Why 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.
14Orthotic Treatment Components Non-synostotic deformational plagiocephalyDiagnosed with clinical observation.X-ray, CT, and/or MRI MAY be used to rule out craniosynostosisUniform growthBrain determines size and shape of cranium.Maximum growthTreatment is most effective when the head is actively growing.4-7 months is ideal timing.Children can be treated up to 18 months.Compliance23 hours per day.
15The goal of the orthotic treatment program is to provide effective and progressive realignment of the skull.
16Principals 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.
17How 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.
18How 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.
19How 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.
24The deformity may not be obvious in the frontal view.
25After a three month trial of repositioning, who should be referred for a cranial remolding orthosis? Mild: 1 quadrantInvolvement and minimal earshift. (Refer for baseline measurements and monitor.)Mild-ModerateModerate: 2 quadrant involvement and ear shift.(Refer for a cranialorthosis.)Severe: 3-4 quadrant involvement, earshift, and facial involvement.(Refer for acranial orthosis.)MildModerateSevere
27Moderate to severe head plagiocephaly Moderate to severe brachycephalyContinued post-operative remodeling for mild to severe head deformations1/2” liner allows adjustability over shunts
28STARband 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.
29STARlight Side Opening Band Proximal openingSide opening bandApproximately 2/4” clear plastic shell1 1/2” Velcro strap and chafe closureIndications:Deformational PlagiocephalyDeformational Symmetrical or Asymmetrical Brachycephaly
30STARlight Bi-valve Anterior and posterior shells Approximately 1/4” clear plastic shellOverlap designSuperior sliding mechanism1” Velcro strap and chafe closureIndications: Post-op, Scaphy
31STARlight Bi-valve Moderate to severe plagiocephaly Moderate to severe brachycephalyModerate to severe scaphocephalyContinued post-operative remolding for mild to severe head deformationShunt can be monitored through clear plastic.
32STARlight 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.
33STARband 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.
34Contraindications Craniosynostosis Hydrocephalus Contraindicated until the synostotic suture is removed.STARband can be used post-operatively as an adjunct to surgery.HydrocephalusContraindicated 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 monthsAggressive repositioning efforts are recommended.Children older than eighteen monthsCase by case assessment, minimal change expected.
35Ruling 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.
36HydrocephalusCranial orthoses are contraindicated with hydrocephalus unless it is controlled with a shunt.The fluid may be shunted into the heart or the abdominal cavity.
37Hydrocephalus is a contraindication for cranial remolding orthoses. Shunt is often visiblethrough the skin.
38Orthotic Management with the STARband Cranial Remolding Orthosis
39Traditional 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”.
40Traditional Casting Process Casting with flexible fiberglass casting tape is faster and cleanerCasting is accurate, safe and quick for the patient and parentsChanges are documented monthly with hand-measurements.
42Fitting Orthotist trims helmet to fit patient Break in instructions are providedWearing instructions are providedOne week follow-up appointment is scheduled
43Modifications to STARbandTM Progressive Adjustments During the Orthotic Treatment ProgramMonthly appointments with others on a as needed basis
44Frontal 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.
45Modifications cont. Orthotist can heat and press out the plastic Pads can be added for relief and rotation control
46Who covers Helmets? Medicaid Aetna Select Health DMBA Other plans are based on wether it is an exclusion or notEach insurances have various requirements for authorization
47Medicaid Under one year of age Diagonal difference >1.0 cm Requires authorization prior to treatmentBrachycephaly & Scaphocephaly not currently not covered
48Aetna Older than 4 months Younger than 12 months Diagonal difference >.6cmRequires authorization prior to treatmentCovers all three diagnosesBrachycephaly >2 SD above the norm
49IHC Older than 4 months Younger than 12 months Diagonal difference >.6cm3 months positioning therapyRequires authorization prior to treatmentCovers all three diagnosesBrachycephaly >2 SD above the norm
50DMBA Diagonal difference >.6cm Student plan requires authorization Traditional DMBA plan does not require authorizationCovers all three diagnosesBrachycephaly >2 SD above the norm