Cranial Remolding for Deformational Plagiocephaly Presented by: Amanda Pozarnsky, CO, BSPO Board Eligible Prosthetist

History of Cranial Remolding How long has cranial remolding existed????

History of Cranial Remolding For thousands of years, cranial remolding techniques have been used for aesthetic purposes

History of Cranial Remolding 1979 - Clarren developed the first cranial remolding orthosis Today – updated design, same basic principle.

Causes of Deformational Plagiocephaly Positioning in womb Positioning in early infancy Prematurity increases risk “Back to Sleep Campaign” Car seats and other seating systems Torticollis Head preference towards one side

Positioning in Womb Deformation can occur in the womb Limited room in the womb Multiple births

Positioning in Early Infancy Secondary deformational forces caused by sleep and daytime supine positioning Premature birth increases risk Car seats, swing

Torticollis Torticollis is the tightness or contracture of the sternocleidomastiod muscle Typically causes tilt and rotation of the head with loss of ROM 85% of infant’s with plagiocephaly have been diagnosed with torticollis

Why has there been an increased incidence of cranial deformation? 1992 - The American Academy of Pediatrics started the “Back to Sleep” Campaign Recommend babies sleep in the supine position to reduce the incidence of SIDS Incidence of SIDS reduced by >50% Conversely, increased incidence of deformational plagiocephaly Brachycephaly especially

Diagnoses of Cranial Deformities Plagiocephaly – Asymmetrical flattening of the occipital bone with opposite changes of the frontal bone and ear offset Brachycephaly – Symmetrical flattening of the occipital bone, increase in width (M-L) Scaphocephaly – Symmetrical flattening of the parietal bones with elongated length (A-P) Asymmetric Brachycephaly – Combination of Plagiocephaly and Brachycephaly

Head Preference Towards One Side Patient has tendency to look towards one side, but DOES NOT HAVE TORTICOLLIS. Usually caused by habit Parents need to alter stimulation Feeding Car seat placement Crib position

Clinical Signs of Plagiocephaly Trapezoidal head shape when viewed in the transverse plane Anterior ear shift Bossed forehead Facial Asymmetries

Contraindications of Cranial Remolding Orthoses Craniosynostosis – Orthoses are commonly used postoperatively to correct or maintain endoscopic surgical correction Hydrocephaly – may be used if treated with a shunt and cleared by doctor Under 3 months of age – Repositioning efforts should be used Over 24 months of age - The skull is fully fused and no longer pliable N.B. 18 months is commonly the stated end point due to majority of the sutures being fused and the lack of growth at that age

Indications (most insurance requirements) Must be between 3-18 months old 2 months of repositioning efforts Tummy Time Plagiocephaly - Asymmetry exceeding 6mm in any anthropometric measurement Brachycephaly – Two standard deviations from the norm in cephalic ratio

Ideal Protocol Initiate between 3- 6 months old Insurance may take up to six weeks to authorize 4-7 months of helmet therapy Must wear helmet 23 hours/day Follow-up visits every 2-4 weeks

Brand Names of Cranial Remolding Orthoses aka “helmets” aka “bands” All Cranial Remolding Orthoses are regulated by the Federal Drug Administration, FDA STARbandTM from Orthomerica All helmets are BPA Free DOC band® from Cranial Tech The Boston Band from Boston Brace Hanger Cranial Band from Hanger O&P

STARscanner The STARscanner is a laser data acquisition system Non-invasive laser No radiation Scan takes 1.5 seconds to capture image FDA approved Quantitative Data Data used to document for insurance coverage

Plaster Casting Before CAD-CAM technology, practitioners had to take a plaster cast of the patient’s head Patients did not tolerate the plaster casting well Plaster casting is very messy & time consuming Many O&P offices still use plaster casting technique

Union Orthotics & Prosthetics Co. We are the only facility in Western PA with the STARscanner We have 4 offices throughout Western PA with Cranial Remolding Specialists Pittsburgh Cranberry South Hills Greensburg

How is a scan turned into a helmet? Orthomerica uses CAD- CAM software to carve a foam replica of the patient’s head The foam head mold is then corrected using plaster The helmet is fabricated on top of the modified foam mold

How Does the Helmet Work? The helmet contacts the “bossed” areas to resist growth Growth then takes the “path of least resistance” as bone growth is redirected to fill in the empty space inside the helmet

Acquiring a Cranial Remolding Orthosis After the STARscan, it takes approximately ten days for Orthomerica to fabricate a helmet FDA requires Orthomerica to make and have the helmet delivered to us for fitting within 14 days of the scan

STARband Side-opening band 3/16 ” copolymer shell ½” copolymer foam liner If adjustments are necessary, we can remove foam from inner surface of the helmet

STARlight Side-opening band ¼” clear plastic shell Able to heat and flare plastic to adjust helmet Recommended for pt’s with eczema or extreme skin sensitivity

Bi-Valve Helmets Both the STARband and STARlight are available in a Bi-Valve design Used to treat post-op sagittal synostosis and scaphocephaly

Challenging Presentations Severe torticollis’ “C” Shape

Scan Comparison Once a patient has completed 3 months of helmet therapy, a scan comparison is performed Scan comparisons are also offered when a patient is discharged from helmet therapy

Scan Comparison A scan comparison allows an overlay of cross sections from the original scan (red) and the scan after 3 months of treatment (blue) Great tool to track measurements and growth toward correction

Scan Comparison- Brachycephaly

Scan Comparison- Plagiocephaly

Discharge Criteria from Helmet Therapy In order to prevent reoccurrence of deformity. Crawling Independent sitting Multiple sleeping positions Torticollis not a concern on positioning Other common reasons to cease use: Age- Growth rate insignificant Parents choose to cease use

Do Babies Tolerate the Helmet Well? Most babies tolerate the helmet well Very few may experience discomfort due to excessive sweating until body naturally adjusts (1-2 weeks)

Should we be concerned? Bulging above the ears/side opening No concern! It is simply subcutaneous fluid pooling around the snug trimlines Yes, it feels as hard as bone, but the large plates of the skull cannot grow out an opening that small Usually occurs after a few months of use when orthosis becomes more snug

Should we be concerned? Red, peeling, sunburn like appearance in the shape of the orthosis This is contact dermatitis No adjustments to the orthosis will help Cease STARband use until it has cleared up on its own or with mild ointments prescribed by pediatrician

Why put holes in the helmet? Holes are usually drilled into the helmet in the area of flatness to aid in ventilation Holes can also be used to ensure there is sufficient room for growth toward symmetry These cannot be added to bossed areas

Who do I refer my patient to? Children’s Hospital of Pittsburgh Craniofacial Department Pediatrician

Alexandra’s P.H.A.T.E. Raise Awareness Support Group Provide resources to fight insurance denials Donate STARbands to families in need Facebook Twitter

Alexandria’s P.H.A.T.E.

Decorate the Helmet

References Derrow, Amy. MD. “Basic Dermatology Essential for All STARband Users.” Orthomerica STARsummit. Orlando, FL. 21 Oct 2009. NICHD Back to Sleep Education Campaign (August 2011). National Institute of Health. Retrieved August 29, 2010 from http:// www.nichd.nih.gov/sids/. Norquist, Blake. CO. “STARscanner Cranial Comparison Utility.” Orthomerica STARsummit. Orlando, FL. 20 Oct 2010. Norquist, Blake. CO. “Surgical Approaches for the Relief of Craniosynostosis.” Orthomerica STARsummit. Orlando, FL. 21 Oct 2009. Smith, Aaron. CO, LO. “Challenges – The Questions, The Answers, The Messy, Smelly, and Sometimes Frustrating Side of Cranial Remolding.” Orthomerica STARsummit. Orlando, FL. 21 Oct 2010. Tate, Gary. “Alexandra’s P.H.A.T.E.” Orthomerica STARsummit. Orlando, FL. 20 Oct 2010.

Questions ?