Cranial Remolding for Deformational Plagiocephaly

Report
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 36 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
▫ STARband
TM
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 CADCAM 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
?

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