PLAGIOCEPHALY AND TORTICOLLIS PRESENTED BY MARISSA M. MUCCIO P.T.

In April 1992, the American Academy Pediatrics issued its recommendations for the decreased risk of Sudden Infant Death Syndrome. Healthy newborns should be placed on their back primarily or sides secondarily during sleep. Thus was born the "Back to Sleep" campaign via the US Public Health Service. This campaign was aggressively marketed from 1992-1994 with subsequent research confirming the decline in the rate of SIDS with the new sleeping position.

At the same time, cranial-facial centers across the country began noting an unusual dramatic rise in the number of infants referred for cranial deformity. Argenta et.al. 1996, documented 8 patients from 88'-90', 9 patients from 90'-92', and 51 patients from 93'94. Another center recorded a six-fold increase in the number of their referrals, correlating with the timed release of the "Back to Sleep" campaign.

Many of these children, now presenting with ranging severity of misshaped heads, were not found to have true craniosynostosis or plagiocephaly. Plagiocephaly is defined as the malformation of the skull due to premature or irregular closing of one or more sutures. Upon x-ray, their sutures were noted to be patent. Further CT scans showed a majority of the infants had some "spots of bony abnormalities". Enter, the latest concern for parents, physicians, and therapists…. Positional plagiocephaly.

There are three factors that affect the shape of the head in infants: 1. Intracranial volumetric growth 2. osseous development of the cranium 3. intrauterine environment. Positional plagiocephaly refers to the malformation of an infant's head due to extrinsic molding forces rather than the normal intrinsic growth factors. It is characterized by right or left or sometimes bilateral occipital flattening with compensatory bossing of the frontal region. Infants with positional plagiocephaly may also exhibit facial asymmetries, ear displacement, mandibular deviations, and musculoskeletal changes of the cervical spine. Conservative management consists of educating parents on repositioning techniques during awake hours, transportation, and especially during sleep. For the more involved children who do not respond to repositioning early on, there are the cranial molding helmets. There are several models currently being used across the country. All are designed to redirect cranial growth by making contact where growth is not desired and allowing relief spaces where growth is desired. Helmets are generally worn for 22 hours allowing time for hygiene and helmet care. The most severe cases can result in the need for surgical intervention. Kane et.al. 1996 provides a protocol for evaluation of infants with abnormal calvarial shapes.

Pediatric physical therapy came into play for this patient population for several issues. Initially therapists can provide the comprehensive repositioning program to parents. We are also the specialists who evaluate and treat concurring musculoskeletal changes in the cervical spine. Torticollis has been reviewed as a possible cause of plagiocephaly as well as a resulting symptom of.

Torticollis is defined as a postural deformity of the head and neck typically with the neck laterally flexed to the involved side and rotated to the opposite side. It is important to note that torticollis is a symptom and not a diagnosis. There are multiple possible etiologies and differential diagnosis is crucial. Its origins can be congenital or acquired. It is the 3rd most common musculoskeletal congenital anomaly to hip displagia and clubfoot. Some of the possible causes are SCM muscle fibrosis, bony deformities, ocular/visual development, Sandifer Syndrome involving hiatal hernia and esophagitis, neurological syndromes, osteoblastomas, and positional plagiocephaly. Left untreated, torticollis can profoundly affect visual skills, the development of midline, sensory organization, motor coordination, and postural compensations even scoliosis.

Torticollis that is found to have a muscular imbalance as its origin can be conservatively treated by a pediatric physical therapist. Treatment usually consists of a combination of active and passive exercises, neuromuscular reeducation, facilitation of development of age appropriate skills and movement patterns, family education and an appropriate home exercise program.

It is hoped that with the continuing education of physicians and families, the need for costly and burdensome treatment of positional plagiocephaly and torticollis can be greatly reduced.

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