In a literature review comparing orthotic treatment to repositioning protocols among children with posterior positional plagiocephaly, different orthotic treatments, such as helmets and concave pillows, were found to correct head deformities better and faster than repositioning protocols.

“The nonsurgical management techniques of posterior positional plagiocephaly are the repositioning programs, cranial orthosis and sometimes a wait-and-see policy with the hope of spontaneous correction. If the decision of any management is taken, it must be made early in order to be supported by the remodeling capacities due to the growth of the skull,” Julie Paquereau, of the physical medicine and rehabilitation neuroscience division at the Centre Hospitalier Sainte Anne, wrote. “In this context, we decided to perform a literature review of the articles comparing the efficacy of the noninvasive management techniques of posterior positional plagiocephaly. The objective was to provide some elements of answer in order to learn more about the most efficient nonsurgical management of posterior positional plagiocephaly.”

Repositioning vs. orthosis

Paquereau found 12 cohort studies and six literature reviews that compared nonsurgical methods of management of posterior positional plagiocephaly, including use of an orthosis and repositioning sometimes associated with stretching exercises of the cervical muscles.

According to study results, eight studies showed better efficacy of orthotic management compared with repositioning, especially with remolding helmets worn day and night or a concave pillow orthosis. Two of the six literature reviews did not demonstrate evidence of the benefit of using a helmet orthosis vs. repositioning or absence of treatment. The studies also showed that orthotic intervention before age 1 year allows a better correction of the cranial deformity.

“The benefits of the orthosis have been underestimated by several biases in some studies. Yet there seems to be a trend in favor of a greater efficacy of the correction of asymmetry by cranial orthosis — helmet, or custom-made pillow system — than by the repositioning programs,” Paquereau concluded. “This was particularly clear in cases of severe posterior positional plagiocephaly where the orthosis could correct better and faster.”

Bias and limitations

However, Paquereau found several limitations while evaluating the studies and literature reviews. One limitation includes disparities and a weak power of methodology because of the six reviews and the 12 original articles, only two trials were randomized.

A source of bias included the absence of standardized criteria for the evaluation of cranial asymmetry, such as no solid evidence for the validity and the reproducibility of the anthropomorphic measurements, insufficient evaluation of the surface scanners and loss of data secondary to the two-dimensional evaluation. Paquereau also found the use of non-validated subjective scales, sometimes based only on visual evaluation, was problematic because it limited the objectivity of the studies.

Studies that distributed the participants into groups presented bias especially when the parents decided, possibly on the suggestion of the examiners.

The repositioning group was mainly favored by several types of bias, including when plagiocephalies resistant to the repositioning treatment were secondarily included in the orthosis group and treatment duration in the orthosis group tended to be shorter.

Finally, only two studies extended the follow-up beyond the end date of the plagiocephaly management programs, which, according to Paquereau, did not allow with certainty that the cranial asymmetry reduction obtained with the orthosis was maintained with time. Also, while several studies recalled a link between posterior positional plagiocephaly and cognitive and development delay, no author studied the consequences of a reduction of the cranial deformities on these cognitive difficulties.

“Preventing posterior positional plagiocephaly seems essential to us. The results of the quoted studies need to be balanced by the biases inherent to the protocols used,” Paquereau wrote. “However, and despite a few conflicting results, these articles seem to show a higher efficacy of the management by cranial orthosis of posterior positional plagiocephaly compared to repositioning, especially in moderate to severe plagiocephalies.” — by Casey Murphy

For more information:
Paquereau J. Ann Phys Rehabil Med. 2013;doi:10.1016/

Disclosure: Paquereau has no relevant financial disclosures.

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