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The Effect of Torticollis on Helmet Therapy for Deformational Plagiocephaly
Emma M. Kulig, BA, Chelsea R. Horwood, BA, Sarah A. Donigian, BA, Alexander Y. Lin, MD.
Saint Louis University School of Medicine, St. Louis, MO, USA.
Purpose: Children with deformational plagiocephaly frequently have some degree of relative neck muscle imbalance, or torticollis. It is unclear whether torticollis leads to positional preference in sleeping, or the preferential sleep position limits neck flexibility, but it is commonly thought that concomitant torticollis makes deformational plagiocephaly treatment more refractory. It is therefore possible that torticollis could affect the age of diagnosis and treatment of deformational plagiocephaly, duration and effectiveness of helmet therapy, initial and final transcranial differences, or ultimate helmet therapy outcomes. Among patients undergoing helmet therapy for deformational head shape problems, we compared between those diagnosed with torticollis and those who did not have torticollis.
Methods: Patients with deformational plagiocephaly who underwent helmet orthotic treatment from 2006 to 2013 were retrospectively reviewed. The helmet orthotist recorded standard cranial measurements at each helmet adjustment visit, and only patients who completed their treatment course with final measurements were included. Patients who were lost to followup before being discontinued from helmet therapy, or did not have explicit mention of presence or lack of torticollis, were excluded. Continuous variables were compared with parametric tests (t-tests), and categorical variables were compared with chi-square tests.
Results: 155 patients met the inclusion and exclusion criteria. Torticollis (T) was seen in 60% (93/155), and no torticollis (NT) was found in 40% (62/155), p=0.151. Helmet therapy was initiated at age in months adjusted for prematurity (with range): T 6.13 (±1.4), NT 6.6 (±1.89), p=0.096. Asymmetry was measured by transcranial difference (TCD) between frontozygomatic-to-eurion diagonals in millimeters, with initial TCD: T 11.2 (±2.8), NT 8.4 (±4.3), ***p < 0.001; final TCD: T 4.2 (±2.3), NT 3.5 (±2.3), p=0.086; change in TCD: T 7.7 (±2.9), NT 4.9 (±4.3), ***p<0.001. The duration of therapy in months was: T 3.91 (±1.63), NT 3.73 (±1.67), p=0.516; with rate of TCD change (mm/month) being: T 2.3 (±1.2), NT 1.7 (±1.6), *p=0.006.
47% (69/146) of torticollis patients underwent physical therapy (PT) for neck exercises, and their average final TCD (in mm) was 4.4 (±2.6), compared to those who did not get PT at 3.7 (±2.1), p=0.069.
Conclusions: Our data suggest that torticollis does not significantly affect effectiveness or duration of helmet therapy. Although torticollis patients had greater initial transcranial differences (TCD) as would be expected, they ended with similar final TCD measurements, and surprisingly, helmet therapy duration was similar despite the worse initial asymmetry. This greater rate of TCD change is not explained by the similar age at initiation of helmet therapy. In addition, infants with torticollis who received physical therapy did not have improved final transcranial differences as compared to those who did not receive physical therapy. These results suggest that although torticollis and deformational plagiocephaly often occur handinhand, once the decision to proceed with helmet therapy has been made, their outcomes appear to proceed independently. Therefore, treatment can remain independent, with helmeting for the deformational plagiocephaly, and physical therapy for the torticollis.
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