As the NHS report ‘rationing’ hernia operations due to policy updates I can’t help but wonder if even half of these potential surgical patients have been recommended non-invasive treatments such as yoga, pilates, or hypopressives before considering the going under the knife.
Hypopressives is fantastic for posture, back pain and general wellbeing but also has proven results with prolapse, pelvic floor dysfunction, hernia prevention, incontinence and diastasis amongst other core and pelvic floor problems.
If your child has flat head syndrome, you might be wondering what to do about it and how to help your little one. Let’s find out more about the condition and the various gentle, conservative treatment options available for your baby.
What is flat head syndrome?
Flat head syndrome is a name commonly used to refer to brachycephaly and plagiocephaly- both conditions can also be referred to as “positional skull deformity”. Plagiocephaly is where one side of the back of the head becomes flattened, which may result in the front of the head protruding on the opposite side, and the ears positioned asymmetrically. Brachycephaly is symmetric flattening of the back of the head, which can cause the ears to appear prominent and the head appear wide.
There has been a significant increase in the number of babies presenting with flat head syndrome possibly due to the introduction of the “Back to Sleep” (now known as “Safe to Sleep”) positioning recommendations aimed at reducing the risk of Sudden Infant Death Syndrome. Since the early 1990’s parents have been advised to let babies sleep on their backs, and whilst this has been successful in reducing the number of cot deaths, it has lead to an increase in the number of babies with deformational plagiocephaly and brachycephaly.
What causes flat head syndrome?
It can happen during your pregnancy with uterine constraint (when your baby doesn’t have enough room in the womb- especially common in the case of multiple births such as twins) or as a result of birth injury from forceps or vacuum assisted delivery. More commonly, it occurs after birth and is associated with congenital torticollis (or ‘wryneck’), abnormalities of the bones in the spine, neurological impairment (problems affecting the nervous system) or forced sleeping position.
The associated torticollis can occur due to strains of the sternocleidomastoid, a muscle in the
front of the neck, which can occur during difficult deliveries. This muscle trauma the baby’s head into an awkward position, thus exacerbating (or in fact causing) the skull deformity. Wryneck may also cause issues with breastfeeding, as the baby is unable to comfortably turn the head to latch properly- if your baby can’t latch to one side or can’t turn their head to one side, they may have torticollis.
Premature babies are at a higher risk of developing skull deformities as the cranial bones become harder and stronger during the last 10 weeks of pregnancy. Premies may also spend longer periods of time in neonatal ICU on a respirator to help develop their lungs, as a result their heads are maintained in a fixed position.
More commonly, babies are born with a normal head shape which gradually becomes flattened or altered as a result of the position they lie in.
What we look for when diagnosing flat head syndrome
We don’t just look for flattening at the back of the head:
One ear may be placed slightly further forward than the other
One eye may appear larger than the other
One cheekbone may be more pronounced than the other
There may be a subtle (or not-so-subtle) head tilt
The child or baby may have reduced neck movement and are unable to rotate their neck themselves away from the flattened side of the occiput.
In older children, they may have delayed motor development or have failed to achieve certain developmental milestones
Why does it matter if my baby has a flat head?
It’s not just about appearance. Most advice seems to be that once baby’s hair grows out, skull deformities will be “hardly noticeable.” There is a growing body of research which suggests that children with plagiocephaly or brachycephaly need to be monitored for developmental delays or deficits. One study states that “Infants with deformational plagiocephaly comprise a high-risk group for developmental difficulties presenting as subtle problems of cerebral dysfunction during the school-age years.” Another study found that children with plagiocephaly were more likely to require special education services in school than their non-affected siblings (34.9% vs. 6.6%, respectively). The services they required included speech therapy, occupational therapy and physical therapy.
Whilst it is important to note that these findings do not imply that developmental plagiocephaly causes developmental problems, it may instead serve as a marker for developmental risk.
In addition, skull deformities may contribute to headaches, migraines, painful teething, jaw and dental problems. It is therefore recommended that treatment takes place as early as possible, in order to restore normal head shape.
One of the most commonly reported concerns from parents of children with flat head syndrome is their physical appearance and the possibility that he or she will be teased, embarrassed or otherwise stigmatised because of their condition. Parents often first notice the condition through the appearance of uneven bald spots on the back of their little one’s head.
There are numerous treatment options available, and if you are looking for gentle, non-invasive options for your little one there are several to consider. Hands-on treatment and exercises will help to alleviate the strain to the sternocleidomastoid muscle causing the torticollis and encourage normal neck movement in addition to helping to correct the skull deformation. Monitoring for neurodevelopment problems helps to ensure your baby achieves all their developmental milestones.
There is evidence to support the use of chiropractic care in managing flat head syndrome, which states “there was both a statistically and clinically significant reduction in plagiocephaly measurement for this cohort of infants after a course of chiropractic care. As this was an observational study, this cannot be interpreted as cause and effect. However, these results encourage further research, particularly an RCT to investigate the effect of chiropractic care on plagiocephaly in infants.”
Products are available which can be helpful , including pillows for the cot (most are not recommended for use when baby is unsupervised) and car seat, beanie caps, slings and wraps to help reduce the amount of time baby spends on their back.
Cranial molding headbands or helmets are what is often recommended. Helmets can be expensive, uncomfortable (they need to be worn 23 out of 24 hours in the day) and can cause excessive sweating and skin problems due to pressure or friction spots. Fortunately the designs for these are being improved to help make them more comfortable for little one.
How can I help my baby at home?
Tummy time is of the utmost importance. This helps develop shoulder girdle strength which is important for motor milestones such as crawling and eventually walking. In addition, it reduces the time spent lying on their back.
Repositioning: This is best started as early as possible and is most effective with babies under four months of age. Alternating the position your baby lies in at night can also help. Babies tend to prefer to face outward into the room, and being creatures of habit we may be tempted to always place them the same end of the crib. As such, routinely changing this is important.
Place cot toys and mobiles on the opposite side to the ‘flat’ side to encourage your baby to spend time on the side that is not flattened.
Position your little on the opposite end of the changing table when changing nappies. This helps in the same way altering their position in bed does, by encouraging them to look to the opposite side whilst being changed.
Ask your practitioner to show you exercises to help baby at home, such as gentle neck stretches for the sternocleidomastoid for babies with torticollis.
Bialocerkowski AE, Vladusic SL, Wei Ng C (2008) Prevalence, risk factors, and natural history of positional plagiocephaly: a systematic review. Dev Med Child Neurol 50(8):577–586
Boere-Boonekamp MM, van der Linden-Kuiper AT (2001) Positional preference: prevalence in infants and follow-up after two years. Pediatrics 107:339–343
Cabrera-Martos I, Valenza MC, Benítez-Feliponi A, Robles-Vizcaíno C, Ruiz-Extremera A, Valenza-Demet G (2013) Clinical profile and evolution of infants with deformational plagiocephaly included in a conservative treatment program. Childs Nerv Syst 29(10):1893–1898
Cabrera-Martos et al. (2016) Effects of manual therapy on treatment duration and motor development in infants with severe nonsynostotic plagiocephaly: a randomised controlled pilot study. Child’s Nervous System 32 (11) 2211-2217.
Collett et al (2012) Neurodevelopmental implications of “deformational” plagiocephaly. J Dev Behave Pediatr. 26 (5) 379-389.
Douglas et al (2016) Chiropractic care for the cervical spine as a treatment for plagiocephaly: a prospective cohort study. Journal of Clinical Chiropractic Pediatrics. 15 (3)
Knight, Sarah J., et al. “Early neurodevelopment in infants with deformational plagiocephaly.” Journal of Craniofacial Surgery 24.4 (2013): 1225-1228.
Korpilahti, Pirjo, Pia Saarinen, and Jyri Hukki. “Deficient language acquisition in children with single suture craniosynostosis and deformational posterior plagiocephaly.” Child’s Nervous System 28.3 (2012): 419-425.
Lessard S, Gagnon I, Trottier N (2011) Exploring the impact of osteopathic treatment on cranial asymmetries associated with nonsynostotic plagiocephaly in infants. Complement Ther Clin Pract 17(4):193–198
Miller, R.I., Clarren, S.K. (2000) Long-term developmental outcomes in patients with deformational plagiocephaly. Pediatrics. 105 (2)
Persing et al (2003) Prevention and management of positional skull deformities in infants. Pediatrics. 112 (1)
Schertz, Mitchell, Luba Zuk, and Dido Green. “Long-term neurodevelopmental follow-up of children with congenital muscular torticollis.” Journal of child neurology 28.10 (2013): 1215-1221.
I saw a lovely lady in clinic today who was suffering with symphysis pubis dysfunction (SPD), which had been bothering her since she was just 16 weeks along in her pregnancy (she’s now nearing her due date). This is quite a common reason for people coming to see me in clinic, so let’s talk about pelvic girdle pain and how a chiropractor can help you.
Pelvic girdle pain (PGP) is common, but not normal, and as anyone will tell you, being in pain can really sap the joy out of your pregnancy. Symphysis pubis dysfunction is now broadly categorised as PGP- an umbrella term for all pain in the pelvic area which could include the lower back, abdomen, hips and thighs. PGP can cause back, hip and groin pain, disrupt your sleeping and affect your walking, amongst other issues. It’s really not fun! Just to complicate matters further, SPD can affect you at any time during your pregnancy, and sometimes even after giving birth (if not managed appropriately). Needless to say, this can cause physical discomfort and emotional distress so it is important to seek help early on- the sooner treatment begins, the sooner you’ll feel better.
What is Pelvic Girdle Pain?
Pelvic girdle pain simply means pain in the joints of the pelvic girdle, including the two sacroiliac joints at the back of your pelvis and the symphysis pubis joint at the front of your pelvis. Dysfunction within the pelvic girdle can affect the pelvic floor (the basket of muscles which hang from the bones of our pelvis), and if the pelvic bones are rotated or dysfunctional, the muscles don’t hang (or function) correctly, affecting spreading of the pelvic floor muscles and symmetrical dilation of the cervix during labour. This can lead to a difficult birth process for both mum and baby, but fortunately if good care has been taken to protect the pelvic girdle from additional strain and trauma, most women with PGP can have a normal vaginal birth. If you are concerned about the birth process, do discuss this with your practitioner, midwife or GP.
SPD can worsen as the baby increases in weight, as a result of postural changes as pregnancy advances, and resultant changes in the body’s centre of gravity. During pregnancy, our body releases a hormone called relaxin which softens our ligaments (which are like strong elastic bands which connect our joints)- this is to allow the baby to pass through the pelvis during birth, and normally lax ligaments in the pelvis during pregnancy do not cause an issue, however uneven movement in the pelvic joints (often termed “misalignment”) or imbalance in the muscles can cause irritation to the joints of the pelvis, resulting in pain.
To a chiropractor there are numerous other issues in the pelvis that can cause PGP without it being SPD (Gosh, that’s a lot of abbreviations!) so it’s important to rule out other possible causes before working on a diagnosis of SPD.
What are the symptoms of PGP?
Pain in the joints of the pelvis
Clicking or grinding in the pelvic area
Pain on weightbearing on one leg (for example when climbing stairs)
Pain when performing straddle movements (for example getting in or out the car or bath)
Difficulty lying in particular positions (often side-lying)
Pain during intercourse
Why do some pregnant ladies develop PGP and others don’t?
It’s hard to say… the research in this area is largely inconclusive when it comes to identifying risk factors for developing pelvic girdle pain, but we do know one of the major reasons for developing back pain in pregnancy and having difficulties during labour is poor musculoskeletal health in the mother. Why? Well, a job that involves a lot of sitting down and little exercise out of work can mean that the tone and activity in the muscles that stabilise the pelvis (such as the abdominals, pelvic floor muscles and the gluteal muscles in the buttocks) is reduced, and they struggle to tolerate additional stress during pregnancy which can lead to ongoing discomfort.
Around 20% of pregnant women will develop some form of pelvic girdle pain during pregnancy and we know that other risk factors include a history of pelvic or lower back pain (both during pregnancy and when not pregnant). The good news is that whilst 1-2 % of patients may have persistent pain one year after giving birth, in 93% of cases, the symptoms of PGP settle within the first 3 months post delivery.
What can be done to help pelvic girdle pain and symphysis pubis dysfunction?
Pregnant patients require a gentle, drug-free alternative for treating their discomfort and so seeking chiropractic care is a logical choice as it is a safe and effective treatment option, not only for treatment of pelvic girdle pain but also other musculoskeletal problems that may arise during pregnancy. Not only that, but it can help avoid a difficult labour, may mean you can stay at work longer and can reduce long-term disability.
Chiropractic treatment doesn’t just involve manual adjustments of the spine (chiropractic care is SO much more than that). We use numerous gentle techniques during treatments including soft tissue work, fascial release, acupuncture, exercises, postural advice (including optimal foetal positioning) and perhaps most importantly, we work with you to ensure you understand your condition and know how to manage it. Chiropractic treatment is recommended for pelvic girdle pain by the Pelvic Obstetric and Gynaecological Physiotherapy- you can read their guidance on PGP here.
In the case of our patient, we adjusted the sacroiliac joints and pubic symphysis, but in addition we also adjusted the thoracic and lumbar spine, and released the diaphragm and psoas muscles in the abdomen as we know that these abdominal muscles are key contributors to pelvic pain. Remember- only a fool treats where the pain is, so as chiropractors we have to make sure that all factors contributing to the pain have been addressed! Our patient also went away with some kinesiology tape on her pelvis for support- more about that here.
Is there anything else I can do to help?
Yes- there are some simple exercises that you can do at home to help alleviate discomfort. In addition to giving you exercises we also advise you on ways to move that will help protect your pelvis and avoid aggravating the condition. Always speak to your practitioner to determine if an exercise is appropriate before attempting it. All the exercises we provide our patients are bespoke to them based on the results of their examination.
Sometimes a pelvic belt can offer relief, particularly when you’re up and moving around. We prefer to use kinesiology tape to help our pregnant patients as this provides support to the structures without limiting movement.
Aas-Jacobsen E. and Miller J. (2010) Chiropractic care during pregnancy: survey of 100 patients presented to a private clinic in Oslo, Norway. JCCP. Vol. 11. No.2. 771-774.
Andrew C. and Dorey G. (2008) Pelvic girdle pain in three pregnant women choosing chiropractic management: a pilot study using a respondent generated instrument and chiropractor’s assessment tool. Journal of the Association of chartered physiotherapists in women’s health. 102. p.12-24.
Andrew. C and Pedersen P. (2003) A study into the effectiveness of chiropractic treatment for pre- and post partum women with symphysis pubis dysfunction. European Journal of chiropractic. 48. P. 77-95
Borggren, C.L. (2007) Pregnancy and chiropractic: a narrative review of the literature. Journal of Chiropractic Medicine. 6 (2) 70-74
Daly, J.M., Frame, P.S., Rapoza, P.A. (1991) Sacroiliac subluxation: a common, treatable cause of low-back pain in pregnancy. Fam Pract Res J. 11(2) 149-59.
Elden, Ostgaard, Fagevik-Olsen, Ladfors Hagberg: Treatments of pelvic girdle pain in pregnant women: adverse effects of standard treatment, acupuncture and stabilising exercises on the pregnancy, mother, delivery and the fetus/neonate. BMC Complementary and Alternative Medicine 2008, 8:34doi:10.1186/1472-6882-8-34.
Howell, E.R. (2012) Pregnancy-related symphysis pubis dysfunction management and postpartum rehabilitation: two case reports. The Journal of the Canadian Chiropractic Association. 56(2) 102-111.
Kanakaris, N.K., Roberts, C.S., Giannoudis, P.V. (2011) Pregnancy-related pelvic girdle pain: an update. BMC Medicine 9:15.
Peterson, C.K., Mühlemann, D., Humphreys, B.K. (2014) Outcomes of pregnant patients with low back pain undergoing chiropractic treatment: a prospective cohort study with short term, medium term and 1 year follow-up. Chiropractic & Manual Therapies. 22:15
Vleeming, A., Albert, H.B., Östgaard, H.C., Sturesson, B., Stuge, B. (2008) European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal. 17 (6) 794-819
We’ve received some really exciting news today- Philippa has been accepted into the Royal College of Chiropractor’s specialist Pregnancy and Paediatrics Faculty!
Philippa is also a Licenciate to the Royal College’s specialist Pain Faculty– these faculties recognise chiropractors who have undertaken formal postgraduate studies and have specialist knowledge and expertise in their particular fields. Being accepted to these specialist faculties allows Philippa the opportunity to further her skills and learning, take an active role in latest research and develop the evidence base relevant to each field. Exciting times for us at Acorn Health!
The Role of the RCC’s Specialist Faculties
Recognise experience and qualifications relevant to each subject area
Foster open inquiry and debate among practitioners and the wider healthcare community
Encourage further, relevant continuing professional development and study
Define and uphold the competencies of Specialist Faculty members as they pertain to each subject area
Review, disseminate and develop the evidence-base in each subject area
Support specialist faculty members in developing and extending skills and knowledge in relevant subject areas
Kinesiotape is an elasticated cotton tape that can aid function and reduce pain in many injuries and musculoskeletal conditions.
Kinesiotape helps to stabilise joints whilst still allowing them to move through their normal range of motion, as well as providing gentle support to muscles and ligaments under strain, making it a helpful treatment modality for pregnant women. Low back and pelvic girdle pain is a common problem during pregnancy, as well as pain from the round ligaments (ligaments which surround your uterus in your pelvis)- this type of pain often feels like a sharp jab in your lower abdomen or groin. In pregnant women, taping is most commonly used across the lower belly for support, creating a sling or belt around her body to help evenly distribute the weight of a growing baby.
As your bump gets bigger, the lower back muscles have to work harder and harder to stabilise and support your lower back and pelvis. Kinesiotape can be used to support the back or abdomen (or indeed any other areas that are sore and achey!) and help to alleviate some of the postural aches and pains associated with a growing bump!
Interestingly, kinesiotape is also thought to help improve the flow of the lymphatic system, the system in our body responsible for transporting waste products, bacteria and cell debris out of our body. On the skin, the kinesiotape pulls the upper layers of skin, creating more space (known as interstitial space) between the dermis and the muscle. This space is thought to relieve pressure on the lymphatic system by allowing lymph flow and better lymphatic drainage, which helps promotes healing. Really helpful for mums prone to swollen ankles, as it can help to alleviate that swelling!