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.
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.
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.
We don’t just look for flattening at the back of the 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.
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.
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.
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.
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.
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.
We’ll also be running some kinesiology tape during pregnancy workshops periodically throughout the year, so make sure you subscribe to our newsletter and follow our facebook page to keep up to date with these events.
We’re not talking about the BBC PROMS, or in fact anything to do with music. We’re talking about Patient Reported Outcome Measures (PROMs), and they’re far more exciting than the BBC version (in our humble opinion).
Patient Reported Outcome Measures are the tools with which healthcare practitioners and clinicians can better understand the impact illnesses or conditions and treatment are having on our patients’ daily lives. At Acorn Health, we utilise Care Response, a system which gathers the data for us and is supported by the Royal College of Chiropractors.
We don’t collect PROMs purely for our own benefit, it’s also for yours. We want to understand how your pain or problem is affecting your daily life- are you able to wash and dress yourself without pain? Is it stopping you from having a social life? Is it preventing you from working? Not only that, but we want to know how you feel about your pain. Are you worried it’s never going to get any better? Perhaps you’re scared about whether being physically active is going to make it better or worse and had to duck out of that golf game you had lined up. These are all very common concerns (so don’t worry if you’re having them- we all do!) and by understanding what your concerns are and how your pain is affecting you, we can provide a more accurate and more appropriate course of treatment for you. The responses to these questions will also indicate to us whether you are at a low, medium, or high risk of the problem becoming chronic (lasting for a long time) and this can mean that we need to provide you with very specific advice and information in order to prevent this happening- and yes, it can be done!
PROMs are starting to sound really good, aren’t they?
Another fantastic thing about PROMs is that they can tell us whether the treatment plan we have together decided upon is having the effect we want or not. Often, when pain decreases it can be difficult to remember just how bad it was (Remember that saying about giving birth? If we remembered how bad childbirth was we’d never have more than one child!) That being said, PROMs give us a way to determine your response to treatment based on your original responses to the questionnaire.
So how do we put PROMs to use in clinical practice, and how do they help inform our decision making and improve the care we provide our patients? We’ve got a case study here to explain it.
A bit of background- this Patient (let’s call them Patient X… sounds all mysterious and technical doesn’t it!) Anyway, Patient X had sustained a lower back injury in a road traffic accident more than a decade ago and had suffered with recurring episodes of lower back pain which, as seen by the chart below, were having a significant impact on their ADL’s (activities of daily living- things like washing, doing housework and sleeping) as well as their social life (going out to see friends, going to the gym, playing sports), the pain was a 6/10 and it was also making them anxious, depressed, having quite a severe impact on their working day and they had very little ability to cope with, control or reduce the pain themselves. All in all, not a very pleasant situation to find yourself in, but these results are fairly common in the patients we see in clinic. So much so, in fact, that Philippa takes a special clinical interest in chronic pain management– but that’s a story for another time.
The questions on the initial form are part of a validated assessment tool called the Bournemouth Questionnaire, and the answers are scaled on a 0 – 10 linear scale, 0 being “the pain has no interference” and 10 being variations of responses such as “completely unable to carry on” or “extremely anxious/extremely depressed.” As you can see, this patient was also at medium risk of chronicity due to some concerns they had about their back pain and what it meant for them, as they were worrying about it a lot of the time and felt that it was never going to improve.
We normally complete an outcome questionnaire after 2 weeks but in this particular case it was after 4, and Patient X completed this questionnaire which asked how their pain has changed, and also assesses the impact this pain is having on their lives at that time. This is where we get a bit geeky and excited- bear with us while we explain why.
Yes, as you can see below, Patient X’s pain level had increased at the time they completed the outcome questionnaire because (by their own report) the “Sciatic nerve in left leg has been irritated since last weekend” after spending a weekend doing a lot of heavy work in the garden…. they knew it wasn’t the best idea (!) However, despite the fact that they’d been doing quite hard physical work and had a slight flare-up as a result, they still reported they were “much improved” as a result of treatment, and their Bournemouth Questionnaire (the one that tells us how the pain is impacting on your day-to-day life) had reduced from 52/100 to 34/100 (which is computed as a 34.62% improvement!)
How is it possible that the pain could actually have increased, but Patient X felt better? Well, as we do with all our patients, we had a lengthy chat with Patient X about their pain, and how it was impacting them, and how they could manage it more effectively, as well as what we could do to help. Studies have shown that in some specific cases, a pain management course is actually more helpful than physical treatment, so we always include pain management as part of our treatment programmes. The more control you have over your pain, the less pain you feel. So through understanding pain and knowing what’s going on, what the cause was (in this case a mechanical issue with how a joint in the lower back was moving) what it isn’t (lower back pain is very rarely serious) and what to do about it (treatment and active self-management), Patient X felt less pain as they were less threatened by it, understood what was going on, were less concerned by the pain and able to move more normally without fear of pain.
After speaking to Patient X to establish what they felt had changed, the overall message was “I know what’s happening now, and I know what to do about it.” Woohoo! This is why it’s absolutely critical that we convey the right messages to you and help you to understand your pain. As practitioners, we also know that pain in itself is a really unreliable indicator of the severity of the underlying issue. To use our favourite analogy- think how painful a papercut can be despite the fact it’s a fairly minor injury. Pain in itself is just a symptom and studies have shown it does not relate to the severity of the underlying problem- in fact, some studies show that pain related fear is more disabling than the pain itself!
To understand more about pain and what causes pain, this should be your next bit of reading: Understanding Pain.
Let’s get back to Patient X, who today completed their final outcome assessment.
As you can see, the pain has dropped now to a 3/10. Those sections where Patient X reported were a 9/10 (ability to complete ADL’s and impact on social life) have dropped to a 3/10 and 2/10 respectively, impact on work was initially 7/10 and is now 0/10, anxiety and depression are both down from 7/10 to 1/10, and ability to cope with, control and reduce the pain was initially a 7/10 and is now a mere 2/10!
Whilst plenty of naysayers might say “Sure, but they’re not pain free and their Bournemouth Questionnaire isn’t zero.” If you had an illness or disease that lasted several years, would you take a few pills and expect it to be cured? No. Realistically, you’d hope that it would be better, as it is for this patient. Recovery takes time and is something that cannot be rushed. If you recall, Patient X’s problem had started over a decade ago, so we’re delighted that two months later the pain has improved this significantly. Not only that, but Patient X reports feeling “much improved” as well so we know they’re happy with how they’ve progressed- which gives us all sorts of warm fuzzy feelings. Hooray for job satisfaction!
So what happens now? At this stage, we’ll see a lot less of Patient X as they are formally discharged from care. The pain is now so minimal and intermittent that after discussing it with them, they’re happy to manage it themselves at home with stretches, exercises and lifestyle modifications (such as taking regular breaks from sitting whilst at work). We’ll check up on them in a few months to review their exercises, identify if there are any issues that have crept back on and this also gives us an opportunity to discuss their progress with them and if they have any further concerns. Of course, we’re always at the end of a phone or email, Facebook, Google+ or Twitter if they (or you) want to get in touch in the meantime!
We never guarantee 100% cure as nothing in medicine can. No pill, no operation, no treatment. There are no guarantees. What we do say at Acorn Health is that we will always give you the very best treatment and care, in accordance with the latest research guidelines and current evidence base. We can also say (thanks to another fancy PROMs questionnaire) that we have 100% satisfaction rates from every patient we’ve seen since we opened back in 2014, and that makes us very happy indeed.
So there’s a little overview and case study into how PROMs are put into use in clinical practice, and why we utilise them! If you’d like to know more, or would like to get in touch to book your own appointment, you can contact us using the form below.
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As part of our community initiative, we organised a British Red Cross Paediatric First Aid Course held on 5th October 2015 at the Emsworth Community Centre.
In 2012, over 3,000 babies in the UK died before their first birthday and over 2,000 children died between the ages of 1-19. The most common cause of death was injury. Recent estimates suggest that 21% of child deaths involved ‘modifiable factors’- in other words, something could possibly hav
e been done to prevent the death.
We were trained by Maggie from the British Red Cross, and covered lots of personal learning objectives which included everything from “What do I do if my child has swallowed something dangerous?” to “How do I handle a nosebleed?!”
Other key learning topics included:
– Dealing with an emergency
– Choking baby and child
– Unconscious breathing baby and child
– Unconscious not breathing baby and child (CPR)
– Fever and febrile seizures
– Head injury
– Severe allergic reactio
– Bleeding heavily
– Asthma attack
– Broken bones, strains and sprains
As you can see from the photos, we learnt how to perform CPR on babies and young children, how to tie a sling, and basic first aid techniques such as putting someone into the recovery position. The hands-on learning is invaluable as it gives you the confidence to perform the techniques- would you know how to do this in an emergency?
We hope to organise a series of these events, to be the first to find out about upcoming course dates please subscribe to our newsletter below.
To see more photos of what we got up to on the course, view the album here.
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!
We are also going to be announcing some new dates for our parent and baby workshops later on in the year, please like our facebook page for updates!
T: 01243 379693