Prevention and Early Intervention of Torticollis/Plagiocephaly for At-Risk Infants

Prevention and Early Intervention of Torticollis and Plagiocephaly for At-Risk Infants

By: Rachel Earnhardt, SPT

 

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Background

I have always enjoyed interacting with kids and babies, and have spent some time now at UNC focusing on this area of physical therapy with the goal of working in pediatrics upon graduation. During my UNC Hospital clinical rotation, I was able to spend a week at the Pediatric Department and fell in love with the neonatal intensive care unit (NICU). I then worked for 8 weeks in a private outpatient pediatric clinic, where my clinical instructor saw many infants who presented with torticollis (shortened muscles on one side of the neck) and/or plagiocephaly (flattened or misshapen head).^1,2 I chose to focus my Critically Appraised Topic in Evidence Based Practice II on different treatment methods used for these conditions. The topic led me to a number of therapy principles and techniques that directly impact the development and growth of infants. An overarching theme that presented was the lack of awareness in parents and guardians of tools they can use to facilitate movement and development. Based on this information, I formed an idea for my capstone project.

 

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Statement of Need

Since the Back-to-Sleep campaign, there has been a significant rise in head shape deformities for newborns, with higher prevalence in preterm infants and those spending time in the NICU.³ Torticollis and plagiocephaly tend to present adjunctly, as head shape may be altered due to side preference and visa-versa. For plagiocephaly especially, there is a small window of time for interventions to be effective, and if the baby is not treated, it could cause developmental delays and other issues as they get older (aesthetics, vision problems, breathing and hearing problems, being able to fit hats/glasses, etc.).⁴ During physical therapy treatment sessions for these patients, there is a lot of education for the parents on movements, positioning, and stretching to help their child. In discussion with many new parents, they are unaware of the potential for this condition and the easy ways to help prevent it. There are many prevention and early treatment methods, but there is limited access for families of at-risk infants to receive this information before there is noticeable malalignment seen in either the follow-up clinic or the general pediatrician.

 

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Project Overview & Purpose

There are many resources available for families once a baby is being treated for torticollis/plagiocephaly, as physical therapy clinics have an abundance of handouts and guides in the clinic. There does, however, seem to be a gap in materials provided before the infant develops either condition. Many of the suggested treatment methods can be used as preventative measures, but in reality can only be used if one is aware of their existence. Based on experience in the clinic and interactions with families, numerous new parents have limited knowledge of either condition, the importance of tummy time, and strategies to promote motor development at home.

After an infant is discharged from the NICU, the family will return home and potentially still receive supervised care. However, there can be large gaps in the time between discharge and when a family returns to a follow-up clinic or pediatrician, often several months. With infant cranial growth occurring exponentially over the first year of life, a month’s time could make a substantial impact on development.⁵ The creation of quick reference and resource guides, given to parents/guardians upon hospital discharge, could potentially change this occurrence.

 

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The Project 

The critically appraised topic (CAT) on torticollis/plagiocephaly treatment methods compared helmet therapy, physical therapy, and repositioning therapy. Different treatments were applied over differing timelines, attempting to synthesize the efficacy of such methods. This CAT helped set the foundation and direction of the other products.

The evidence table analyzes current literature in terms of risk factors, prevalence, prevention methods, early treatment methods, and long term outcomes for at-risk infants.

An educational brochure, or parent pamphlet, given at hospital discharge could be an effective way for parents of at-risk infants to become more knowledgeable, and spread the information to a wider audience.

A YouTube video was created to provide instruction and demonstration of several handling methods and tools parents/guardians could use for infants to promote even development. These tools can be used during feedings, diaper changes, play time, holding the baby, and more. In addition, the video describes how an individual could easily check the infant’s head for symmetry at home. Link: https://www.youtube.com/watch?v=5GxncbWmwyE

By providing these products, there will hopefully be greater awareness and concern for torticollis and plagiocephaly, which will lead to improved identification, earlier treatment, and better outcomes.

 

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Health Literacy

Since my project is geared towards parents and families, health literacy is an important aspect of the finished products. I completed viewing the voicethreads and reviewed the information on the Capstone wiki for health literacy. I incorporated the information into how I structured my parent pamphlet and the script for the YouTube video. The aim of the pamphlet was to be at a 6^th grade reading level, and the video to use simple language through the voiceover. If any medical/health terms were introduced, they were defined for basic understanding. It was challenging to complete this task and convert physical therapy concepts into layman’s terms. While analyzing the materials for language literacy, I also considered formatting and simplicity of the message in order to give the information without overwhelming the reader or viewer. I tried to incorporate photos to enhance the message, use bullet points or lists, and have 2-3 take-away messages in the products. I decided not to include references on the parent pamphlet to promote ease in reading, but had them available if there was greater interest. I consulted with many friends and family members of various educational levels to ensure all were able to understand what was being provided, as well as received feedback from committee members for structure and terminology.

 

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Evaluation

My committee members provided feedback throughout the semester on the products in terms of readability, layout, and content in order for them to most useful to parents and families.

As this project targets at-risk infants discharged from the hospital and would need to follow the families over time, direct feedback was not applicable at this stage. For formal evaluation, I have created a proposed evaluation form for parents/guardians to fill out at the 1-year follow-up visit to the clinic. This assesses the materials’ ease of access, usefulness of information, parent understanding of material, etc. The provided form will be given to parents/guardians in paper format, but can be viewed currently through the following link: Parent Feedback Form

 

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Self-Assessment

I chose to complete this capstone project as I saw a need through both the clinic and family/friends. In patient and family interactions, I was astounded that many had not learned about the importance of tummy time and different tools they could use at home to help prevent torticollis and plagiocephaly. It meant a great deal to me to be able to learn more and work with a population I am passionate about and help towards my goal of working in a pediatric department of a hospital or outpatient pediatric clinic that sees many infants.

While there was a great deal of interest in the project, it was not without its challenges. First, simply deciding on what products to create was a big discussion piece. There was the matter of where to give the information, who would be best served with it, and how to present it. This particular step helped me in thinking about the bigger picture of health care and how to use other providers and technology to better help patients. It was also challenging for me to find good quality, relevant research to incorporate into my products and reflect evidence-based practice. Using tools learned from our Evidence Based Practice course was essential in learning how to sort through current articles and publications. Additionally, scheduling to work with infants and their families was difficult in its own sense, as many parts had to coordinate to create the products. I learned quite a bit about scheduling, discussion with parents/families, and education of the physical therapy role in a child’s life. This was my first time creating educational material for parents/guardians as well as uploading a video onto YouTube, so I learned a lot about formatting, visual aesthetics, health literacy, user friendliness, and technology in general. While I wish I could have include some different things into my products, I am overall extremely happy with my capstone project. I hope to continue to expand on these tools when working with patients and families in the future to promote the ability to move, reduce pain, restore function, and prevent disability.

 

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Acknowledgements

I would like to thank several individuals who played a vital role in the success of this project. My committee member Dr. Dana McCarty, PT, DPT, PCS, C/NDT, for her extensive knowledge of this population. Her research and experience in treatment for at-risk infants were invaluable in terms of feedback and direction for the project. My other committee member Dr. Kerry Blazek, PT, DPT, PCS, for her vast knowledge of this population as well. Her current position working in the NICU and follow-up clinic at UNC-Hospitals made her a tremendous resource for parent and family needs and suggestions for treatment. My advisor Dr. Deborah Thorpe, PT, PhD, for being an essential guide throughout the project. Her willingness to meet to discuss ideas, providing useful resources and educational opportunities, feedback, and direction were instrumental in making this project attainable. All members of the committee provided incredible feedback and suggestions for current and future directions of the project. Lastly, a large thank you is warranted to my family, specifically my cousin Krystal Reece, for allowing me to use her baby girl as the star for the YouTube video. It has been a pleasure working with every single person who has assisted in this project and I am looking forward to opportunities to work with them in the future!

 

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References

1. Martiniuk ALC, Vujovich-Dunn C, Park M, Yu W, Lucas BR. Plagiocephaly and developmental delay: A systematic review. J Dev Behav Pediatr 2017;38(1):67-78. doi:10.1097/DBP.0000000000000376.
2. Ballardini E, Sisti M, Basaglia N, et al. Prevalence and characteristics of positional plagiocephaly in healthy full-term infants at 8-12 weeks of life. Eur J Pediatr 2018;177(10):1547-1554. doi:10.1007/s00431-018-3212-0.
3. Wittmeier K, Mulder K. Time to revisit tummy time: A commentary on plagiocephaly and development. Paediatr Child Health 2017;22(3):159-161. doi:10.1093/pch/pxx046.
4. Linz C, Kunz F, Böhm H, Schweitzer T. Positional Skull Deformities. Dtsch Arztebl Int 2017;114(31-32):535-542. doi:10.3238/arztebl.2017.0535.
5. Lennartsson F, Nordin P, Wennergren G. Teaching parents how to prevent acquired cranial asymmetry in infants. J Pediatr Nurs 2016;31(4):e252-61. doi:10.1016/j.pedn.2015.12.010.

Please See Evidence Table for Additional References

*signed consent was received by the mother of the infant before any posting of videos