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Effectiveness of Conservative Therapy and Helmet Therapy for Positional Cranial Deformation

Steinberg, Jordan P. M.D., Ph.D.; Rawlani, Roshni B.A.; Humphries, Laura S. M.D.; Rawlani, Vinay M.D.; Vicari, Frank A. M.D.

Plastic and Reconstructive Surgery: March 2015 - Volume 135 - Issue 3 - p 833–842
doi: 10.1097/PRS.0000000000000955
Pediatric/Craniofacial: Original Articles
Press Release
Video Discussion
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Background: The authors investigated the effectiveness of conservative (repositioning therapy with or without physical therapy) and helmet therapy, and identified factors associated with treatment failure.

Methods: A total of 4378 patients evaluated for deformational plagiocephaly and/or deformational brachycephaly were assigned to conservative (repositioning therapy, n = 383; repositioning therapy plus physical therapy, n = 2998) or helmet therapy (n = 997). Patients were followed until complete correction (diagonal difference <5 mm and/or cranial ratio <0.85) or 18 months. Rates of correction were calculated, and independent risk factors for failure were identified by multivariate analysis.

Results: Complete correction was achieved in 77.1 percent of conservative treatment patients; 15.8 percent required transition to helmet therapy (n = 534), and 7.1 percent ultimately had incomplete correction. Risk factors for failure included poor compliance (relative risk, 2.40; p = 0.009), advanced age (relative risk, 1.20 to 2.08; p = 0.008), prolonged torticollis (relative risk, 1.12 to 1.74; p = 0.002), developmental delay (relative risk, 1.44; p = 0.042), and severity of the initial cranial ratio (relative risk, 1.41 to 1.64; p = 0.044) and diagonal difference (relative risk, 1.31 to 1.48; p = 0.027). Complete correction was achieved in 94.4 percent of patients treated with helmet therapy as first-line therapy and in 96.1 percent of infants who received helmets after failed conservative therapy (p = 0.375). Risk factors for helmet failure included poor compliance (relative risk, 2.42; p = 0.025) and advanced age (relative risk, 1.13 to 3.08; p = 0.011).

Conclusions: Conservative therapy and helmet therapy are effective for positional cranial deformation. Treatment may be guided by patient-specific risk factors. In most infants, delaying helmet therapy for a trial of conservative treatment does not preclude complete correction.


Video Discussion by Kant Lin, M.D., is available online for this article.

Chicago and Park Ridge, Ill.

From the Ann and Robert H. Lurie Children’s Hospital of Chicago; the Division of Plastic Surgery, Northwestern University Feinberg School of Medicine; and the Advocate Medical Group, Lutheran General Hospital.

Received for publication March 25, 2014; accepted September 26, 2014.

Presented in part at the 81st Annual Scientific Meeting of the American Society of Plastic Surgeons, in New Orleans, Louisiana, October 26 through 30, 2012; and at the 92nd Annual Meeting of the American Association of Plastic Surgeons, in New Orleans, Louisiana, April 20 through 23, 2013.

Disclosure: The authors have no financial interest in any of the products or devices mentioned in this article. There were no sources of funding for this work.

A Video Discussion by Kant Lin, M.D., accompanies this article. Go to and click on “Video Discussions” in the “Videos” tab to watch.

Frank A. Vicari, M.D., Advocate Medical Group, Lutheran General Hospital, 1675 Dempster Street, 3rd Floor, Park Ridge, Ill. 60068,

©2015American Society of Plastic Surgeons