We read with great interest the article, “Effectiveness of Conservative Therapy and Helmet Therapy for Positional Cranial Deformation” by Dr. Steinberg et al.1 We would like to congratulate the authors on their work comparing conventional therapy with helmet therapy in the treatment of deformational plagiocephaly and deformational brachycephaly. Although numerous studies have looked into this matter without a clear consensus, this study has raised several interesting issues.
Deformational cranial anomalies can cause significant distress to parents, as their wish for a perfect child is lost. Many parents request helmet therapy, which in the United Kingdom can cost approximately £2500, with no proven benefit. Moreover, many parents are unaware of the complications and difficulties associated with helmet therapy.2
A lack of randomization in this study, although understandable, reduces the strength of the study and the conclusions the authors draw from the results. Furthermore, the population sizes (n = 3381 for conservative treatment and n = 997 for helmet therapy) at the start of the study means similar groups are being compared, thereby introducing bias into the study.1
The use of repositioning therapy and physical therapy in the treatment of deformational plagiocephaly and deformational brachycephaly has been shown to be effective, and is widely regarded as the mainstay of conservative management. The authors in their study have allowed a number of patients (n = 534) to cross over from this conservative therapy to helmet therapy, thereby introducing a confounding factor during statistical analysis of the data. Following analysis, it was reported that 77.1 percent of patients achieved complete correction with conservative therapy compared with 95 percent of patients receiving helmet therapy. As a result of the aforementioned statistical analysis for the crossover group, we believe these results are somewhat misleading, suggesting that helmet therapy affords better complete correction results.1
In addition, patients in the helmet therapy group received repositioning therapy and physical therapy. It was not clear what proportion of these helmet patients received repositioning therapy/physical therapy. This potentially adds a confounding factor, as it makes outcomes difficult to assess. Does helmet therapy alone or in combination really improve cranial index? Therefore, the authors’ conclusion can seem misleading.
In summary, the optimal treatment of deformational plagiocephaly and deformational brachycephaly is not fully understood when reading this article. Patient-specific factors in conjunction with parents’ wishes need to be considered on a case-by-case basis when deciding which therapy will have the best clinical outcome for children presenting with complex cranial deformities.3 In an insurance-based health care system, helmet therapy is a potentially useful adjunct; however, when social health care is available, the cost of helmet therapy significantly outweighs its benefits.
The authors have no financial interest to declare in relation to the content of this communication.
Christopher G. Lutterodt, M.B.B.S.
Amir Sadri, B.Sc., M.B.Ch.B., M.R.C.S.
Simon Eccles, B.D.S., F.R.C.S., F.R.C.S.(Plast.)
Chelsea and Westminster NHS Foundation Trust
London, United Kingdom
1. Steinberg JP, Rawlani R, Humphries LS, Rawlani V, Vicari FA.. Effectiveness of conservative therapy and helmet therapy for positional cranial deformation. Plast Reconstr Surg. 2015;135:833–842
2. Wilbrand J, Wilbrand M, Yves Malik C, et al. Complications in helmet therapy. J Craniofac Surg. 2012;40:341–346
3. Joganic J, Lynch J, Littlefield T, Verrelli B.. Risk factors associated with deformational plagiocephaly. Pediatrics. 2009;124:e1126–e1133
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