Head Starts

Can deformational plagiocephaly cause torticollis in children?

Deformational plagiocephaly (DP) is a condition in which the cranium is deformed as a result of external molding forces occurring during the prenatal and/or postnatal period; the time period when infant skulls are most malleable.1 These forces result in asymmetry of the head, and possibly face, of the infant.1

There has been a dramatic increase in the incidence of DP since the "Back to Sleep" campaign was introduced by the American Academy of Pediatrics in 1992.2,3 Prior to 1992, it was estimated that one in 300 infants developed DP; since that time, referrals have increased by 600 percent.3 Risk factors associated with the development of DP include congenital muscular torticollis, low birth weight, premature birth, intrauterine position and intrauterine constraint, male gender, first born birth rank and brachiocephaly.1,2

Although often considered only a cosmetic concern, there is an association between DP and auditory processing disorders, mandibular asymmetry, and strabismus, though causation has not been established.1 Children with DP are also at risk for future learning difficulties in school, such as language disorders, learning disability and attention deficits.4 Miller et al found males with abnormal head shapes at birth to be the highest risk group for later problems in school.4 In addition, I have noted some children with DP to have an increased frequency of ear infections on the side of flattening. Because of these many issues, families are usually eager to treat DP.1

Conservative strategies include parental counseling, counter positioning, physical therapy and orthotic devices.1 As primary care providers are the most likely to encounter DP during well child visits, it is important that they be comfortable assessing and managing DP and torticollis and be willing to refer for additional services when needed.3

Torticollis and Deformational Plagiocephaly

It is a frequent hypothesis in the research literature that the major cause of DP is limited head mobility in early infancy secondary to cervical imbalance, primarily congenital muscular torticollis.3,5,6 I have noticed a trend in my practice that children with DP present at birth without cervical muscular limitations who were subsequently treated with an orthotic device developed a cervical muscular imbalance as the shape of the cranium became more symmetrical. At the current time there does not seem to be any literature noting this trend, although there is limited evidence as to whether torticollis leads to, or results from, DP.

In the study completed by van Vlimmeren et al, researchers noted that passive ROM in the cervical spine was normal in all children at birth and 7 weeks of age and did not seem to influence the severity of DP.1 They concluded that DP at birth was not a predictor of DP at 7 weeks.1 Other researchers have found postnatal defects of cervical mobility to be a crucial component in the development of DP.6 This is evidence of the complexity of the relationship between cervical range of motion and DP and the probability of multiple factors affecting the development of DP and cervical musculature defects with no definitive causal pathway.

Monitoring With Treatment

In cases in which cervical muscle dysfunction is not present with DP initially, it is imperative that the cervical musculature be continually reassessed as treatment progresses and the shape of the cranium improves. As the cranium becomes more round on the side of flattening, the biomechanics of the cervical musculature that attaches there change. The rounding of the cranium effectively shortens muscles on the side of initial flattening. If there was no asymmetry between the two sides initially this will produce an asymmetry that needs to be addressed to maintain the biomechanics of the system. This rounding of the cranium can also produce tension in the posterior cervical musculature.

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It is important that the families of infants receiving treatment for DP be educated on the importance of this possibility and maintaining the range of motion of the cervical musculature and signs of potential restriction. As the treatment becomes more aggressive, particularly when orthotic management is included, it is even more critical that the status of the cervical musculature be carefully monitored.

An additional concern in children with cervical musculature dysfunction, either initially or throughout the treatment process, is the development of speech. It is a common occurrence for children with torticollis to exhibit speech delays in the future when language development is expected. This can be hypothesized to be associated with the close association between cervical musculature and muscles associated with speech production. This also will need to be monitored during, and potentially after, treatment, depending on the age at which a child is discharged from therapy and/or orthotic management.

In conclusion, DP is a condition of deformation of the cranium that may be present at birth or develop in the postnatal period due to external forces on the head. It is vital that when infants with DP are treated the cervical musculature is monitored for restrictions and asymmetries throughout the course of treatment, particularly in instances in which DP is present without cervical musculature dysfunction initially.

Also, overall development needs to be monitored into school age due to an increased risk of subtle problems at this time. The careful monitoring of cervical musculature and global development will provide the best outcome for infants and children in terms of motor function and overall development, as well as for the shape of the cranium.


1. van Vlimmeren, L., van der Graaf, Y., et al. (2007). Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: A prospective cohort study. Pediatrics, 119, 408-418.
2. Cherney, J., & Littlefield, T. (2002). Deformational plagiocephaly more frequent in multiple-birth infants. ACPOC News, 8(4), 6,8-10, 13, 16.
3. Looman, W., & Kack Flannery, A. (2012). Evidence-based care of the child with deformational plagiocephaly, Part 1: Assessment and diagnosis. Journal of Pediatric Health Care, 26(4), 242-250.
4. Miller, R., & Clarren, S. (2000). Long-term developmental outcomes in patients with deformational plagiocephaly. Pediatrics, 105, 26-30.
5. Rogers, G., Oh, A., et al. (2009). The role of congenital muscular torticollis in the development of deformational plagiocephaly. Plastic and Reconstructive Surgery, 123(2), 643-52.
6. Captier, G., Dessauge, D., et al. (2011). Classification and pathogenic models of unintentional postural cranial deformities in infants: Plagiocephalies and brachycephalies. Journal of Craniofacial Surgery, 22(1), 31-41.

Sara Howard is a physical therapist for the Infants and Toddlers Program through Montgomery County Public Schools in Maryland. She received her DPT from University of Maryland at Baltimore.


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