Physiotherapy and positional plagiocephaly (“flattened” head shapes)

by | Mar 10, 2019 | Kid's Health topics

Physiotherapy and positional plagiocephaly (“flattened” head shapes)

by | Mar 10, 2019 | Kid's Health topics

Well hello everyone! My name is Lisa and I am a paediatric physiotherapist. This is my first blog ever!!!! So I am a little bit nervous but also super excited to be able to share some of my knowledge and experiences with children and their development. I really hope what I share is of some benefit or interest to you.

Today I am going to follow on from a talk about plagiocephaly posted late last year by Dr Katie Drewett (, and talk briefly about the way I manage positional plagiocephaly through physiotherapy.

What is positional plagiocephaly?

Just to recap from Dr Katie’s talk, positional plagiocephaly is one of a group of terms used to describe a positional asymmetry, “flat spot” or “odd” head shape caused by positioning. It is a flattening on one side of the head caused by spending long periods of time on one side compared to the other. Other “odd” or “flattened” head shapes I see in clinic include brachycephaly (flattening across the back of the head leading to a head shape that is very wide at the back compared to the front); and scaphocephaly (flattening on both sides of the head leading to a narrow head shape). Plagiocephaly is the most common presentation and is what I will refer to in this article, but the overall management principles can apply to all “flat spots” caused by positioning.

What causes positional plagiocephaly?

Newborn babies’ skulls are soft, thin and flexible and therefore prolonged pressure on one area can cause the individual bones of the skull to slide and move over one another causing flattening in that area. This flattening can be caused by prolonged pressure in utero (inside the uterus/during pregnancy), after birth from the baby not having opportunity to change position enough or from difficulties moving their head due to neck tightness or muscle weakness. A small percentage of head asymmetries can also be caused by an early fusion of the bones in one area which then causes the head to grow asymmetrically or out of proportion. This is known as “cranial synostosis” and often requires surgery. An assessment by a medical professional such as a paediatric physiotherapist, GP or Paediatrician can help determine this.

What do paediatric physiotherapists do?

As a paediatric physiotherapist, my aim is to assess for developmental and or movement difficulties and provide activities to support development of weaknesses in these areas. When assessing an infant with an “odd” head shape or “flat spot”; I look for muscle tightness, weakness, motor and sensory difficulties to determine if the flattening is due to the position the head spends time in or early fusion, in which case I will refer onto a specialist for further assessment and management.  I also assess the baby’s environment and opportunities for play and movement. This helps me to determine the appropriate method for management.

How do we manage “odd” head shapes or “flat spots”?

Methods of management for positional head asymmetries include:

  1. Positional/ exercise therapy
  2. Cranial orthosis (helmet)

Positional head asymmetries are graded by the severity of flattening plus associated facial asymmetries (differences in facial features between sides). This severity in conjunction with the age of the baby will determine the preferred method of management.

If your child has an asymmetrical head shape, your paediatric physio will grade the severity based on how bad the flattening is and if it has affected the appearance of the face. They will then decide on a plan of management based on this and the age of the baby.

In most cases, positional/ exercise therapy is the preferred method (as directed by your paediatric physio), unless the asymmetry is severe with associated facial asymmetries and/ or the infant is older (usually more than 6 months old). In which case a referral to an orthotist who specialises in cranial orthotic management is recommended.

There is a good amount of research that shows us that there is no significant difference in the overall outcome of using a cranial orthosis (helmet) compared to exercise therapy to treat positional plagiocephaly and helmet management is very expensive.

Research tells us that the asymmetry may resolve quicker with a helmet, however they can be expensive, and they need to be worn up to 23 hours day for an average of 12 weeks depending on the severity and age of the infant. Wearing a helmet can lead to other difficulties with sleep, irritability and minor motor delays due to the weight of the helmet. Infants must have good head control to be fitted with a helmet due to the moulding process and therefore infants are not considered for helmet therapy until at least 4 months of age. Even if helmet management is chosen, it is still recommended that infants also to do the required exercise therapy as they will usually have associated weakness, tightness of muscles or delays.

Most positional asymmetries are noticed under 4 months of age. The most rapid period of brain growth in an infant is between 4 and 12 months of age and is therefore the period of time where most change in the head’s bony structure will also occur. Therefore, the goal of therapy is to develop the strength and motor control of the infant as soon as the “flat spot” is noticed, so that they can achieve independent movement to change position regularly such as rolling over and tummy time and therefore reduce the amount of prolonged pressure on their skull. It is also imperative to educate the carer about the importance of changing positions for play and minimising time in static positions such as lying in a pram and car capsule as these positions place pressure on the head and increase the risk of positional changes.

The only exception to this is sleep. SIDS guidelines state that infants must be slept on their backs to minimise the risk of SIDS. Due to this, health professionals will often recommend parents ensure they turn the infants head on different sides for each sleep. This is good, however, when an infant is still quite young and hasn’t developed neck control yet, their head will often fall back onto the ‘flat spot’ as gravity will force the weight of the head to fall to the flattest area. I also find recommending this as a main strategy can stress many parents out, as they worry that the infant is not keeping their head on the other side or are concerned about waking their baby up. It also causes some parents to look at other ways to keep the head on the other side by using pillows, towels and changing the position of their baby from their back which is NOT recommended by SIDS.

So rather than stress parents about sleep time, I prefer to work on the ‘active’ or ‘awake’ time. I teach parents exercises to use at nappy change time and when the baby is awake to develop strength in the neck and back muscles to develop motor skills so that they can in turn start to change their own position independently when awake and when asleep.  Placing the infant in different and varied positions for play (side lie, back, tummy) can also help. And using a baby carrier for mobility rather than a pram also reduces the time that the baby is lying on their “flat spot”. Encouraging active movement helps to develop the balance system (vestibular system) which is very important for motor control. Infants with well-developed balance skills and who are provided with good amounts of vestibular input tend to develop motor skills earlier than their peers and are less likely to develop head asymmetries. The type of exercises and positions I teach parents is dependent on the location of the flattening, the cause of the flattening (I.e. weakness, tightness, prolonged positions in static positions) and the age of the infant.

What do I do if I am concerned about my baby’s head shape?

If you have concerns about your infant’s head shape, would like further information or an assessment contact your GP, child health nurse, Paediatrician or paediatric physiotherapist.

I hope you have found this intro to the management of positional plagiocephaly useful and I look forward to sharing information and tips on other child development topics with you.

My next topic will be on Developmental Coordination Disorder (DCD) so stay tuned for that.

Have a great day!





Find us on Facebook

About Dr Megs

About Dr Megs

Megan is a Brisbane and Ipswich-based paediatrician in public and private practice, and mum to two small children. You can usually find her working hard in private practice at Paeds in a Pod North Lakes and Greenslopes, and in public practice at Ipswich Hospital.

PLEASE NOTE: This blog is written for the purpose of providing GENERAL advice about common children's health topics (and of course recipes). It is NOT a substitute for a proper medical assessment and examination by a qualified physician. If your child is unwell, seek medical and attention and advice in person.