Question
What is the indicator that you use to determine when a child is ready for discharge with a home program? How frequently do you have these children come in for a recheck?
Answer
When speaking of cranial deformations, we must remember that we are not truly affecting the shape of the skull with our interventions. We are really looking for the consequences of cranial deformations which often means screening for orthoses and focusing on the developmental delays. The child's entire program should be based on catching up to age appropriate levels and dealing with the development delays. In this case, I would allow the orthotist to do the rechecks. In cases where the child is not getting orthoses, and we are doing positioning only, I would monitor and do measurements at least once a month. If the plagiocephaly is very severe, I do weekly measurements. I want to be sure that cranial vault asymmetry index values are not getting worse but are instead getting better.
For children with torticollis, I look at the ICF model and first consider the impairment and the impact on activity and participation. I would discharge a child that does not have developmental and movement problems when they approach their typical age performance. But for indicators that a child is ready for discharge based on the impairment measurement, such as the range of motion values that they are getting for their neck into lateral flexion, I would use a percentage value. A goal may be that I would like to have a children within 15 degrees of normal before they get discharged. Usually I am seeing them a little longer than that to try and be sure that they are getting even closer.
There are some children whose torticollis is never resolved. At that point, we have to see if it is impacting their life in any way. The children who really do not get that last 15 degrees are really good candidates for tot collars. Even though there is not a whole lot of evidence in the research about tot collars, I have to say that every time I have used them, they have had much better results than just doing the stretches and exercises alone. I will have the children that are getting within 15 to 5 degrees with torticollis do monthly rechecks. Again, if I keep getting the same values and see that they have plateaued on their progress, I would then consider discharge.
