The Somatic Connection  |   October 2014
“ As the Twig Is Bent, so Grows the Tree”: Part 4
Author Affiliations
  • Hollis H. King, DO, PhD
    University of California, San Diego School of Medicine
Article Information
The Somatic Connection   |   October 2014
“ As the Twig Is Bent, so Grows the Tree”: Part 4
The Journal of the American Osteopathic Association, October 2014, Vol. 114, 809. doi:
The Journal of the American Osteopathic Association, October 2014, Vol. 114, 809. doi:
Kluba S, Lypke J, Kraut W, Krimmel M, Haas-Lude K, Reinert S. Preclinical pathways to treatment in infants with positional cranial deformity [published online July 15, 2014]. Int J Oral Maxillofac Surg. 2014. doi:10.1016/j.ijom.2014.05.011.  
This observational study describes the “preclinical” course (authors defined preclinical as all health care visits occurring before being seen in their clinic) of 218 children with positional cranial deformity. Researchers in the Department of Oral and Maxillofacial Surgery at the University Hospital Tübingen, Germany, were concerned about delays in referral for helmet therapy because in their experience there are time-dependent elements for optimal outcomes. 
Positional skull deformities fall into 3 types, as follows: (1) plagiocephaly or parallelogram-style sloping head, which was measured by the cranial vault asymmetry index (CVAI) consisting of a ratio of head diameter, head length, and angles between the skull diagonals; (2) brachecephaly, which was determined by the head width-to-length ratio called the cranial index; and (3) a combination of plagiocephaly and brachycephaly. 
The data collected in this study indicated that the deformity typically became noticeable at between 3 to 4 months and that the average time to presentation at the Tübingen clinic was 6 months. These researchers were concerned that helmet therapy, if indicated, should start by age 4 to 6 months. In this study, if the child had been seen for physiotherapy or osteopathy, he or she presented to the clinic significantly later (P=.023). This implied criticism of physiotherapy and osteopathy is later discussed in the context of the need to rule out craniosynostosis by ultrasonographic examination, which typically occurs only in oral maxillofacial surgery clinics. It is also mentioned that if parents agree to helmet therapy, then physiotherapy and osteopathy can be simultaneously applied. 
More than half of the children seen in this study received helmet therapy, which the authors describe as low risk and noninvasive. There is mention of research describing the long-term consequences of head shape deformities including cognitive or motor dysfunction, but there is no description of the research on the outcomes of helmet therapy. My own clinical experience in evaluating and treating children with cranial deformity and who have had helmet therapy leads me to advise caution before helmet therapy is undertaken. Overall, this article is informative, especially in making the case for early evaluation to rule out craniosynostosis, a potentially lethal condition. 
   “The Somatic Connection” highlights and summarizes important contributions to the growing body of literature on the musculoskeletal system's role in health and disease. This section of The Journal of the American Osteopathic Association (JAOA) strives to chronicle the significant increase in published research on manipulative methods and treatments in the United States and the renewed interest in manual medicine internationally, especially in Europe.
   To submit scientific reports for possible inclusion in “The Somatic Connection,” readers are encouraged to contact JAOA Associate Editor Michael A. Seffinger, DO (, or JAOA Editorial Advisory Board Member Hollis H. King, DO, PhD (