European Journal of Pediatrics

, Volume 165, Issue 3, pp 149–157 | Cite as

Plagiocephalometry: a non-invasive method to quantify asymmetry of the skull; a reliability study

  • Leo A. van Vlimmeren
  • Tim Takken
  • Léon N. A. van Adrichem
  • Yolanda van der Graaf
  • Paul J. M. Helders
  • Raoul H. H. EngelbertEmail author
Original Paper


Deformational plagiocephaly (DP) in newborns and very young children is a common problem in daily practice. The intrarater and interrater reliability of plagiocephalometry (PCM), a new, non-invasive, inexpensive instrument to assess and quantify the asymmetry of the skull, is evaluated at the outpatient Department of Physical Therapy of the Bernhoven Hospital at Veghel, The Netherlands. Using a thermoplastic material to mould the outline of the infant’s skull, a reproduction of the skull shape is performed on paper, allowing for accurate cephalometric measurements. Fifty children (aged 0–24 months), with or without positional preference of the head, and with or without DP, were measured three times by two separate, experienced pediatric physical therapists. Intraclass correlation coefficients (ICC) regarding the measurements of the drawn lines were all above 0.92 (intrarater reliability) and 0.90 (interrater reliability). The ICCs of the plagiocephaly indicators ear deviation (ED), antero-sinistra−antero-dextra (ASAD), postero-dextra−postero-sinistra (PDPS) and oblique diameter difference (ODD) were 0.88, 0.57, 0.92 and 0.96, respectively, for the intrarater reliability and 0.90, 0.65, 0.94 and 0.96, respectively, for the interrater reliability. The ICCs of the two indices oblique diameter difference index (ODDI) and cranial proportional index (CPI) were 0.97 and 0.96, respectively, for the intrarater reliability and 0.95 and 0.92, respectively, for the interrater reliability. The limits of agreement according to Bland Altman, comprising 95% of the differences between two measurements (2 sd), were 4.3 mm (ED), 5.9 mm (ASAD), 3.0 mm (PDPS), 3.4 mm (ODD), 2.7% (ODDI) and 4.5% (CPI) for the intrarater reliability, and 3.7 mm (ED), 5.2 mm (ASAD), 2.4 mm (PDPS), 3.3 mm (ODD), 2.9% (ODDI) and 5.8% (CPI) for the interrater reliability. Conclusion: We conclude that PCM is an easy-to-apply, non-invasive and reliable measurement instrument to assess skull asymmetry with good clinical accuracy and low application costs. PCM might serve as an instrument to be used in all levels of care for children with DP, and might provide information concerning the natural course of DP, as well as the assessment of the effects of conservative treatment strategies on DP.


Reliability Plagiocephaly Torticollis Asymmetry in infancy Measurement 





Cranial proportional index


Deformational plagiocephaly


Ear deviation


Intraclass correlation coefficients


Oblique diameter left


Oblique diameter right


Oblique diameter difference


Oblique diameter difference index







The authors thank Lonneke van Soest, PT, PCS, MA and Judith Timmers, PT, PCS, BSc of the Department of Physical Therapy, Bernhoven Hospital, Veghel, The Netherlands, for their contribution in the acquisition of the data.


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Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Leo A. van Vlimmeren
    • 1
  • Tim Takken
    • 2
  • Léon N. A. van Adrichem
    • 3
  • Yolanda van der Graaf
    • 4
  • Paul J. M. Helders
    • 2
  • Raoul H. H. Engelbert
    • 2
    Email author
  1. 1.Department of Physical TherapyBernhoven HospitalVeghelThe Netherlands
  2. 2.Department of Pediatric Physical Therapy and Exercise PhysiologyUniversity Medical Center, Wilhelmina Children's HospitalUtrechtThe Netherlands
  3. 3.Department of Plastic and Reconstructive Surgery, Erasmus University Medical Center RotterdamSophia Children's HospitalRotterdamThe Netherlands
  4. 4.Julius Centre for Health Sciences and Primary Care, Clinical EpidemiologyUniversity Medical CenterUtrechtThe Netherlands

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