1/12/2015
WHEELCHAIR
SEATING:
POSITIONING THE HEAD
Introductions
• Who I am
• Who are you?
• Goals for this session?
• Handouts
Michelle L. Lange, OTR/L, ABDA, ATP/SMS
What we will be covering:
Assessment
• Positioning Assessment
• To position the head, we first need to
• Common positioning challenges of the head
• Causes
• The position of the head is extremely
• Suggested strategies
• Goals
perform a seating assessment
dependent on the position of the
pelvis and trunk
• Seat to back angle and position in
space allows the client to “balance”
the head
Impact of general position on the
head
What do you think?
• Kian
• Kian
• Very poor positioning led to extreme neck hyperextension
• What is wrong with his head
and choking
position in this picture?
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What do you think?
What do you think?
• Kian
• Kian
• What would you adjust?
• Hint: we already positioned the
pelvis in neutral and adjusted the
headrest
• Supporting the trunk aligned
the neck, reducing
hyperextension and
improving vision, breathing
and swallow
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Look Again…
Positioning Challenges: Head
• Decreased head control
• No head control
• Lateral neck flexion
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Let’s Try It!
Let’s Try It!
• “Normal” Head position
• Flexed head position
• Hold your head up as anatomically correct as possible
• Note the position of your pelvis and trunk
• Note your vision, swallow and breathing
• Let your head fall forward
• Note the position of your pelvis and trunk
• Note your vision, swallow and breathing
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Let’s Try It!
Let’s Try It!
• Hyperextended head position
• Lateral flexion head position
• Let your head fall forward
• Note the position of your pelvis and trunk
• Note your vision, swallow and breathing
• Let your head fall forward
• Note the position of your pelvis and trunk
• Note your vision, swallow and breathing
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Decreased Head Control
Decreased or No Head Control
• Possible Causes:
• decreased neck strength
• hyperextension of neck in compensation for poor trunk control
• forward tonal pull
• visual impairment, particularly a vertical midline shift
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Vertical Midline Shift
Neck Hyperextension
• Headrest not in optimal
position
• Trunk control not optimal
• Where would you move
headrest?
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Correct Placement is critical…
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Decreased or No Head Control
• Interventions:
• Increase trunk extension and scapular retraction
• neck rest
• posterior head support
• change pull of gravity against head by reclining or tilting seating
system
• anterior solutions
• refer to behavioral optometrist, if appropriate
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Recline for Head Control
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Posterior Head Supports
• Many posterior head rests or head supports are on the
market
• None will be effective if the client’s head never touches it!
• Tilt can be used to enlist gravity in the battle
• Ensure that pelvis and trunk are in an optimal position to
facilitate head control
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Occipital and Suboccipital
Posterior Head Supports
• Occipital support contacts the upper rear of the head
• AEL
• Suboccipital can actually provide postural support as it
“cups” the occipital shelf
• This also can reduce neck hyper extension
occip
ut
Soft
Curved
Tri-pad
Suboccipu
tal shelf
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Posterior Head Supports
Posterior Head Supports
• Otto Bock
• Otto Bock
Concave, fixed or
adjustable
Lateral Control
3 pad, fixed or
hinged
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Belled
Komfi Fit
Molded
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Posterior Head Supports
Posterior Head Supports
• Otto Bock
• Moldable
• Stealth Products Comfort Plus Series
• Hinged version
Swing away
assembly on
rear
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Posterior Head Supports
Posterior Head Supports
• Stealth Products Tri-Comfort Plus Series
• Stealth Products Combo Series
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Posterior Head Supports
Posterior Head Supports
• Stealth Products All Positioning Series
• Stealth Products QCRS Series
• Nino version
• Occipital, suboccipital and lateral options
• Premade configurations
• Custom configurations
All positioning
headrest
Building a Head Support
Building a Head Support
• Occipital Support
• Large or small
• Large is more contoured
• Children have large heads in proportion to their bodies
• Suboccipital Support
Building a Head Support
Building a Head Support
• Lateral Supports
• Materials and Upholstery
• Foam is standard, but solid gel can be used too
• Smoother upholstery = less friction. Less bald spots!
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Building a Head Support
Building a Head Support
• Mounting and Swing-Away
• Separate depth adjustment for occipital and suboccipital pads
• Accessories
• Switches
• Access to AT
• AbleNet Specs mounting plate SSM-100
Switch used with spot pad
for stability
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Building a Head Support
Stealth Headrest
• Accessories
• Speakers
• Auditory scanning
• Other auditory output
Case Study
Case Study
• Hannah
• Hannah
• Poor head position
• Leaning to side
• Propped on chest
• With suboccipital and
lateral supports added
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Case Study
Case Study
• Hannah
• Hannah
• Right lateral support
• Improved head
provided by
suboccipital and
spot pads
• Suboccipital limits
any hyperextension
position allowed
switch access by left
side of head
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Case Study
Head Support Fitting
• Hannah
• Much improved visual gaze
• Impact on swallow and breathing
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Posterior Head Supports
I2i Head Support
• Stealth i2i
• Clinical Indicators:
• No pressure on the occiput for clients who extend in response to
contact with this area
• Encourages midline head position
• Prevents hooking
• Minimizes neck hyperextension
• Head, Neck, Shoulders Positioning
System
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Brian – seat to back angle
i2i Head Support
• Before and After
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Brian has limited hip flexion and so
required a more open seat to back
angle to prevent posterior pelvic tilt
and improve head posture
Brian
Head Support Fitting: i2i
Brian’s posture had worsened after
an increase in dosage in his
Baclofen pump led to very low tone
in the trunk
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Posterior Head Supports
Posterior Head Supports
• Symmetric Designs
• Symmetric Designs
• moldable
Standard
Combination
Large
Small
combination
Full support
Small
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Posterior Head Supports
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Posterior Head Supports: Whitmyer
• Symmetric Designs
• Savant headrest
Plush
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Posterior Head Supports
Posterior Head Supports
• Whitmyer
• Whitmyer
Three pad
Contoured cradle
Single Sub-Occipital
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Whitmyer Heads Up
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Custom Options
• Sometimes a custom headrest is indicated for specific
control
Aspen Seating
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Dynamic Options
Dynamic Posterior Head Supports
• Providing movement at the head has several goals:
• Absorbs force to protect equipment from breakage
• Diffuses force to reduce extensor patterns
• Increases tolerance to seating system
• Miller’s Adaptive Technologies
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Dynamic Posterior Head Supports
Dynamic Posterior Head Supports
• Miller’s Adaptive Technologies
• Stealth Tone Deflector
• 10 degrees any direction
• Absorb and Avert!
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Dynamic Posterior Head Supports
Anterior Head Solutions
• Symmetric Designs Axion Rotary Interface
• Tread lightly – many clients will not tolerate anterior head
support and many caregivers are resistant to the idea
• Controversial whether to use in transport
• At the least, use anterior trunk support if anterior head support is
used
• Soft collar is safest in transport
• Do not attach collar to seating system
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Anterior Head Solutions
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Forehead Strap
• Forehead band or strap
• Halo
• Chin support/orthosis
• Baseball cap/helmet attached back
• Collars
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Forehead Strap
Forehead Strap
• Whitmyer
• Savant with forehead strap
• Static Strap
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Forehead support
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Halo
• Stealth lateral pads used to limit forward movement
Rehab. Designs of Colorado
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Collars
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Collars
Soft cervical collar
Symmetric Designs
HeadMaster
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Collars
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Collars
• Danmar Swirl
• Adjustable firmness
Hensinger
Collar
Danmar
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Chin Prompt
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Hat
• Stealth i2i
Attached to back
or headrest post
Whitmyer
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Head Pod
Decreased or No Head Control
• Goals:
• elongation of neck extensors (if shortened by neck hyperextension)
• capital flexion (chin tuck)
• to promote visual attention to the environment, peers, etc.
• increased function
• improved swallow, feeding, breathing
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Decreased or No Head Control
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Lateral Neck Flexion
• Goals, cont.:
• prevent subsequent deformity of neck and shoulder girdle
• prevent over stretching of neck extensors and shortening of neck
flexors (if head is usually hanging down)
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Lateral Neck Flexion
Lateral Neck Flexion
• Possible Causes:
• decreased neck strength
• muscle imbalance/tone/torticollis
• ATNR
• scoliosis
• visual impairment, particularly a horizontal midline shift
• Interventions:
• address scoliosis
• headrest with lateral support
• posterior support with 3 point lateral control
• either side of head and along jaw line that is deviated laterally
• custom molded headrest
• horizontal tilt, if severe and if pressure ok
• refer to behavioral optometrist, if appropriate
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Horizontal Midline Shift
Lateral Head Support
• TOT Collar
• For Torticollis
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Lateral Head Support
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Lateral Neck Flexion
• Goals:
• prevent subsequent deformity of neck and shoulder girdle
• right head for vision, feeding and respiratory status
Stealth
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Case Study
Case Study
• Wesley
• Age 8
• Diagnosis: spastic cerebral palsy
• Manual tilt in space wheelchair
• Linear seating system
• Current access to AT: right head switch for AAC
• Wes
• Problem: his access has recently deteriorated, impacting his
communication
• Goal: to restore prior access skills
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Case Study
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Questions?
• Wes
• Evaluation: headrest had slipped back on hardware, requiring neck
flexion against gravity and rotation for access
• Solution: move headrest forward 1 ½”
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Questions?
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Product Demos
• It can be challenging to recommend equipment without
actually trying it out, particularly with certain items
• Talk to Scott about product demos you may need, as well
as your local Stealth rep
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Thank you!
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Contact Information:
• Stealth Products, Inc.
• www.stealthproducts.com
• Michelle L. Lange, OTR, ABDA, ATP/SMS
• MichelleLange@msn.com
• www.atilange.com
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