docWheelchair Seating: Positioning the Head
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Wheelchair Seating: Positioning the Head
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? 1 1/12/2015 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 M. Lange 1.2015 Look Again… Positioning Challenges: Head • Decreased head control • No head control • Lateral neck flexion M. Lange 1.2015 M. Lange 1.2015 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 2 1/12/2015 M. Lange 1.2015 M. Lange 1.2015 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 M. Lange 1.2015 M. Lange 1.2015 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 M. Lange 1.2015 M. Lange 1.2015 Vertical Midline Shift Neck Hyperextension • Headrest not in optimal position • Trunk control not optimal • Where would you move headrest? 3 1/12/2015 M. Lange 1.2015 Correct Placement is critical… M. Lange 1.2015 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 M. Lange 1.2015 Recline for Head Control M. Lange 1.2015 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 M. Lange 1.2015 M. Lange 1.2015 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 4 1/12/2015 M. Lange 1.2015 M. Lange 1.2015 Posterior Head Supports Posterior Head Supports • Otto Bock • Otto Bock Concave, fixed or adjustable Lateral Control 3 pad, fixed or hinged M. Lange 1.2015 Belled Komfi Fit Molded M. Lange 1.2015 Posterior Head Supports Posterior Head Supports • Otto Bock • Moldable • Stealth Products Comfort Plus Series • Hinged version Swing away assembly on rear M. Lange 1.2015 M. Lange 1.2015 Posterior Head Supports Posterior Head Supports • Stealth Products Tri-Comfort Plus Series • Stealth Products Combo Series 5 1/12/2015 M. Lange 1.2015 M. Lange 1.2015 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! 6 1/12/2015 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 M. Lange 1.2015 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 7 1/12/2015 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 M. Lange 1.2015 Case Study Head Support Fitting • Hannah • Much improved visual gaze • Impact on swallow and breathing M. Lange 1.2015 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 8 1/12/2015 M. Lange 1.2015 M. Lange 1.2015 Brian – seat to back angle i2i Head Support • Before and After M. Lange 1.2015 M. Lange 1.2015 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 M. Lange 1.2015 Posterior Head Supports Posterior Head Supports • Symmetric Designs • Symmetric Designs • moldable Standard Combination Large Small combination Full support Small 9 1/12/2015 M. Lange 1.2015 Posterior Head Supports M. Lange 1.2015 Posterior Head Supports: Whitmyer • Symmetric Designs • Savant headrest Plush M. Lange 1.2015 M. Lange 1.2015 Posterior Head Supports Posterior Head Supports • Whitmyer • Whitmyer Three pad Contoured cradle Single Sub-Occipital M. Lange 1.2015 Whitmyer Heads Up M. Lange 1.2015 Custom Options • Sometimes a custom headrest is indicated for specific control Aspen Seating 10 1/12/2015 M. Lange 1.2015 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 M. Lange 1.2015 M. Lange 1.2015 Dynamic Posterior Head Supports Dynamic Posterior Head Supports • Miller’s Adaptive Technologies • Stealth Tone Deflector • 10 degrees any direction • Absorb and Avert! M. Lange 1.2015 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 11 1/12/2015 M. Lange 1.2015 Anterior Head Solutions M. Lange 1.2015 Forehead Strap • Forehead band or strap • Halo • Chin support/orthosis • Baseball cap/helmet attached back • Collars M. Lange 1.2015 M. Lange 1.2015 Forehead Strap Forehead Strap • Whitmyer • Savant with forehead strap • Static Strap M. Lange 1.2015 Forehead support M. Lange 1.2015 Halo • Stealth lateral pads used to limit forward movement Rehab. Designs of Colorado 12 1/12/2015 M. Lange 1.2015 Collars M. Lange 1.2015 Collars Soft cervical collar Symmetric Designs HeadMaster M. Lange 1.2015 Collars M. Lange 1.2015 Collars • Danmar Swirl • Adjustable firmness Hensinger Collar Danmar M. Lange 1.2015 Chin Prompt M. Lange 1.2015 Hat • Stealth i2i Attached to back or headrest post Whitmyer 13 1/12/2015 M. Lange 1.2015 M. Lange 1.2015 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 M. Lange 1.2015 Decreased or No Head Control M. Lange 1.2015 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) M. Lange 1.2015 M. Lange 1.2015 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 14 1/12/2015 M. Lange 1.2015 M. Lange 1.2015 Horizontal Midline Shift Lateral Head Support • TOT Collar • For Torticollis M. Lange 1.2015 Lateral Head Support M. Lange 1.2015 Lateral Neck Flexion • Goals: • prevent subsequent deformity of neck and shoulder girdle • right head for vision, feeding and respiratory status Stealth M. Lange 1.2015 M. Lange 1.2015 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 15 1/12/2015 M. Lange 1.2015 Case Study M. Lange 1.2015 Questions? • Wes • Evaluation: headrest had slipped back on hardware, requiring neck flexion against gravity and rotation for access • Solution: move headrest forward 1 ½” M. Lange 1.2015 Questions? M. Lange 1.2015 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 M. Lange 1.2015 Thank you! M. Lange 1.2015 Contact Information: • Stealth Products, Inc. • www.stealthproducts.com • Michelle L. Lange, OTR, ABDA, ATP/SMS • MichelleLange@msn.com • www.atilange.com 16
