Guide for Finding the Best Head Position for Your Client

Even though we are taught that seating and positioning begins at the pelvis, it is common for people to attempt to reposition a client's head and/or the head support equipment the moment they see the client's head not perfectly positioned at midline. Head supports and components of head supports are important pieces of the seating system puzzle. It is essential that the proper time and considerations are given to selecting these items as a part of the evaluation process. This guide is intended to help complex rehabilitation technology (CRT) provision teams with finding the best position, and subsequently the best equipment, for a client's head.

Before Ordering Equipment

What to do:

• Before ordering, a thorough mat evaluation is key. Not only parameters and measurements, but all of the subjective information will be extremely helpful (head position, excessive drooling, difficulty breathing, headaches, etc.).
• Always start with the pelvis, then trunk, and then the lower & upper extremities. Follow this order in supine or seated position.
• Determine if client needs an accommodation or correction of posture. You may find they need a mix of both approaches.
• Simulate head position with your hands. This will help you to determine active movement, amount of support, location, and size of lateral or anterior supports if needed.
• Once you determine the best head position with your hands, review the equipment options with other members of the complex rehabilitation technology (CRT) provision team. Identify the head support and components that best duplicate your hand simulation and meet the other needs identified by the team.
• Establish realistic goals. It might not be possible to correct a specific posture, but improvement in swallowing, breathing, or the visual field are great results that will increase function and quality of life.

What to consider:

• Visual problems are frequently misinterpreted or misdiagnosed. Refer to a specialist if necessary.
• For clients with or without flexible asymmetries, look for corrective postures that allow for alignment of trunk and head.
• For clients with non-reducible asymmetries, look for a personal posture that respects the asymmetries.
• Consider aesthetics. If the head support is too bulky, uses too many accessories, or is simply unattractive, chances are the client or caregiver will not use them as intended.
• Look for the cause, not the symptom. Common symptoms include: head down, hyperextension of the neck, excessive drooling. Dig deeper and find out what is causing these symptoms. Poor neck strength, deviated postures in pelvis or trunk, and visual impairments are examples of causes we want to address.
• Clients with progressive conditions might need additional support over time. Make sure to choose a system with compatible hardware to be able to mount components like lateral facial pads, anterior supports, etc. when needed.

During Delivery of Equipment

What to do:

• In wheelchairs with power or manual tilt, tilt the wheelchair as much as possible, and swing away lateral trunk supports and armrests. Transfer the user and position the pelvis in the most neutral position, as close to the back support as possible.
• As recommended in the previous "Before Ordering" section, position the pelvis first, then the trunk and lower/upper extremities before positioning the head.
• Use the tilt and recline as needed. Each wheelchair will offer different mechanisms to do this: power actuators or mechanical tilt/recline in manual tilt wheelchairs. Get familiar with the equipment and take advantage of these functions.
• On a sagittal plane, determine the most beneficial thigh-to-trunk angle and head angle.
• Overall, look for the most functional position, even if that means a deviation from a perfect alignment.
• Review the goals established by the team at the beginning of the process and look not only for progress in position, but also in areas like breathing, alertness, communication, learning, comfort, and seating tolerance.

What to consider:

• Check the thigh-to-trunk angle and increase trunk extension as needed to find the position where the client's head is most stable. This will facilitate breathing, swallowing, the visual field, etc.
• Go from less to more. Try to use the minimum amount of components needed. Make sure each component has a function. When placing the head support and its components, avoid direct pressure on the temporal area and eyes, mastoid process, and mandible.
• It is paramount to receive input from the client and make adjustments as needed. Depending on the client's ability to communicate, you may gather this information in both verbal and non-verbal forms. Pay close attention to non-verbal cues, such as increased work of breathing or a decrease in the presence of muscular tone.

After Delivery of Equipment

What to do:

• During a follow-up visit, always reassess overall position. Look for changes in other areas that may affect the position of the head.
• Take pictures, if permitted, and track the client's progress.
• Review the goals established by the team at the beginning of the process and look not only for progress in position, but also in areas like breathing, alertness, communication, learning, comfort, and seating tolerance.
• Reassess goals, make necessary changes, and establish new goals if needed.

What to consider:

• Sometimes improvements in position are imperceptible, but they have improved levels of fatigue, breathing, pain, etc. All of this is improvement, too.
• Maintaining the most functional position of the head is a dynamic process that needs periodic evaluations. Don't be afraid to make changes and try new strategies if your client needs them.

References

1. Lange, M.L. & Minkel, J.L. (2018). Seating and Wheeled Mobility. A Clinical Resource Guide. Thorofare, NJ. Slack Incorporated.
2. Watanabe, L. (2020, June 07). The critical role of head positioning & support for kids. Mobility Management. Retrieved from: https://mobilitymgmt.com/articles/2020/06/07/head-positioning-for-children.aspx.
3. Lange, M.L. (2017). Positioning the head. Proceedings of the 33rd International Seating Symposium: Be Empowered. 02-04 March 2017. Nashville, TN.
4. Caneiro JP, O'Sullivan P, Burnett A, Barach A, O'Neil D, Tveit O, et al. The influence of different sitting postures on head/neck posture and muscle activity. Manual therapy. 2010; 15: 54-60.
5. Sisto, S.A., Druin, E. & Sliwinski, M.M. (2009). Spinal Cord Injury. Management and Rehabilitation. St. Louis, MO. Mosby ELSEVIER.
6. Watanabe, L. (2013, June 01). Using your head. Mobility Management, ATP Series.