Stability at the Top

Everyone who’s ever played a game of Jenga can attest that it’s not the blocks at the top that cause the giant crash. Rather, it’s the instability of the base.

That logic also applies to head and neck positioning.

“Creating a stable pelvis and spine is really about building a stable tower to create an upright head,” explains Pete Cionitti, director of product management, Therafin Corp.

When the tower starts to sway before crashing, the blocks at the top often end up misaligned. If you think of the head and neck the same way, it’s easy to see how every decision about positioning affects the way the client ultimately sees and interacts with the world.

So once a clinician has the building blocks of the foundation in place, what can be done to ensure the top has the necessary stability for life-long benefits?

The Importance of Getting It Right

Figuring out the geometry of head and neck positioning is paramount, as proper head and neck positioning has many benefits for clients. In fact, missing the mark on this important positioning component sends shockwaves though the client’s physical, social and clinical states of being.

Consider the function of the head and neck.

“Most of our basic, everyday functions occur with the head. Vision, hearing, breathing, communication and eating all involve the head and neck,” says Gabriel Romero, VP of sales and marketing, Stealth Products.

Proper head and neck positioning greatly improves vision and with it mobility, says Amy Morgan, national clinical education manager at Permobil. “The head must be stable for the eyes to work effectively. Vision is directly related to mobility, and having a stable support for the eyes to work off of makes this much more effective.”

For example, correcting head and neck positioning helps clients use environmental controls, such as switches and head arrays, more effectively, says Sam Hannah, ATP, Symmetric Designs.

“When the head is aligned and supported, movement from this position is less strainful and will result in more ability to engage and then return to a neutral position,” he says.

In addition, Morgan says that proper positioning improves client operation of head controls.

“Proper support and positioning of the head supports/switches is critical for safe and effective operation of a driver control that is operated with the head. Just like the eyes need a stable base for controlled scanning, vision, etc., proper head/neck supports allow the user to access the driver control/switches in a more controlled manner,” she says.

In addition to navigating the environment safely, vision is imperative for communication, social interaction and learning, says Hannah.

“The eyes serve as a very important way in which we communicate,” Romero says. “A gesture — respect, interest, appreciation and understanding — is often a gateway to learning. Eyes are capable of expressing emotions as well.”

Not to mention, interacting with the world is challenging when the chin is dropped and the eyes are looking downward, Cionitti says.

“Eye contact is needed to truly connect with individuals or when speaking with groups,” says Steffen Tiskus, training and development coordinator, power positioning, Motion Concepts.

Tiskus also warns that improper head and neck positioning compromises nonverbal communication along with verbal communication. He explains that nonverbal communication is often overlooked but has great importance in overall communication.

Proper positioning also improves basic bodily functions, including inhalation, exhalation and swallowing, which in turn “leads to improvements in nutritional status (and) reduction in choking risks,” says Tiskus.

Clinically speaking, proper head and neck positioning is essential to preventing deformities such as scoliosis, kyphosis, and cervical and pelvic obliquities, according to Romero.

Morgan explains that better alignment can reduce muscle tightness and pain — pain that might include everything from headaches to disc herniations.

“Abnormal posture can impact the nerves and spinal cord in a negative way, causing upper-extremity weakness, paresthesias (and more),” Morgan says. In addition, contractures of the head and neck can develop, and resulting asymmetries can negatively impact the vision system.

Getting this aspect of seating right is so essential that it is often considered to be the most challenging aspect for seating professionals, Tiskus says.

The Clinical Cues for Positioning

Wondering whether a client is at risk for poor head and neck positioning? Two screening criteria can alert clinicians that head and neck positioning might be an issue.

The first is the client’s diagnosis. Some diagnoses intrinsically lead to poor head and neck positioning:

• Cerebral palsy
• Amyotrophic lateral sclerosis (ALS)
• Multiple sclerosis
• Arthritis
• Traumatic brain injury
• Muscular atrophy
• Stroke

Spinal and pelvic deformities also require head and neck support.

“A kyphosis or scoliosis can result from many different disabilities and lead to improper alignment of the head and neck,” says Hannah.

Other deformities can include forward head posture, cervical lordosis, hyperkyphosis, lateral flexion contractures, abnormal cervical rotation and torticollis, according to Morgan.

“Improper support can also contribute to upper back, scapular and shoulder issues as the body tries to find stability elsewhere,” she says.

Tiskus points out that severe extensor tone can present some challenges with head and neck positioning as well.

In addition, look for dysphasia and respiration as head and neck positioning can help solve these problems.

Clinicians need to pay attention to swallowing and oral secretions, says Stephanie Tanguay, a clinical education specialist at Motion Concepts. “Some consumers will be at risk for aspiration, and specific head positioning may be a critical aspect of preventing this.”

“Aspiration as the result of dysphagia can lead to serious pneumonias that can be life threatening,” adds Cionitti. Good head positioning along with care in feeding can greatly reduce aspiration.

“A decrease in respiration can have both immediate and long-term effects. Over the long term, there can be serious pulmonary hypertension and edemas which can even lead to heart failure. A well-positioned head can help keep the airway open and improve respiration,” he says.

The second red flag for poor head and neck positioning is client symptoms.

“Difficulty swallowing, breathing, headaches and pain, low blood pressure, and eye gaze position are all some of the warning signs that the head/neck are not positioned properly,” Hannah says.

Other “warning signs include excessive flexion/extension in the cervical spine, inability to hold the head against gravity, difficulty in swallowing/breathing (and) pain in the cervical spine,” says Tiskus.

Romero says that fatigue, excessive drooling and coughing can be signs that the head is not in the correct position. He says it’s important to position the head so that clients don’t use up all of their energy to hold the head upright.

According to Morgan, if improper head/neck positioning is not addressed, it can worsen over time, leading to progressing deformities.

“Gravity has an effect on everything, so when we are working with clients who have limited movement, the head becomes the pendulum of the body. Where the head is placed usually dictates where the body will end up,” explains Romero. “Creating sound positioning options allows for the client to control the stability needed in the cervical region. It becomes harder and harder to position a client who has been sitting one way their whole life. If we can position the client the right way early on, it gives them a greater chance of having a comfortable and correct seating position that will help prevent the bones and muscles from growing incorrectly.”

Correcting Improper Positioning

Proper head and neck positioning is a long-term process, the key to which is setting goals and figuring out how to meet those goals, says Chris Reidmiller, national sales manager, Therafin Corp.

For example, some goals could be “improving comfort, oral motor function, heightened awareness, airway passage, preventing postural deformity and providing stability for function,” says Reidmiller.

At the same time, goals need to be realistic, says Tiskus, because there are “trade-offs between more aggressive positioning options versus the inevitable reduction in movement that these type of supports provide the individual.”

To set goals, clinicians must gather as much information as they can from clients. Asking some key questions can lead clinicians in the right direction.

“What is the therapist working with? Is the client faced with a progressive or regressive disease? Could a headrest possibly work as a therapy tool?” Romero says. “Each question and answer should carefully be evaluated in order to give the client the necessary positioning.”

Romero suggests that clinicians use journaling to record as much information as possible during the seating evaluation.

“By writing as much information down as possible during an evaluation, this allows the therapist/clinician to look back at the end of the day and reevaluate if any changes would positively affect the client’s ability to be more mobile,” he says. “This could also help in future evaluations (and) tracking progress of a client.”

During a seating evaluation, clinicians should consider the client’s current position, what the most functional seated position would be, range of motion, the extent of deformities, and how seating surfaces and other positioning components will affect head and neck position, says Hannah.

“Almost every major part of the body (pelvis, torso, arms and legs) coincides with each other when positioning the body. Move one part and it will move the other,” says Reidmiller.

“The client’s lower body and trunk should be well supported to ensure the head and neck can be positioned with minimal support,” says Hannah. “Stabilizing the client’s trunk will put less strain on the head and neck. Head and neck positioning needs to be considered as part of the entire seating system to be effective. Once the trunk is well positioned and supported, the head and neck can then be positioned so that (it) makes, breathing, swallowing and vision less effortful.”

Tanguay adds that “head positioning away from midline may be a compensation result of deficits of specific quadrants of the consumers’ visual field. It is important to determine if the head position is a purposeful attempt to see from an intact aspect of the optic field.”

Morgan warns that supporting the head is a delicate balance because the clinician doesn’t want the client to rely too much on the provided supports.

“For example, the rehab team may attempt to use a lateral swingaway head positioning pad to keep the client from rotating or laterally tilting to that side; however, the client senses the support pad, and it actually encourages them to push into the pad instead,” she says. “This can be problematic from a hardware perspective (having to withstand that extra force) and is also contrary to the intention of the pad itself. Another option might be to try to control the head with an occipital pad so that sensory feedback is not provided in the direction of the movement we are trying to control.”

One way to address this issue, Morgan says, is to avoid prescribing too many supports. She recommends using swing-away technology or equipment with parts that can be removed for part of the day.

Still, Morgan says that getting positioning right will require trial and error.

Step Up Your Positioning Game

Fortunately, choosing systems that provide good head and neck support is easier today than it used to be.

Several manufacturers make head positioning devices, and the choices have expanded, Hannah says.

Many of today’s systems have sought-after features such as customization, dynamic components, fine-tuning adjustability, and head rotation support.

However, clinicians need to err toward simplicity as they solve client positioning problems.

“Keeping the systems as simple but effective as possible can help us make sure we are not just successful in a clinical environment only,” says Romero. “We have to remember that families take these products home with them. If they cannot replicate proper positioning of a head positioning system by themselves or get frustrated with how it functions, we do not gain ground on creating a functional system.”

Morgan agrees. She believes the key is easily adjustable, durable hardware. Morgan explains that the hardware needs to hold up against high amounts of forces, such as from individuals with a lot of tone. She acknowledges that this combination is not always easy to come by.

In addition, Morgan says the positioning hardware needs to blend in well so that people see the client and not the chair.

In fact, seeing the client is really the key to the whole head and neck positioning game. When the client is properly positioned, everything falls into place physically, socially and clinically instead of crashing down.