Michelle L. Lange, OTR/L, ABDA, ATP/SMS
Hannah is a 14 year old young woman with the diagnosis of cerebral palsy. She was born prematurely. Other diagnoses include cortical visual impairment (CVI), chronic lung disease, adrenal insufficiency, and type II diabetes. She has had her salivary glands removed and is now on Robinol which is reducing her secretions and subsequent aspiration. She is on oxygen and uses BPAP at night. She has a low core temperature and heart rate. Circulation is reportedly poor, particularly in her legs. She takes cortisol for the adrenal insufficiency. She has not yet begun puberty and is small for her age.
Hannah was seen to evaluate her wheelchair positioning and access to a communication device.
Hannah was seated in an Aspen Seating Orthosis (ASO), a custom molded seating system. She also had external lateral knee supports and a Stealth Comfort Plus head support. Hannah was positioned well in the seating system overall with the exception of her head position. Her head tended to hang forward and to her right side. Her head appeared to be laying on her upper right chest.
Hannah was outgrowing the ASO and modifications for growth were recommended, specifically increasing seat depth and width.
Her current head position was impacting breathing, swallowing, and vision.
- Breathing: As Hannah already required oxygen, this head position was certainly not ideal. Her neck was not aligned, constricting the trachea.
- Swallowing: Although Hannah does not eat by mouth (she has a g-tube), she does swallow her secretions at times. Her head position was limiting her ability to swallow at all, increasing secretions. If she were able to swallow, this could be unsafe and lead to aspiration due to the position of the esophagus and trachea.
- Vision: Hannah’s visual field was greatly limited by her head position. She could view primarily the lower right quadrant. Unfortunately, her communication device was mounted in front of her and she could not see the display. As a result, she used auditory scanning to ‘listen’ to her choices as she was unable to see them.
Head Position: Hannah had adequate range of motion in her neck to come to an upright and neutral posture but could not achieve or maintain this position on her own. She tolerated this position well when held there by the evaluator. A Stealth Products i2i head support was tried and improved her head position. Next, a Stealth Products Ultra head support (including occipital, suboccipital and lateral supports) was tried, also with good results. Hannah indicated a preference for the second option. Although non-verbal, she can communicate, and her opinion is critical! Once her head was upright, Hannah smiled for the first time in the evaluation.
Access for Communication: Hannah had never been able to access her communication device independently – at age 14. Others would help her to press a switch with her hand, using hand over hand support. Once Hannah’s head was well supported, she was able to turn her head with good control to her left side. We placed a switch in this location, and she was able to independently activate the switch to scan through vocabulary choices on her communication device. She and her Mom were so excited! Not only was she able to independently scan and select, Hannah could actually look at her device! Although her vision is impaired, Hannah can see her display, greatly improving her communication.
So how did this head support make such a difference for Hannah? The previous head support was a Comfort Plus which did not provide any lateral support to prevent collapse to the side. The Ultra provided three points of contact: a right lateral pad above and behind her ear, the right side of the suboccipital pad, and the left side of the suboccipital pad. All three points of contact were required to provide neck alignment. A similar strategy is often used at the trunk to address lateral scoliosis by providing two points of contact to the ribcage and one point of contact at the lateral pelvis. Once Hannah’s head was aligned laterally, she tended to collapse into neck hyperextension. The suboccipital pad not only provided lateral support at the neck but, sitting just below the suboccipital shelf of the skull, prevented neck hyperextension.
The Ultra head support includes the option to replace a lateral support pad with a switch. Hannah had best results using an AbleNet Specs switch. This was attached to the lateral swing-away assembly using a dedicated switch plate (SSM-100). The swing-away assembly has a ball and socket type adjustment at the switch plate and the attachment to the occipital pad. This provides very precise switch placement. Once the switch is in position, the assembly swings out of the way, as needed (i.e. a haircut) and then locks back into a consistent position. Consistent position is critical to successful switch access. If Hannah had still required auditory output during scanning, we could have placed an embedded speaker in the right lateral pad. The pad would then provide both postural support as well as auditory output.
Determining the best head support and placement for Hannah improved her breathing, swallowing, vision, and access for communication. And now the world can enjoy her smile!
Michelle is an occupational therapist in private practice, Access to Independence. She is a well-respected lecturer and author. She is the co-editor of Seating and Wheeled Mobility: a clinical resource guide, editor of Fundamentals in Assistive Technology, 4th ed., NRRTS Continuing Education Curriculum Coordinator and Clinical Editor of Directions magazine. Michelle is a member of the Clinician Task Force. Michelle is a RESNA Fellow, certified ATP, certified SMS and is a Senior Disability Analyst of the ABDA.