Heads Up! What causes poor head position?

Michelle L. Lange, OTR/L, ABDA, ATP/SMS

One of the most challenging areas of wheelchair seating is achieving and maintaining the head in a neutral and upright position. Many times, we assess, provide optimal seating, and still the client continues to stare at their lap. Before going to the closet to pick out a solution, we need to know what is causing the issue.

So, what does it take to hold our head upright?

• Adequate muscle strength. Our head weighs about 10 pounds (approximately the weight of a bowling ball) and a certain degree of strength is required to hold that up. For clients who tend to hold their head forward, every inch of forward head posture can increase the mechanical weight of the head on the spine by an additional 10 pounds! This makes the head ‘feel’ heaver and harder to return to upright.
• Muscle balance. To balance this bowling ball on top of our spine, we must balance muscle groups – flexors and extensors. For many people with abnormal muscle tone (increased, low, and/or fluctuating), this is exceedingly difficult.
• Sensory input. Our brains are hardwired with a sense of upright and midline. Most of the time, we seek out an upright head position. If you place a person on a therapy ball and move them about, the head will seek out upright. This is driven by vision, vestibular, and proprioceptive input. If sensory input is atypical, the position of the head may be affected.

Clients who require head support in wheelchair seating may display decreased head control and/or suboptimal head positions. Decreased head control is typically caused by decreased neck strength or paralysis. Suboptimal head positions may be caused by:

• an inability to balance muscle groups to keep the head upright
• forward tonal pull (actively pulling forward)                                     
• hyperextension of the neck (attempting to increase trunk extension) in compensation for poor trunk control
• visual impairments such as midline shifts and cortical visual impairment
• an attempt to optimize swallowing
• an attempt to optimize breathing
• a wide variety of other causes are possible

It is important to identify the cause of a suboptimal head position before choosing the best intervention.

Keep a look out for the next blogs in this series, “What Seating Interventions Optimize Head Position?” and “Head Positioning – Matching Product to Client Need.”

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