Max: facing the world again!

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

Background:

Max is a 33 year old man with the diagnosis of cerebral palsy. He lives at home with his parents and volunteers at an animal shelter. He is a long-term user of assistive technology, including a communication device and power wheelchair. Max uses both a manual tilt in space wheelchair, as well as a midwheel drive power wheelchair with a compact joystick. He is seated in a molded seating system that fits him well.

But there was a problem – Max can’t look straight ahead.

Current Positioning:

Max sat with his neck hyperextended and rotated to his right side, influenced by an Asymmetrical Tonic Neck Reflex (ATNR) (see Figures 1-3). The current Stealth Products Comfort Plus head support could not limit this posture. His right ear was chronically folded forward, leading to redness and breakdown (see Figure 4).

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Max’s head position was significantly limiting his visual field. Breathing and swallowing were not optimal with his neck so rotated and hyperextended. Finally, this position was exacerbating his extension. He needed a solution to maintain his head in a more neutral position.

Evaluation:

I was able to manually move and hold Max in a nearly neutral position. He did have some slight residual rotation to the right that could not be corrected. I did have to use a great deal of force to bring him to a corrected position, however, I did not have to use as much force to maintain this position as his tone was reduced. Moving past midline was triggering Max’s ATNR. Keeping him as close to midline as possible reduced the influence of this reflex which contributed to the neck rotation and hyperextension.

A lateral support could be added to the Comfort Plus head support, but this was not adequate to correct Max’s position. A Stealth Products Ultra head support was tried as this provides more support; however, this did not significantly improve Max’s head position. His strong tone simply overcame the supports on the Ultra. Next, a Stealth Products i2i head support was tried, and Max’s head position was greatly improved. He also tolerated this well (see Figures 5 – 7). Max trialed a loaner i2i support for several weeks before a final recommendation was made to ensure this would meet his needs. The i2i typically has long anterior ‘arms’ which can be helpful for many clients in keeping the head in midline and preventing ‘hooking’ – where the client may drop their head forward and come up to the side, between the bottom of the head support and the back of the seating system. Max did not require this portion of the head support and so an i2i with shorter arms was ordered. As a result, the i2i did not need to flip-back for transfers, as Max could readily clear the bottom of the head support. Ear cut-outs were also ordered, preventing his right ear from folding over.

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Max exerts significant forces against the head support and this had led to the current Comfort Plus often moving out of position. The i2i was ordered with a Tone Deflector to absorb and dissipate these forces (see Figure 7). As a result, the new i2i remains in position. The Tone Deflector is a dynamic component which incorporates small elastomers inside which absorb forces exerted by the client, allowing a small amount of movement, and protecting the hardware from loss of position and even breakage.

The i2i head support system has made a significant difference in Max’s life:

• limiting neck rotation and hyperextension has reduced his overall extension.
• Max’s seating tolerance has increased, and he has less pain.
• Max no longer has skin breakdown behind his right ear.
• He can now actually see the display on his communication device!
• He can see where he is driving and, with reduced overall extension, is able to drive his power wheelchair with good control (see Figure 8).

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.