Wheelchair Seating: Achieving and Maintaining an Upright Head Position

Not everyone who uses a wheelchair requires head positioning. Head support may only be necessary for safety during transportation if the transportation occurs while the patient is seated in their wheelchair. Sometimes head supports are required to provide posterior support during tilt or recline. Many clients, however, have decreased or no head control and may require specific seating interventions.

Positioning the head involves much more than the presence of a head support. The pelvis and trunk must first be in an optimal position to provide a well-aligned base for the optimal level of head control. Below, we’ll explore the difference between decreased head control and no head control, and the different head support interventions that apply to both.

Decreased Head Control

What Defines Decreased Head Control?

Head control is decreased if the client has difficulty bringing and maintaining their head into an upright and aligned posture.

What Causes Decreased Head Control?

Decreased head control may result from a decrease in neck strength, forward flexor tone, or even a visual impairment (specifically, a vertical midline shift or Cerebral Visual Impairment).

Solutions to Decreased Head Control

Interventions for decreased head control are primarily various styles of posterior head supports. Most only provide support at the occiput. However, some do add suboccipital support, which provides additional support and minimizes hyperextension. Lateral support is also available as needed.

No Head Control

What Defines the Absence of Control?

Clients with no head control cannot achieve or maintain an upright head position without significant support, often anterior to the head. 

What Causes the Absence of Head Control?

Total lack of head control is due to severely decreased neck strength, sometimes seen in clients with conditions such as ALS, SMA type I, and congenital myopathies, as well as in clients with very high-level spinal cord injuries.

Solutions to the Absence of Head Control

In the case of absent head control, support is required anterior to the head. This support may be a forehead strap, rigid swing-away anterior forehead supports, or a collar. 

Long-Term Goals

The goals of addressing decreased and absent head control are to:

  • Align the neck for improved swallowing, breathing, and vision
  • Improve head control and, subsequently, function, such as activating a head switch.
  • Prevent overstretching of the neck extensors, which could further worsen head control

My series of MedBridge courses covers head positioning, as well as many other facets of wheelchair seating, such as wheelchair power mobility assessment and training, wheelchair seating assessment, and positioning of various areas of the body.