There are a variety of neurological conditions that lead to problems with head control, and this blog discusses how we best address these problems through the use of neck collars and other strategies.

Neck muscle weakness and neck muscle tightness are contributing factors leading to difficulty lifting and maintaining the head in its desired position. Headaches, neck, shoulder and back pain can occur when head positioning is not managed. This is in addition to the impacts it has on a person’s breathing, swallowing, eating and drinking abilities, communication, and interaction with other people. All of which significantly impact a person’s quality of life.

Motor Neurone Disease (MND) and head position.

Motor Neurone Disease (MND) is a debilitating neurological condition that can destroy the cells that control movement.  A frequent problem caused by MND is the loss of strength in the neck, causing a person’s head to drop to the side or the front. Some people experience weakness in the muscles at the back and front of the neck, resulting in reduced control in either the forward or backward planes of movement, or both.

This might look like someone’s head falling backwards, which can put a lot of strain on the front of the neck. This could also look like someone’s head falling forwards with their chin almost resting on their chest, depending on how weak the muscles at the back of the neck are. Another common head position thought to be brought about by weakness on one side of the neck is a head that falls forward and to one side – visualise your right ear nearly resting on your right shoulder. Having the head in this sustained position without the strength to move out of this position nearly always results in significant neck pain, negatively impacting a person’s quality of life. It can also lead to muscle tightening and subsequent muscle shortening, which presents even more difficulties.

Management of head position

The management of head and neck posture will depend on a physiotherapist or occupational therapist establishing the primary cause of the impaired head position and careful assessment of the structures which support it. Management will differ depending on the direction the head falls into and the overall body posture, function, and mobility. Careful consideration is made as to what activity may be taking place when the correction is needed.

A physiotherapist or occupational therapist will be able to highlight the problem and help create goals that will guide the success of the management.

Let’s start by having a look at the overall posture in different environments.

• Resting and sleeping in bed:
  Supportive pillows can improve the posture and support of the head to allow for overactive muscles to become less active or for tight muscles to be lengthened to reduce neck stiffness and pain. However, the effectiveness is dependent on the correct positioning of the pillows each time, so a positioning photo board is often used for this.
• Sitting in a chair or recliner:
  An occupational therapist can advise on the need for more support through a seating assessment. This might look like something as simple as rolling up a towel and placing it behind the lumbar region of your lower back to help correct a slumped posture or the prescription of a high back chair with armrests that will enable a person to sit for longer whilst maintaining an upright head position. If more support is required due to poorer head control and overall reduced sitting balance, a seating or wheelchair assessment is indicated.

Did you know an average person’s head weighs close to 5kg? So even the slightest movement of the head forwards, backwards or sidewards increases the strain on the neck muscles, resulting in muscle tightness and pain.

Using the tilt-back option on your wheelchair and sitting in a more reclined position in the car or a recliner will help take some of the head’s weight from the neck. Tilting backwards will also allow a person to interact with the environment around them by being able to see more.

Using a headrest to help support the head will also help keep the head in a better alignment. An occupational therapist can trial and prescribe various headrests to aid with positioning, control, and support.

Wearing a neck brace can be an effective way to help hold a head upright if it is very weak.

Some people require wearing a neck brace when standing and walking, especially if their head and neck are weak and unstable. Similarly, a neck brace can be worn when in the car during transit to reduce pain and instability from the movements when a car changes direction, goes around a roundabout or drives over speed bumps.

When walking, wearing a neck brace can hold up the head to improve a person’s visual field and the ability to interact with others around them. By improving a person’s visual field, you can reduce the risk of falling as they will see and respond to uneven terrain or any obstacles they come across.

A physiotherapist or occupational therapist will prescribe a neck support collar to improve the head position for certain parts of the day. Neck collars can be soft or more rigid depending on the amount of external support required to position the head.

Neck collars commonly prescribed for people with minimal neck weakness and mild loss of control include soft collars. More rigid collars are prescribed for people with more significant weakness and less control of the head.

The following neck support collars all have a range of advantages and drawbacks, and the effective prescription often depends on a trial of a few options.

• Headmaster collar
• Aspen vista
• Soft collar
• Philadelphia collar
• Head up collar
• Hensinger collar

Most people do not tolerate wearing these collars for very long periods. Some collars are also not to be worn whilst eating due to difficulties with chewing and swallowing food and liquid when wearing them. In addition, certain collars can restrict the rotation of the neck. So care should be taken when wearing collars when walking outdoors as they will limit the ability to scan safety to cross a road, for example.

In addition, it’s not unusual for people to use more than one different collar – they may have one more suitable for wearing in the car and one more suitable to assist with head position during meal times.

Stretching tight muscles and strengthening weak muscles to improve neck positioning and control can be an essential part of managing head and neck stiffness and pain. A physiotherapist can assess the strength and length of the neck muscles and then prescribe an exercise program tailored to improving pain and maintaining range. These exercises must be done carefully to avoid muscle overload, injury and discomfort to the person. In MND, there is less of a focus on strengthening weak muscles; however, using the strength and movement a person has to mobilise the head and neck can have a hugely positive effect on pain and discomfort.

Some people with a poor sitting balance due to weak trunk muscles may benefit from support around their trunk to create more stability which will positively improve your head and neck position. This might look like lateral supports added to the wheelchair or cushions placed in the recliner chair.

Physiotherapists will prescribe exercises that will challenge sitting balance and trunk control which can also help you control the head and neck. The stronger and more controlled the trunk muscles are, the better the spinal alignment will be, which will improve your head and neck posture.