I’m an OT that works with patients with dementia, and have a patient who has developed such stiff neck flexion that it is difficult for staff to feed her. Initially with gentle PROM we could assist the patient with holding her head upright during meals, often by just holding the palm of our hand gently against her forehead. Over the last few weeks, however, her neck has become more stiff, to the point that a soft collar was trialled, but this caused redness and potential pressure points. She sits in a tilt Broda style w/c. Is there anything else we can try to make meals easier for her?
This therapist is describing a condition known as head drop.
Head ptosis, or head drop, results from weakness of the neck extensors, or increased tone of the neck flexors. It is most commonly seen in elderly patients with myasthenis gravis or ALS. I recently saw a woman with MSA (multisystem atrophy) who had developed head drop as well. Sometimes the phenomenon occurs in Parkinsonian syndromes or without a known cause. Regardless of the etiology, head drop can be a difficult issue to correct.
Above all, I would caution not to attempt any positional intervention without the involvement of the physician. Any time you are addressing spinal deformities, particularly those of the frail elderly with possible arthritic changes, there is always a risk of injury.
This therapist has already met the basic needs- getting the pelvis and trunk in the optimal position though custom seating in a tilt-style wheelchair. Manual passive positioning of the head during meals and the use of neck collar is also a common rehab approach. But as this therapist discovered, there is a potential for skin breakdown from pressure along the jaw and chin from the neck collar.
Head straps that attach to the head rest are another option, which when alternated with the collar, may reduce the risk of skin breakdown from a single source. Sometimes a call to the manufacturer of the existing wheelchair may help as there may be an accessory that would be an easy fit. If not, bringing in an orthotist or rehab technology supplier might be useful in coming up with a custom solution.
I have heard of success with the Headpod, although I have no personal experience with it. Worth a look though.
Whatever intervention you try- supporting under the chin or pulling the head back- there is the risk of skin breakdown from pressure, aspiration from an open airway, and injury to the cervical spine. Alternating between techniques may decrease the risk of skin problems, and using gravity for passive extension during non-meal times will help maintain range of motion and prevent contractures. In some cases, oral feedings for adequate nutrition may not be realistic due to a compromised swallow function. In such cases, G-tube feedings may be needed to maintain good nutrition with pleasure feedings as tolerated for, you know, pleasure!
Get a speech therapist involved if swallowing is a concern.
Other OTs out there… any suggestions?