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Head Drop

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Dear DQ,

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.

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Soft 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.

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Head strap

I have heard of success with the Headpod, although I have no personal experience with it.  Worth a look though.

HeadPod

Headpod

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?

 

 

 

 

 

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4 comments

  1. Any good news for head drop. Mine started last August 2014 and in January of 2015 I was sick with cold and sinus infection. I rested a lot nd my head miraculouly came back up. Was good until July when it started to fall again. It’s not totally down now but at least half way and I’m struggling.. August of last year my chin was down on my chest. Any new help?

    Kay

    • Kay I am sorry, I just saw this. Not being familiar with your story, it’s hard for me to say. As far as “new help”, I guess I don’t know the answer to that either. It would depend on the pathology of your issue.

  2. THANK YOU SO MUCH FOR POSTING THIS INFO. I HAVE BEEN FIGHTING THIS FOR OVER 30 YEARS AND HAVE NEVER HEARD, NOR HAD A DEFINITIVE DIAGNOSIS OF “HEAD DROP”. MY DISABILITY DIAGNOSIS IS “CERVICAL SPINE IMPAIRMENT” (D/T trauma, lax ligaments, etc..) THANK YOU, THANK YOU, THANK YOU.

    • Jackie I’m so glad I could help- although I don’t know how useful this post is. Any treatment approaches that work for you?

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