Holding head in extension responses Part 2
Paul E Prusakowski
Description
Collection
Title:
Holding head in extension responses Part 2
Creator:
Paul E Prusakowski
Date:
4/18/2014
Text:
- Hi Paul, I once made a panel that extended from the lumbar region to the top of the occipital portion of the head. I made pack like straps that held the thoracolumbar portion in place and then did an elastic head band (like adidas sweat band). It was for a college professor and he loved it. call me if you would like to discuss.
- If your patient's willing to wear a baseball cap, I learned this trick from someone in Florida!
My patient had ALS and wanted to keep walking for exercise, but his chin was on his chest without support. Everything we tried failed till we came up with this.
It attached to his pants and kept them up (and also to the back of his cap) and worked well because he also lost a significant amount of weight from his illness and didn't want to 'spend his children's inheritance' purchasing new clothes!
The velcro was attached to his center belt loops in the back. The straps were all adjustable as he required more extension control. The hat was made pretty snug and I added some silicone strips inside the brim to keep the hat from sliding. It worked while he was ambulatory and could operate the velcro opening and closings. I put large loops on so he could use his entire wrist rather than just his fingers as he weaknened. It worked for a long while then he became bedbound where it wasn't an issue sadly. He was a trooper and fought to the end. For him what I did was magic.
- Danmar Hensinger c collar coupled with headband if needed. I just did one this morn on a hypotonic CP kiddo so she can see her environment and better use her ipad & talker. They were really excited so hopefully it works out.
- We have used SOMIs for similiar patients.
- The LIDO from Orthomerica works good for this application.
- If you are looking at a Florida summer, you might consider a traditional two-post cervical orthosis. They may not look as sleek, but may be more tolerable with a warm humid climate. I think that Florida Brace Company makes them.
- I recently had a patient with ALS with the same symptoms I used a headmaster cervical orthosis which worked well, the patient stated it was very comfortable
- We use here a support with an helical spring that can be attached to a wheelchair or a chair , something like that .
We use it a lot with CP children and sometimes with some neurologic adult patients that can´t support their head but have movement control over an horizontal plane .
<URL Redacted>
<URL Redacted>
- I am wondering if you are thinking about a Minerva Brace, with the head strap. I was taught that this strap was for allowing the stability (carefully, compliant person) so they could brush teeth, etc, with the anterior chin part removed. Helps with hygiene with the balance.
The second thought I had was to do more of a torticollis brace. I think a custom likely would be best, but this is also reading between the lines of your note. I think eating would be a concern/issue that I would address.
My other concern would be skin breakdown and skin pressures. With such a small area of correction, as well as the amount of weight/force on this area, I could see pain and/or skin breakdown fairly quickly. I gather that a custom or semi-custom approach may be best for the long term due to length of need, hygiene, and corrective pressures in bony areas without much padding.
As I type this, I am thinking I would likely start with a Minerva or Minerva style brace, increase the posterior metal thickness, so really you are using the chest piece and attachment of the Minerva. Then, I would do a headband style connection similar to a thickly padded cranial remolding helmet with the top cut off, with a pair of straps on this to don/doff. The headband would be two pieces, front and back. That way, the head would be controlled, there would be enough padding for more comfort, and it would be functional as well as easy to build and adjust.
Just my two cents. As in O&P, everyone has an opinion and there is more than one way to correct an issue correctly.
- Please see the links below to the Fillauer Torticollis Joint. There is available an extension bar for use with larger patients (We sell as many for Adults as we do pediatric) It offers a wide range of adjustment in flexion/extension, height, and rotation.
<URL Redacted>
http://fillauer.com/pdf/M024-Torticollis.pdf
- Two options I have used in the past may be helpful, and are much less involved than a TLSO with some kind of superstructure (although I have done any number of those as well).
One is a wire frame CO, originally intended for the cervical extensor weakness of ALS patients. Its primary limitation is that it provides no control against lateral bending, but it is a rare hypotonic head-on-chest patient that has good lateral control. However, not all of these patients need lateral control, and it is a simple and low-profile device. There are two that I know of, one by Trulife, and the other is called the Headmaster, although I don't think it is nearly as useful as the Trulife.
Another option is to use a SOMI, and with this you have the option of using only the chin piece, as it is completely separate from the occiput piece. The support is very good, and the malleable chin piece can be easily molded for a good fit on the mandibles. If more support is needed the occiput piece can also be mounted, with straps connecting to the chin piece.
One challenge common to all of these is the effect of the dead weight of the head concentrated on the chin. The skin can break down very quickly without the proper padding, and the chin piece of a SOMI will have to be augmented. It was intended for cervical fractures, and assumed functional neck musculature. I usually modified these to be significantly thicker, and with some kind of thickish gel pad for better pressure distribution.
The TLSOs can certainly work. We usually used the proximal extensions of a Minerva, but in that case you have to use both, as the aluminum frame of the posterior extension will bend trying to resist the weight of the head. This will also require a modified chin pad, as its stock padding is not nearly as good as the SOMI, and the weight of the head will compress that foam to the point where the patient will feel the rivets holding the metal chin cup.
- I think a company called RMI has devices for this. I'm on the road so phone pics will have to do, but
http://www.oandp-l.org/shared/dxlpr.png
- I've used the Johnson's CTO from Trulife as TLSO seems to be too much work donning and doffing for pt. Nothing really great for this trouble, not enough area for pressure distribution. IMO.
- I have found a helium balloon work well...
- I have had several patients with this condition and have had good success with a SOMI, often only using the head band. If the patient is in wheelchair, I always try to cause some extension at the neck via chair tilt if possible. I did have a very complicated patient most recently that, after many different trials (collars, SOMI, etc) ended up using an inflatable neck pillow often used by people when they are in an airplane. The inflation aspect was particularly good as she was able to alter the extension herself.
- We use Headmaster frame collars quite successfully. AKA Wireframe collar from Trulife.
- If your patient's willing to wear a baseball cap, I learned this trick from someone in Florida!
My patient had ALS and wanted to keep walking for exercise, but his chin was on his chest without support. Everything we tried failed till we came up with this.
It attached to his pants and kept them up (and also to the back of his cap) and worked well because he also lost a significant amount of weight from his illness and didn't want to 'spend his children's inheritance' purchasing new clothes!
The velcro was attached to his center belt loops in the back. The straps were all adjustable as he required more extension control. The hat was made pretty snug and I added some silicone strips inside the brim to keep the hat from sliding. It worked while he was ambulatory and could operate the velcro opening and closings. I put large loops on so he could use his entire wrist rather than just his fingers as he weaknened. It worked for a long while then he became bedbound where it wasn't an issue sadly. He was a trooper and fought to the end. For him what I did was magic.
- Danmar Hensinger c collar coupled with headband if needed. I just did one this morn on a hypotonic CP kiddo so she can see her environment and better use her ipad & talker. They were really excited so hopefully it works out.
- We have used SOMIs for similiar patients.
- The LIDO from Orthomerica works good for this application.
- If you are looking at a Florida summer, you might consider a traditional two-post cervical orthosis. They may not look as sleek, but may be more tolerable with a warm humid climate. I think that Florida Brace Company makes them.
- I recently had a patient with ALS with the same symptoms I used a headmaster cervical orthosis which worked well, the patient stated it was very comfortable
- We use here a support with an helical spring that can be attached to a wheelchair or a chair , something like that .
We use it a lot with CP children and sometimes with some neurologic adult patients that can´t support their head but have movement control over an horizontal plane .
<URL Redacted>
<URL Redacted>
- I am wondering if you are thinking about a Minerva Brace, with the head strap. I was taught that this strap was for allowing the stability (carefully, compliant person) so they could brush teeth, etc, with the anterior chin part removed. Helps with hygiene with the balance.
The second thought I had was to do more of a torticollis brace. I think a custom likely would be best, but this is also reading between the lines of your note. I think eating would be a concern/issue that I would address.
My other concern would be skin breakdown and skin pressures. With such a small area of correction, as well as the amount of weight/force on this area, I could see pain and/or skin breakdown fairly quickly. I gather that a custom or semi-custom approach may be best for the long term due to length of need, hygiene, and corrective pressures in bony areas without much padding.
As I type this, I am thinking I would likely start with a Minerva or Minerva style brace, increase the posterior metal thickness, so really you are using the chest piece and attachment of the Minerva. Then, I would do a headband style connection similar to a thickly padded cranial remolding helmet with the top cut off, with a pair of straps on this to don/doff. The headband would be two pieces, front and back. That way, the head would be controlled, there would be enough padding for more comfort, and it would be functional as well as easy to build and adjust.
Just my two cents. As in O&P, everyone has an opinion and there is more than one way to correct an issue correctly.
- Please see the links below to the Fillauer Torticollis Joint. There is available an extension bar for use with larger patients (We sell as many for Adults as we do pediatric) It offers a wide range of adjustment in flexion/extension, height, and rotation.
<URL Redacted>
http://fillauer.com/pdf/M024-Torticollis.pdf
- Two options I have used in the past may be helpful, and are much less involved than a TLSO with some kind of superstructure (although I have done any number of those as well).
One is a wire frame CO, originally intended for the cervical extensor weakness of ALS patients. Its primary limitation is that it provides no control against lateral bending, but it is a rare hypotonic head-on-chest patient that has good lateral control. However, not all of these patients need lateral control, and it is a simple and low-profile device. There are two that I know of, one by Trulife, and the other is called the Headmaster, although I don't think it is nearly as useful as the Trulife.
Another option is to use a SOMI, and with this you have the option of using only the chin piece, as it is completely separate from the occiput piece. The support is very good, and the malleable chin piece can be easily molded for a good fit on the mandibles. If more support is needed the occiput piece can also be mounted, with straps connecting to the chin piece.
One challenge common to all of these is the effect of the dead weight of the head concentrated on the chin. The skin can break down very quickly without the proper padding, and the chin piece of a SOMI will have to be augmented. It was intended for cervical fractures, and assumed functional neck musculature. I usually modified these to be significantly thicker, and with some kind of thickish gel pad for better pressure distribution.
The TLSOs can certainly work. We usually used the proximal extensions of a Minerva, but in that case you have to use both, as the aluminum frame of the posterior extension will bend trying to resist the weight of the head. This will also require a modified chin pad, as its stock padding is not nearly as good as the SOMI, and the weight of the head will compress that foam to the point where the patient will feel the rivets holding the metal chin cup.
- I think a company called RMI has devices for this. I'm on the road so phone pics will have to do, but
http://www.oandp-l.org/shared/dxlpr.png
- I've used the Johnson's CTO from Trulife as TLSO seems to be too much work donning and doffing for pt. Nothing really great for this trouble, not enough area for pressure distribution. IMO.
- I have found a helium balloon work well...
- I have had several patients with this condition and have had good success with a SOMI, often only using the head band. If the patient is in wheelchair, I always try to cause some extension at the neck via chair tilt if possible. I did have a very complicated patient most recently that, after many different trials (collars, SOMI, etc) ended up using an inflatable neck pillow often used by people when they are in an airplane. The inflation aspect was particularly good as she was able to alter the extension herself.
- We use Headmaster frame collars quite successfully. AKA Wireframe collar from Trulife.
Citation
Paul E Prusakowski, “Holding head in extension responses Part 2,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/236266.
