GUEST BLOGGER: Kathryn Biel.
Patricia submitted this question:
So how do you improve head control? I have tried several courses and have left with no real answer to this question. Do you have any ideas?
Head control is a tricky thing. It is the result of the interplay of the vestibular system, the visual system, motor control, strength, muscle tone, and endurance. In theory, it is one of the first things to develop. Head control is developed through prone. The vestibular and visual systems are critical in developing the desire to lift the head and push up onto prone prop and eventually on to extended arms. At this point, the eyes develop convergence and divergence, and the Symmetrical Tonic Neck Reflex is used to assist in getting the child into quadruped.
I’m guessing that your patient is beyond this infant stage. Depending on the age of the patient, as well as the presence of co-morbidities, may impact your treatment strategies. A thorough visual assessment (by Developmental or Behavioral Optometry) is necessary to determine if the Visual Righting and the Vestibulo-Ocular Reflexes are intact. These are a major driving force in providing the motivation to lift the head to midline in the first place. Cortical visual impairments and visual field cuts can often result in a person holding their head out of midline, as that is how functional vision is accessed. It is important to determine where the functional visual field is so that you are not asking a person to function where he or she cannot see.
For strength development, go back to prone. Development of the back and neck extensors, as well as shoulder girdle strengthening, is critical in possessing head control in the upright position. If extensor control is not present to counter balance flexor strength (which is developed in supine), then functional midline co-contraction will not be realistic.
In terms of sitting, in order to gain head control, you must first tackle the pelvis. Trying for head control without a well-seated pelvis is like building a house from the roof down. The pelvis must be supported and neutral. Assuming that the patient you are looking to develop head control in is multiply impaired, in addition to controlling the pelvis, you are looking to fully support the trunk as well. This includes adaptive seating that supports the trunk laterally, and helps to correct any curves (forward/back as well as lateral). The feet and legs should be well supported to further provide a stable base of support. Remember, if you are asking a person to work on head control, then that is what they are working on. It does not include working on trunk control.
Over the past few years, I’ve used a few different trunk supports on wheelchairs that have helped to improve upper trunk and scapular position. These include the Stealth I2I head and neck support system and the use of two AEL Y-shaped trunk supports (one on each side). In the past, I’ve also used the Headmaster collar to work on very small range head control (lifting from the resting position on the collar to fully upright).
I would love to hear what other therapists are doing to work on head control. Please let me know, and Patricia, I hope this helps!
~Kathryn Biel, PT, DPT