When prescribing a wheelchair and seating system there is usually discussion on what are blanket-branded as accessories. When we look at the definition of an “accessory” we find:
NOUN – a thing which can be added to something else in order to make it more useful, versatile, or attractive. “a range of bathroom accessories”
synonyms: attachment · extra · addition · add-on · retrofit · adjunct · appendage · appurtenance · (additional) component · fitment · supplement
We could consider headrests and laterals as accessories by definition, but how well will the seating system work with asymmetrical postural needs without these components? Whilst a cup holder is an addition that is useful and potentially versatile it’s not part of the seating outcome so much as an accessory that aids functional independence. There is an array of solutions that could assist in the task of carrying a drink from different accessories through to task adaptation.
However, when we consider seating requirements it can create confusion when we use this wording “accessory” – especially when we are justifying equipment applications for a reader that may have little or no clinical experience. It is important to consider the language we use when articulating needs and using clear clinical justification for all the essential components of the solution.
Postural supports should not be seen as merely useful add-ons but as a fundamental part of the overall solution.
The Seating System
With the increased images of end users in new equipment flooding some social media platforms we often see some unique and amazing modifications and configurations of AT solutions, but it also highlights some frequent and common configurations that have a cookie cutter feel to them. Of course you cannot know the background, history, assessment findings or goals for these images, they are just moments in time caught on camera but it does highlight some fundamental oversights commonly seen in the prescription process.
Let’s take the backrest for example. Most manufacturers offer a selection of back heights within the selected style, this can be further configured with how and where it is mounted onto the wheelchair. The back height is particularly crucial when identifying functional use such as for an active self-propeller or in a tilt in space chair. I have seen numerous images of children in active user style manual wheelchairs with back rests at shoulder height or higher. This configuration can have a negative impact on the child’s functional ability and the development of an effective push stroke. We want to provide support when required but also enable freedom for function.
Some of these set ups are also utilising shoulder harnesses and when the back height is not inline with the shoulder you cannot achieve the appropriate line of pull. In NSW, Australia I have seen many backrests set up and integrated into the function of the headrest. It was a common solution with some population groups through various custom seating clinics. However from my experience these were only as effective as the contouring and materials used.
For individuals with postural positioning requirements, the ability to provide angulation and appropriate support, it is tricky to achieve when extending a back support to integrate occipital support. This brings us back to Accessories vs Postural supports…is a head support an accessory or a crucial part of the solution?
When prescribing any seating component, we are essentially matching needs identified from the assessment to product parameters that provide points of control or forces that will support those needs. As such, identification of a headrest should be part of the initial postural solution rather than viewed as an extra add on at the end. What do we need to consider when identifying a potential head support?
A properly configured and positioned head support is an essential component of a wheelchair. The position of the head can affect common activities and daily functions such as:
- Socialisation and communication
- Safe Swallowing
- Attention to Task
The first question to address is around the intended use. Is there a postural requirement to provide support, is it for resting when in tilted position or is it too meet safety recommendations when using the chair as an occupant seat in transport? Each of these reasons will guide the potential solution.
Head Support for postural support
The head position will affect posture and balance, just as posture and balance affect head positioning. Poor seating positioning, unbalanced musculature, decreased innervation and neural disruptions can all contribute to head position. Understanding where the head needs to be supported is crucial for best outcomes.
When considering a head support, a posterior head support is usually the simplest and least restrictive, as such this is likely to be an initial consideration. The pad is designed to be positioned in the suboccipital area with the goal to prevent excessive extension, rotation, or lateral flexion.
Other considerations include:
- Address pelvis head and trunk alignment before trying to fit for a head support
- Remember that head position changes constantly with the slightest body movement
- Aim to position the pad in the suboccipital area posteriorly, and avoid resting on the ear if positioned laterally
- Consider a head support with lateral, anterior/posterior, height, and angle adjustability, that can support the head posteriorly and laterally
- Choose head support hardware that has offset capabilities to accommodate a head position out of midline
Head Support in Tilt-in-Space
It is considered best practice to prescribe a headrest for mobility bases with tilt in space or recline features. It is important to consider the different impact that movement of the user’s centre of gravity will have on head positioning when utilising these chair features. Ensure it has been set to maximise support in positions required without impeding function in a neutral position.
The head support should not be seen as just an add on; clinical consideration, function and seating principals need to be applied to the clinical reasoning process. A head support shouldn’t be a prop for poor positioning or a last minute add on but an integrated consideration.
Clinical Education Specialist
Tracee-lee Maginnity joined Permobil Australia in July 2019, as a clinical education specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.
Tracee-lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.