Managing Neck Muscle
Weakness
Based in large part on an
article written by
Pamela A. Cazzolli, R.N.
Some people with ALS develop muscle
weakness of the neck. This may cause limited mobility of the head. Turning the
head from side to side or holding the head upright may be difficult, as the
neck supports the head that weighs about 20 pounds. Limited head movement can
contribute to a stiff neck, a poor head posture, and severe pain if these
problems are not managed. In fact, neck muscle weakness can lead to a vicious
cycle of limited head mobility and a stiff neck (resulting in pain and
impairing head mobility ever further), causing more pain with emotional
distress. Emotional stress can also compound muscle tightness and cause pain.
People with neck muscle weakness are
vulnerable to injury. If the head suddenly flops backward, forward, or
sideways, this can cause muscles and ligaments in the neck to tear. It can also
cause serious injury to the cervical spinal cord or vertebrae in the neck. Such
injuries may be a result of "overstretching" due to a sudden
excessive force that propels the neck forward, backward, or to one side or
another. Hyperextension (backward) or hyperflexion (forward bending) injuries
may be referred to as a "whiplash."
This can occur, for example, when a
person is transferring in or out of a bed or a chair and the neck is jarred.
For some people, even a slight jerk of the head can cause a torn muscle in a
weak neck. Injuries to the neck can be very painful, especially when turning
the head, raising and lowering into bed and rolling over when in a lying
position. Besides causing pain and injury to the neck, poor head posture can
aggravate breathing, swallowing and communication.
Through effective management of neck
muscle weakness, complications of pain and injury can be prevented or treated.
Finding the best methods for supporting the head in an upright position to
protect against injury is essential.
Strategies
for improving the head posture and promoting head/neck mobility, comfort and
safety include:
1. Achieve and maintain a good body
alignment when sitting to promote an upright head position. Use of a cushion,
pillow, or rolled towel behind the lumbar region of the low back not only helps
to align a slumped posture, but will help keep the head and shoulders from
slouching forward. If sitting in a high back chair, placing a rolled towel
behind the neck also improves the head posture and helps prevent or alleviate
discomfort in the neck. Placing a pillow under each arm or on top of each
armrest of the chair helps promote an upright head position, and provides
maximum comfort when sitting for a long time. Proper alignment of the head,
neck, and body allows the lungs to expand for better breathing.
2. Wearing a soft collar or a neck brace,
called a cervical collar, is an effective method of holding up the head if this
is difficult. A collar supports the head when the person is walking or being
transferred from one sitting position to another. To protect against injury
from sudden motion, people with advanced neck weakness should wear a collar
when they are moving or being transferred from one seat to another, when
walking, or riding in the car. Use of a collar to hold up the head when walking
permits a better sight line and may reduce the risk of falling.
3. Identify and use the appropriate
cervical collar(s) that will best meet your needs. Most people with neck
weakness are unable to tolerate wearing a collar all the time, especially one
that can lead to skin breakdown and discomfort. A variety of comfortable
collars are available. One of the most common is a soft foam collar. Although
non-rigid collars provide comfort, they offer minimal support if neck weakness
is advanced. One popular lightweight collar is the Headmaster Collar™ (Symmetric
Designs Ltd., Salt Spring Island, BC). It is a low-profile cervical collar with
a padded chin rest. The padded tubular design feels cool and comfortable, even
in warm weather, and does not constrict the neck. Another collar to consider is
the Miami J Cervical Collar™ (Jerome Medical, Moorestown, NJ). It offers good
neck support with a breathable type of foam and is found to be comfortable by a
number of collar wearers. Cervical collars can be obtained at most medical
suppliers, and the cost is usually covered by health insurance if ordered by
the physician.
4. To promote comfortable use of head
support, alternating the use among several collars may be a solution to
reducing pressure points on the skin of long-term collar wearers. In addition,
a thin-cushioned skin dressing, such as Duoderm® (ConvaTec, Princeton, NJ), can
be applied over pressure areas to protect against skin breakdown. In some
countries, Duoderm is referred as Granuflex® or Varihesive®.
5. Leaning back in a reclining chair is
another method to support the head and to help keep the head from falling
forward. This may include a reclining wheelchair with a high back or one on
which a headrest can be attached. Power lift chairs also recline, and with a
push of a button they can recline back exactly to the desired angle. People
with excessive oral secretions might have difficulty reclining backward. To
help prevent choking on oral secretions, the head can be positioned to the side
and propped with a pillow.
6. Using a wheelchair head support
system can position the head in an upright position by a band across the
forehead that attaches to an adjustable headrest that mounts to a chair. Some
head support systems include the use of an elastic band, such as the Dynamic
Forehead Strap System (Whitmyer Biomechanix, Inc., Tallahassee, FL) that moves
with the user for a greater degree of movement and comfort than is provided by
conventional bands. Head support systems usually can be obtained from a medical
supplier who specializes in wheelchair accessories. People who need maximum
support in holding up the head and who cannot tolerate long term use of a
cervical collar might benefit from intermittent use of a head support system.
7. When in bed, avoid sleeping on a pillow
that is too high. This will not only strain the neck, but may cause wakefulness
at night. A rolled towel placed underneath the back of the neck with the head
resting on a low pillow can provide support and comfort of the neck and head
when sleeping. In addition, people who have trouble keeping their head upright
might try lying in bed a few times during the day to relieve the neck muscles.
8. Stretching exercises of the neck
muscles can help promote mobility of the head, alleviate stiffness of the neck,
and help prevent and treat neck pain. To avoid injury, evaluation and training
of other exercises by a physical therapist or a visiting nurse may be
warranted. Two exercises can be done safely:
- Slowly turn your head to the right as far as possible, hold, and
return to the center. Do the same to the left.
- Tilt your head straight over towards the right ear, hold, and
return it to the center. Do the same on the left side.
9. People who have unresolved neck pain
or difficulty holding up their head should consult with their physician who may
prescribe physical therapy for treating their problems. A physical therapist is
specially trained to evaluate the neck, help relieve neck pain, make
recommendations for supporting the neck and head, and provide education on
reducing the risk of neck injuries. Some methods of treatment may include the
use of moist heat, massage and exercises that stretch the neck to alleviate
stiffness and to enhance mobility and comfort. Life should not have to be a
"pain in the neck."
Choosing a Neck Support for Patients with ALS
ALS patients usually wear neck supports
only for specific activities (i.e. walking, reading, riding in a car or
airplane, writing, or dressing). At other times, wheelchair head rests or high
back chairs provide the needed head support. Neck supports should not be worn
while eating. Neck supports that immobilize weakened neck muscles are usually
rigid, uncomfortable, and may inhibit speech and swallowing. It may be
difficult to find a collar that will meet all the needs of an individual
patient and the type of support needed will change if weakness progresses. The
therapist or physician will need to test the strength of the neck and upper
body muscles to determine the degree and type of support required.
The patient should take an active role,
with the help and advice from the medical team, in choosing the neck support
that best meets their individual needs. Most patients prefer the least
"restrictive" collar as possible, but one that will also provide
adequate support. The proper amount of support, combined with appropriate
seating, postural training, and exercise, can improve comfort, function, and
independence for most ALS patients. Important questions to ask when selecting a
collar include:
1. Does the collar
provide adequate support?
2. Does the collar
cause sweating or friction?
3. Does the collar
cause a "choking" sensation?
4. Is it
affordable?
5. Is it
cosmetically acceptable?
Based on experience and input from
patients, the following is a listing of collars that have been successfully
used for patients with amyotrophic lateral sclerosis.
Soft Collar |
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These collars are inexpensive and can be
purchased from most medical supply companies. They are used when there is
very mild neck weakness to prevent fatigue and strain. When significant neck
weakness occurs, these collars are not adequate to support the weight of the
head. Since they tightly encircle the neck, they may feel restrictive and
uncomfortable and therefore, they usually are worn only for brief periods of
time. Soft collars are available with or without a vinyl stabilizing panel and in various
contours, foam densities (medium, firm) and heights (2", 3",
4", 4.5") to fit wide range of patient neck sizes. |
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Headmaster Collar (Adjustable Wire Frame
Cervical Collar) |
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This collar is lightweight, open, and
is comfortable in warm climates. It is easily formed by
hand to fit snuggly under the chin. It is made of a
specially tempered wire frame which is liberally padded with foam rubber
covered in a soft, washable fabric and uses a velcro closure strap attached to cushioned back piece. It is very
helpful for patients with weak neck extensors to prevent the head from
falling forward. However, if weakness is present in rotation and/or lateral
flexion (i.e. when shaking the head "no" or touching the ear to the
shoulder), it will not be adequate and more support is needed. Symmetric Designs Ltd. 2059 North End Road, Salt Spring
Island, BC, Canada, V8K 1C9 Toll Free Phone (Canada &
USA): 800-537-1724 |
Executive Collar |
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Similar in
general design to the Headmaster Collar, this collar is made of a
comfortable, lightweight Kydex frame and has an open neck design. An
occipital pad (back piece) attached to hook 'n pile strap can be positioned
to fit any neck circumference. Available in small (4" height), medium
(4½ height) and large (5" height) sizes. As with the Headmaster, it is very helpful
for patients with weak neck extensors to prevent the head from falling
forward. However, if weakness is present in rotation and/or lateral flexion
(i.e. when shaking the head "no" or touching the ear to the
shoulder), it will not be adequate and more support is needed. |
Reprinted with permission by
Pamela A. Cazzolli, R.N., ALS Nurse Consultant in Canton, OH. During her practice, she has interacted with
over 2000 people with ALS. For many
years, she served as the Nurse Consultant of the ALS Association Eastern Ohio
Chapter, including six years as the Nurse Coordinator of the ALS Center at the
Cleveland Clinic Foundation.