Introduction

We describe a practical approach to the patient presenting with an abnormal head posture (AHP).^1,^2,³ Chapter 81 details the causes, types, and physiologic basis of abnormal head postures.

Nomenclature

The three axes of rotation are “yaw” (about the vertical axis), “pitch” (about the anteroposterior axis), and “roll” (about the left-to-right axis) (Fig. 114.1). An AHP is described by these axes: yaw corresponds to head turn or face turn, pitch to head tilt, and roll to chin up or chin down.“Torticollis” refers to any abnormal head posture; sometimes, it is reserved for head tilt. “Compensatory head posture” is an AHP adopted to improve vision.

Fig. 114.1 Graphical depiction of the axes of rotation of a three dimensional object.

Patient history

The age of onset of a head posture is infrequently available. The patient and family do not recognize an AHP unless extreme. Old photographs provide reliable historical information about the onset and severity.

Characterization of the head position

Clinicians estimate the angle of head positions in degrees. Orthopedic goniometers (Fig. 114.2A), arthrodial protractors (Fig. 114.2B),⁴ and other devices including cervical range of motion devices (Fig. 114.2C)⁵ have been used to improve precision. Placing a prism (or yoked prisms) of increasing power in the line of sight until the head appears straight also may be used to measure the head position. Clinical photographs are a convenient, accurate, and reproducible way to document a head position (unpublished data). To obtain an accurate photograph, provide a target requiring fine visual resolution to ensure that the patient is fixating on the camera as the photograph is taken. Eliminate confounding background objects. Have a child sit up straight, off of the parent’s lap, to minimize leaning. Obtain similar photographs with each eye covered if head position changes with monocular viewing.