When an Armrest Isn’t Enough – Wheelchair Seating for the Upper Extremities

While most people using wheelchair seating technologies do not require specific upper extremity support, some clients do require interventions in this area beyond the simple arm rest. These clients include those who need additional support, who assume destructive upper extremity postures, who demonstrate extraneous movements, and who are self-abusive. Below we will outline the cause, intervention, and goals for each of these scenarios.

Need for Additional Support

Clients who require additional support are those whose arms fall off of standard armrests or remain hanging in the lap. These clients are at risk or have already developed subluxed or dislocated shoulders.

Causes
Lack of shoulder integrity may be caused by:

• Decreased strength
• Paralysis
• Decreased muscle control
• Abnormal muscle tone
• Postures that continually pull on the humerus

Interventions
If standard armrests are insufficient, wider armrests can be made. Arm troughs can also be used and include contours designed to provide increased postural support and prevent the arm from falling off of the trough. These are available in different styles and with hand pads.

Forearm straps may also be required to prevent the arm from falling. If the client uses mobile arm supports, this becomes a part of the seating system.

Goals
A loss of shoulder integrity can be painful and so comfort is a goal. For some clients, this additional postural support may enhance functional use of the arm. For others, adequate support can prevent further loss of integrity of the shoulder girdle.

Destructive Postures

Over time clients may assume postures that can lead to orthopedic losses. These include shoulder retraction, shoulder protraction and elbow extension.

Causes
These postures are typically the result of increased tone and reflexes. Some of these postures worsen with anxiety or may be seen as a part of a “fixing” pattern as the client attempts to maintain an upright posture.

Interventions
If the arm posture can be attributed to reflexive activity (i.e. tonic labyrinthine), changing the client’s position in space may be helpful. If the client is “fixing”, it is important to provide adequate proximal stability to break up this pattern.

In shoulder retraction, blocks placed behind the elbow may encourage the arms to remain forward. Sometimes arm straps are required to maintain the arms in a more anatomically correct position or to prevent injury – particularly in clients who retract and extend their arms to the sides. Of course, any strapping is contra-indicated if the client uses their arms functionally. Strapping in this case may be misconstrued as a restraint.

In shoulder protraction, the shoulders are rounded forward. It is important to promote trunk extension, and my course, Wheelchair Seating Assessment: Positioning the Trunk, covers effective strategies to achieve this.

Elbow extension is difficult to address in seating. Some have tried orthotics or splinting, but this is not always effective. Strapping is sometimes required to prevent the client from injuring the elbow joint due to strong and continual extension.

Goals
The goals of addressing destructive upper extremity postures are to achieve neutral alignment to protect the shoulder and elbow joints, to reduce risk of injury from arms being caught in doorways, and to break-up muscle tone patterns to improve function. Clients who tend to retract their shoulders, particularly when the client is tilted most of the time, are at particular risk of anterior shoulder dislocation. Clients who extend, and often adduct, and internally rotate their upper extremities are particularly at risk of elbow dislocation.

Extraneous Movements

Extraneous movements are uncontrolled movements that can lead to injury of the client or others around them. These movements may also impede function.

Causes
These movements may be due to athetosis or dystonia. Anxiety may worsen these movements. The client may also be attempting to stabilize.

Interventions
Movement is not generally a problem, but unintentional movement may result in the arms contacting sides of doorways, leading to injury. Flailing movements of a seated person may result in undesired contact with standing bodies nearby – sometimes resulting in what may appear to be inappropriate touching. Uncontrolled movement may also impede function by reducing stability or interfering with intentional movements. The main strategy for controlling these movements is to block them.

If the client can reach and grasp, they may be able to hold onto a vertical or horizontal post attached to a tray or the wheelchair frame to limit movement of that extremity or to increased stability. If the client cannot grasp, she may be able to tuck an arm into a cuff to again limit movement and/or increase stability. The last option would be to strap the arms down, if necessary.

Goals
We control or limit uncontrolled movements of the upper extremities to reduce risk of injury to the client and others, to reduce anxiety, to increase stability and to allow for functional tasks.

Self-Abusive Movements

Self-abusive movements of the upper extremities cause injury to the client themselves. These movements may be intentional or compulsive.

Causes
Some clients engage in these behaviors as a form of self-stimulation or as a component of anxiety. Clients diagnosed with Cornelia deLange syndrome or Lesch-Nyhan syndrome have a compulsive drive to self-injure and, in the case of the latter, injure others, that is involuntary.

Interventions
Interventions are similar to some used for uncontrolled movements. In severe cases, the client must be restrained to prevent self-harm. For clients who may be seeking stimulation, it is important to provide alternative sensory input, a means of communication and independent control.

Goals
The goals of addressing self-abusive movements are to reduce the risk of injury to the client or others, and reduce anxiety by making the client feel safe.