Upper extremities Most people using wheelchair seating technologies do not require specific upper extremity support. Most wheelchairs include standard armrests, though these provide little real support. Instead, as the name implies, an armrest is designed to provide a temporary place to rest the arm and may be useful to push off from in order to perform a weight shift or to transfer in and out of the wheelchair. Clients who do require intervention in this area include those who need additional support, those who assume destructive upper extremity postures, those who demonstrate extraneous movements, and those who are self- abusive. Need for additional support Clients who require additional support are those whose arms would slip off the armrests or remain hanging in the lap. These clients often are at risk for or have already developed subluxed or dislocated shoulders. Lack of shoulder integrity may be caused by decreased strength, paralysis, decreased muscle control, abnormal muscle tone, and postures that continually pull on the humerus. If standard armrests are insufficient, wider armrests can be made. Arm troughs include contours designed to provide increased postural support and prevent the arm from falling off the armpad. Arm troughs are available in different styles and with hand pads (Figure 58). Forearm straps may be required to prevent the arm from falling. If the client uses mobile arm supports, these become a part of the seating system. Figure 58: Arm Trough Note . From Ottobock, n.d., retrieved from https://professionals. ottobockus.com/zb2b4o . © Ottobock. Reprinted with permission. A loss of shoulder integrity can be painful, 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. Addressing destructive postures Clients may assume postures that, over time, can lead to orthopedic losses. These include shoulder retraction, shoulder protraction, and elbow extension. 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. If the arm posture can be attributed to reflexive activity (e.g., tonic labyrinthine), changing the client’s position in space may be helpful. If the client is “fixing” or trying to stabilize his or her body, it is important to provide adequate proximal stability to break up this pattern. In shoulder retraction, blocks placed behind the elbows (Figure 59) may encourage the arms to remain forward, unless the client lifts up and over the blocks. 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 contraindicated in clients who use their arms functionally and may be misconstrued as a restraint (Babinec et al., 2015). The topic of restraints will be addressed later in the course. In shoulder protraction, the shoulders are rounded forward. It is important to promote trunk extension using strategies that were presented earlier, including anterior trunk supports.
Elbow extension is difficult to address in seating. Some have tried orthotics or splinting, but these interventions are not always effective. Strapping is sometimes required to prevent the client from injuring the elbow joint. 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. A client who tends to retract the shoulders, particularly when he or she is tilted most of the time, is at risk of anterior shoulder dislocation. Clients who extend, and often adduct and internally rotate, their upper extremities are particularly at risk for elbow dislocation. Figure 59: Posterior Elbow Block
Addressing extraneous movements Extraneous movements are uncontrolled movements that can lead to injury to clients or others around them. These movements, which can also impede function, may be due to athetosis or dystonia. They may be worsened by anxiety. Sometimes the movements are an attempt to stabilize the body. Movement is not generally a problem, but unintentional movement may result in arms getting caught between the lateral trunk support and the armrests or underneath the armrests, hands falling onto the rear wheels, or arms contacting 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 movements may 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, he or she 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 increase stability (Figure 60). If the client cannot grasp, he or she may be able to tuck an arm into a cuff to again limit movement and/or increase stability (Figure 61). The last option would be to strap the arms down, if necessary. Again, this could be misconstrued as a restraint, and this will be addressed later in this course. Figure 60: Vertical Post
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Book Code: PTNC1023
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