To set the scene: many people who’ve had a stroke end up with mobility difficulties, and as a result come to depend on a wheelchair.
80 per cent of these individuals develop shoulder subluxation as a result of muscle weakness creating shoulder joint destabilization, together with gravity pulling down on the head of the humerus bone (1).
Linked to this, 29 per cent of post-stroke patients suffer from shoulder pain (2).
After traumatic brain injury, one report has shown that 84 per cent of the patients developed contractures, and after just four weeks 23 per cent of these contractures had become ‘fixed’ (3).
In this article, we look at the preventative measures we can apply for wheelchair occupants to protect against, and relieve, upper extremity damage and pain
To control our hands we need to have control of our arms, and for that we need control of our shoulders.
The shoulder is the most mobile joint in the body. It comprises a complex structure of bones, ligaments, and muscles that work together to keep it stable.
However, because the shoulder is so mobile, it is also very susceptible to dislocation.
Shoulder subluxation, a partial dislocation of the shoulder joint, is not uncommon.
This occurs when the ball of the upper arm bone, the humerus, partly comes out of the glenoid socket in the shoulder.
Complications of shoulder subluxation include: shoulder pain, loss of upper extremity function, tone increase, tendinitis of the rotator cuff tendons, and stiffening of the shoulder joint capsule.
A shoulder subluxation is often the result of trauma, injury, neuromuscular disease, or a stroke (CVA) that weakens the arm muscles.
It is therefore critical that early intervention be applied, since this can prevent these problems developing.
In addition, apart from the loss of function, these sudden onset mobility challenges frequently come with severe pain.
Despite progress in many aspects of wheelchair development, an area that has had little attention to date has been the facilitation of the use and the preservation of function of our upper extremities.
This function can be affected by back supports that are too high or too vertical, and thus restrict our shoulder blades from behind.
On the other hand, chest or shoulder harnesses can heavily restrict movement to the front.
Over and above avoiding restrictions to functional movement, what positive actions can we take?
For day-to-day functionality, the use of our hands and upper extremities can be critical.
Overall, we are trying to achieve the balance of postural management with facilitating functional activity.
But what has been available to facilitate this?
Arm supports, rests, or troughs?
Most wheelchairs are supplied with an arm rest.
However, most wheelchairs’ arm rests do little to prevent or alleviate the problems of reduced functionality and pain described above.
Maybe this is because these parts of the chair are still often being referred to as arm rests, showing no recognition of their clinical importance? If we call them the ‘correct’ term of arm supports, maybe a better product might be prescribed.
What are the challenges with common wheelchair arm supports?
Just as foot supports should be adjustable to achieve the optimum distance for the lower leg from the seat cushion, arm supports should be finitely adjustable to get the forearm (and therefore the upper arm) at the right height, to sit comfortably in the shoulder socket.
Further, the top of the arm support should support the forearm and wrist so that they do not fall off the support (figure 1):
When the arm support is provided in the form of a standard ‘trough’, there are three problems with this design.
One is that the trough restricts movement and thereby restricts both physical rehabilitation and also general function; secondly, the arm tends to be forced parallel with the seat frame, whereas the anatomically correct position is to allow the forearm to rotate medially by 10-15 degrees; and thirdly, the hand tends to fall into a flattened pronated position and the fingers and wrist remain unsupported (figure 2).
To have a perception of where the arm should rest: while seated, drop your arms down by your sides in a relaxed position. Then flex your arms at the elbows and see where your forearm and hand positions end up.
This is the anatomically preferable resting position of the hand and forearm, and thence the upper arm and shoulder joint.
A practical support
So what do we need for an anatomically correct arm support?
The answer is one that supports the elbow at the right height (supporting the elbow vertically in line with the shoulder joint will help prevent subluxation); one that supports the distal forearm in a medially rotated position (i.e. when it is across the body); one that permits dynamic movement of the forearm; one that supports the hand in the optimal position and with the thumb abducted; and one that allows hand movement, but can absorb unintended tone.
Such a device is now available in the shape of the Bodypoint Dynamic Arm Support (DAS).
This device was first invented by the Belgian physiotherapist and seating specialist Bart Van der Heyden (4) in 2009, and has since been developed and released by Bodypoint (5,6).
The DAS supports the distal forearm in an anatomical resting position, as well as supporting the hand and fingers, thereby providing three points of support for the upper extremities. Positioning the hand so the thumbs are abducted and extended, with the fingers extended, provides a tone-inhibiting position.
In the event that tone of the finger flexor muscles occurs, the dynamic finger section of the DAS will absorb tone, while a strap over the hand will control the hand position during extensor spasms.
In addition, by allowing the elbow section to pivot, shoulder movement can remain, and even be trained, while the upper extremities are held in a safe anatomical position.
The DAS also helps keep the hand in view, thereby reducing what is termed ‘neglect’ i.e. out-of-sight, out-of-mind.
The DAS offers unique adjustment where:
• Gross lateral and rotational positioning can be accomplished through appropriate placement of the base plate
• A pivot system allows for 60 degrees of total range of motion (ROM): 30 degrees of internal rotation and 30 degrees of external rotation at the shoulder, which in turn
• Facilitates active ROM and proprioceptive exercise
• Allows for optimal positioning that can be changed as needs change
• Progressive position changes are possible over time
• Each component can be individually adjusted for fit and function.
The DAS is appropriate for the management of hypertonicity, resistance to passive movement, shoulder pain, and shoulder subluxation involving neurological involvement of the upper extremities arising from:
• Stroke (CVA)
• Brachial plexus injury
• Other progressive or traumatic neurological impacts on the upper extremity as may be seen in diagnoses such as spinal cord injury (SCI), traumatic brain injury (TBI), muscular dystrophies, multiple sclerosis and Parkinson’s.
The ability to set up the device correctly, and the means for allowing movement in the right planes, are both critical for pain relief, for early physical rehabilitation, and for dynamic functionality.
As ever, the earlier the intervention, the fewer the subsequent complications, and the faster the rehabilitation.
For more information, contact BES HEALTHCARE
- Arya KN, et al. 2018 Rehabilitation methods for reducing shoulder subluxation in post-stroke hemiparesis: a systematic review. Topics in Stroke Rehabilitation 25, 68-81
- Adey-Wakeling Z, et al. 2015 Incidence and Associations of Hemiplegic Shoulder Pain Poststroke: Prospective Population-Based Study. Archives of Physical Medicine and Rehabilitation 96, 241-247.
- Mousa AS, et al. 2022 Assessment of Extremities Muscle Contracture for Critically Brain Injured Patients. International Journal of Novel Research in Healthcare and Nursing 9, 147-157
- www.super-seating.com Figure 2
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