If you’ve worked long enough with complex rehab seating & mobility consumers, this scenario is surely familiar. Your client, his elbow clenched around that armrest, has the look of a drowning man clinging desperately to something solid.

So as the ATP, what do you do? Where do you start in this situation, or whenever confronted by upper-extremity positioning that appears less than optimal?

When it comes to upper-extremity positioning, what is “optimal” in the first place?

What Does Proper Upper-Extremity Positioning Look Like?

Asked to describe optimal arm positioning, Bart Van der Heyden, PT, Bodypoint’s clinical specialist for Europe and the Middle East, says, “An ideal upper-extremity position would be a position where the individual can enjoy optimal functionality, activity and interaction with his/her environment, while minimizing the risk for upperextremity injuries.”

While optimal positioning is different for every client, Ryan Hagy, MOT, OTR/L, ATP, area VP of sales for United Seating & Mobility, says, “There’s an optimal position to promote the most functional independence and also to prevent stretching on the muscles. Over the long term, you can start getting subluxation of the shoulder, or have contractures. So we’re trying not to create any deformity, yet provide support that’s substantial enough for them, whatever their needs may be, and allowing for the most function.”

Generally speaking, Hagy adds, optimal positioning can be described this way: “The shoulder’s probably in 0° to 10° of flexion to off set a little bit forward; neutral rotation down by the side; the elbow flexion is about 90°; the wrist and hand are supported in that neutral position.” This positioning, Hagy explains, should “allow for efficient movement in any direction and the functional use of their hands, if they have the ability to use their hands.”

Building on those ideas, the goal of an armrest, then, “is to adequately support the upper extremities without interfering with their function,” Hagy says. “It’s not impeding their function, and it’s not going to lead to other joint deformities or orthopedic conditions.”

“If the deltoid muscle’s strength is compromised,” Van der Heyden says, “support for the forearm and the hand is needed in order to avoid subluxation and dislocation of the gleno-humeral joint. It’s important to also evaluate the impact of upper-extremity positioning interventions on transfers, mobility and ADLs and adjust the entire seating system accordingly.”

Finding Optimal Upper-Extremity Positioning for Seating & Mobility Clients

If those are the ideal descriptions of proper upper-extremity positioning and the ideal goals for armrests, the reality of what consumers want to accomplish every day — not to mention their clinical conditions, lifestyles and personal preferences — can require clinicians and providers to make significant and highly individualized adjustments to each client’s mobility system.

For instance, what’s optimal upper-extremity positioning for an active wheelchair user who transfers into and out of his chair multiple times per day?

Says Van der Heyden, “Specific to the seating solution, this means that we’re trying to stabilize the pelvis, lower extremities and trunk, which will help to provide a stable base for functional upperextremity activities. If the individual has no fixed deformities, we’re trying to support a neutral and midline position of the pelvis, lower extremities of the spine while supporting normal spinal curves and cervical lordosis.

“Trunk support should be placed as high as the client needs to feel comfortable and stable, while allowing movements of the scapula. These basic seating techniques will help with aligning and stabilizing the gleno-humeral joint. Depending on the needs of the individual, positioning seat cushions, pelvic positioning belts, lower body position systems like adjustable foot supports, back support systems and upper-body positioning belts might be used.”

Hagy adds that for consumers who self propel their chairs, additional factors come into play.

“If they’re a functional propeller, you need to provide the desired amount of support,” he says. “But if they’re a propeller, a lot of times you lean toward that minimalist idea, where you don’t want to add too much weight, you don’t want to add too much interference to propulsion movement. So hopefully, less is more.”

And the plan may change yet again if consumers who self propel also need to use armrests to perform weight shifts.

“If they push up on their armrests for weight distribution, if they transfer using their armrests, then we may have to add a single post,” Hagy agrees. “That’s why there are so many different styles of armrests and so many different styles of armpads and ways to support the upper extremities, because it’s just so varying depending on the person’s presentation.”

“Wheelchair users are individuals, each with different interests in life as well as different physical and functional levels of ability,” Van der Heyden says. “In order to provide the best possible upperextremity position for the wheelchair user, a seating assessment should be done. With the information from the seating assessment, we can work towards a user-centered seating solution.”

The Gravity Factor

Now, back to our original question: What do you do when a client is literally hanging on his armrest?

Gabriel Romero, director of sales & marketing of Stealth Products, is familiar with that kind of presentation.

“I look at a couple of things,” he says, when meeting that client. “I look at the seat width. I want to see if he’s leaning because the chair’s too wide and there’s no hip guide support, so now he’s able to slide. You see his pelvis sliding to the opposite end because there isn’t a boundary there for him.”

Adding a physical boundary, though, won’t necessarily stop the sliding that can cause the client to hang on that armrest.

“Gravity is going to dictate where your body is going to go,” Romero says. “I’ve seen kids sitting perfectly on their pelvis, but gravity is their enemy. If they’re static, you’ve got laterals on them and you’ve got a decent headrest on them, and they’re feeling, ‘I can’t move, I’m not dynamic enough. So what am I doing? I’m starting to fatigue in this position because I can’t reposition myself.’”

In explaining the challenges of upper-extremity positioning, Romero references a famous poster of basketball legend Michael Jordan, his arms spread so they’re at right angles to his body and parallel to the ground.

“If you just do that for a little bit, you’ll see that your arms weigh something,” Romero points out. “That means if you don’t have them supported, your body is going to go in that direction.”

Upper-Extremity Positioning Issues in Disguise

Romero relates an example of an older boy brought to Stealth Products by his mother, who was concerned over his head positioning.

“This young person was showing that he had cervical issues, and his head was leaning to the right side,” Romero says. “He was very weak.”

Romero says his initial impression was that the boy’s positioning was “decent.” He was a bigger kid, and his wheelchair back angle was open “so he could sit back a little bit and lean back.”

The boy’s mother wanted to improve her son’s head positioning, and after observing the boy for a short while, Romero could see why. “His head started sliding off the headrest to the right,” he says. “Basically, no lateral strength at all.” The mother also said the boy would start coughing when his head started sliding; she believed the position of his head was causing the cough.

Romero says he first thought about putting a specific type of headrest onto the chair to stop the sliding from happening.

“But the real problem was that his arms weren’t on an armrest,” Romero says. “They were leaning on his belly and leaning between his legs. Where was gravity pulling him? Straight down. His shoulders were rotated in and were causing him to slide off the headrest because he wasn’t really using the headrest, and then gravity took his head to the right.”

Romero grabbed a tray, added some padding, put it onto the wheelchair and laid the boy’s arms onto it so they were supported. Then he gave the boy time to relax again from all the activity, and waited to see what would happen.

The sliding stopped. “You could see him supporting himself when he needed to off that tray,” Romero says.

Ironically, the mother admitted she already had a wheelchair tray, but that it was too large and bulky — a perfect example of a solution working in a clinic, but not in the family’s real-life environment or lifestyle. “A lot of times, families don’t like trays,” Romero says, “because if somebody’s driving a power chair, they can’t see what’s below their feet.”

The solution: a smaller tray that was less obtrusive, but with enough room for the boy to rest his arms on. Since the boy didn’t have high tone or another condition that would cause his arms to come off the tray, the smaller tray worked well, and without hitting walls, the way the larger tray was prone to do.

“Once we have him supported where his arms were, we had better positioning for his head,” Romero says. The boy’s head stopped sliding, and he stopped coughing as well, once his chest cavity was no longer being closed up by his posture.

“It wasn’t because of his head,” Romero says. “It was gravity pulling him down.”

Because gravity takes some time to fully be felt, Romero likes to try positioning interventions, such as the tray, then wait a bit to see how it truly works once a client’s excitement or adrenaline has worn off .

“Let time work with gravity,” he says, “because then gravity is going to show you what’s really happening in their lives. You give them 15 minutes, you start to see them get into a comfort zone. They’re breathing differently. And now you start to really see what’s happening.”

Upper-Extremity Positioning for Static Wheelchair Users

Gravity also, of course, impacts wheelchair users who have very little or no ability to reposition themselves independently.

“Users who are unable to position upper extremities independently, who have perception and/or sensory deficits, need special care with safe positioning of the upper extremities in order to prevent fractures, contusions, subluxation, lack of blood flow, edema, skin lesions, peripheral nerve damage and contractions,” says Van der Heyden. “Frequent skin checks and upper-extremity posture checks are needed to prevent tissue damage and complications.”

“I’ve had clients who have rubbed the bottom of their arms raw because they had tremors,” Romero says. “If you have somebody who has tremors, you’re basically lighting a fire on their skin. They’re moving back and forth.”

In those instances, Romero says interventions can include a reverse Dartex type of material with a very smooth finish, and/or a gel pad: “Something that will move with them,” he says.

For these clients, Hagy says, “You’re trying to support the whole upper extremity. So if you have the arm height right and the pad right, you really are trying to distribute that weight from the elbow all the way down to the wrist, and they may have a palm extensor pad, too. So all that weight of the upper extremity is dispersed well.”

Armrest height is crucial, he adds, because the weight of the entire upper extremity is being borne by the forearm. “Armrest height is so important because if it’s up too high, then all that weight from the upper arm is just jamming right down into the elbow.”

How Upper-Extremity Positioning Can Help Power Chair Driving

Upper-extremity positioning is also crucial for power wheelchair users to be effective drivers.

“Unfortunately, what I see most out in the field is people being put on a standard type of mounted joystick right off the armrest,” Romero says. “It’s not always the most functional place for a joystick to be for an individual. Sometimes that joystick needs to be off set a little. But if I’m off set in a little bit, I’ve just lost the support I had on the pad. So now what I have to do is create some kind of tray so I can support the wrist and arm coming in midline. The worst thing we can do is say, ‘We figured out how this person can drive. But we put their joystick in an area that’s not supported, so they’re only functional in the chair for a short time.’

“A lot of times I see clients who are struggling to drive with the joystick mounted right off the front of the armrest. They may have a deformity where their arm is shaped inside midline, and they’re able to do left and right as their forward and reverse. They’re fantastic if the joystick is a little off set in.”

For other clients, midline driving can be a way to compensate as a condition progresses.

“ALS is a good example,” Hagy says, “or a progressive (neurological) one like SMA. That’s where height of the armrest and angle of the armrest is key, because if we can keep them on that joystick longer, we can hopefully keep them a little bit more independent. Angling the armrest as they progress and changing the position of the actual joystick in relation to the armrest can be crucial to a lot of patients for keeping them mobile with a joystick.”

“Providing shoulder and forearm stability may help to improve hand control,” Van der Heyden says. “Power controls mounted close to the arm supports — which is typical of most power chair joysticks — require the user to have a sufficient amount of external rotation of the shoulder joint. By using midline controls, the shoulder joint will have less end range of motion (towards external rotation). This may make it easier for the user to use the controls.”

More Positioning Strategies

Let’s go back one more time to that client who is hooking an elbow around one of his armrests.

First of all, that posture is not necessarily a problem, Van der Heyden says, if it’s temporary.

“Compensatory movements like hooking an arm or propping up can be part of ‘normal sitting behavior’ and may temporarily help to make the wheelchair user’s seating position more dynamic, bring variation or increase the amount of stability while seated,” he notes.

“If compensatory upper-extremity movements dominate the user’s seating position during the day, cause pain/discomfort or limit functional activity, it’s important to assess the seating solution and look for seating deficits like lack of stability, poor head position or discomfort.”

After checking some basics such as the seat cushion (see sidebar), Hagy says he looks for “improper back angle or back height, which could actually cause the person to fall forward or cause them some instability. Then you can start looking at weakness: Is there trunk weakness so they need to (hold onto the armrest for) additional support because they need to lean to one side? Is there scoliosis? Is there a spinal curvature to the right or left that is causing them to lean? It could be pelvic obliquity — if their pelvis is higher on one side than the other, it’s going to cause them to compensate with their trunk. You’re also looking for muscle weakness.”

“Using upper extremities to prevent excessive leaning or sliding usually is a sign of insufficient postural stability or postural control while seated,” Van der Heyden says. “Perhaps the seating system does not stabilize the user enough?

“Are postural deformities being accommodated for? Does the user have the physical ability to sit in the provided seating solution? Is the seating solution comfortable? A seating evaluation will provide answers if lateral supports, positioning cushions, back supports, pelvic support belts, upper-body position belts or adjustable foot supports can help stabilizing or accommodating.”

One of the major challenges to achieving optimal upper-extremity positioning is the fact that what looks like an “arm positioning” problem may in fact be rooted somewhere else in the body. And what manifests as a positioning problem somewhere else in the body may actually be caused by poorly positioned upper extremities.

“So at the end of the day,” Romero says, “you have to start looking from pelvis to lateral to headrest. It’s the domino effect of positioning.”