If the pelvis is the foundation of functional
positioning in a wheelchair, then how do the upper and
lower extremities impact optimal positioning?

“The arms are so important,” said Gabriel Romero, VP of Sales & Marketing for Stealth Products. “People always go straight
to the pelvis, but a lot of other things dictate what the pelvis is
going to do. The arms are like wide pillars — they [can be] folded
in front for good frontal support, or pushed to the side so they
can give good lateral support. You really have to figure out what’s
the best solution for them.”

Failure to optimally position the upper extremities, Romero
added, can lead to other positioning problems. “I’ll see a
non-funded or a more basic chair, and I’ll see the person’s
kyphotic positioning just due to armrests not able to be adjusted,
or arm pads not being wide enough. When adults start losing
strength, or children don’t have strength, they’re going to go
wherever their arms take them. You’ll start to see shoulder
dipping, you’ll start to see head tilting because an armrest’s
height or length or width wasn’t considered. A tray platform
wasn’t considered. It’s a ripple effect.”

Upper-Extremity Positioning Goals

So what are the priorities when positioning a wheelchair user’s
upper extremities?

Tina Roesler, PT, MS, ABDA, is Director of Clinical & Business
Development at Bodypoint.

“It depends on the client,” she said. “If I’m looking at someone to
drive power controls, for example, I’m going to look at what maximizes
their stability so they can still use what function they have
to reach the joystick or manipulate the joystick, and what position
helps them maintain that. Say they have tilt in space or recline:
You don’t want them to lose that position when they tilt the chair
back so they can’t reach the joystick to untilt, for example.

“I think we’ve done better at looking at that and discussing
that. I think with some of the higher levels of [spinal cord] injury
that need total arm support, I think we’re doing much better.”

The priorities are much different,
Roesler said, for clients using ultralightweight
wheelchairs: “When you
start thinking about someone who’s self
propelling, it’s not necessarily positioning
per se of the upper extremities,
but the position of the shoulder and
the upper extremity relative to the
chair and the rest of the body. So basic
biomechanics come into play. While
we might not be positioning them statically,
we want to be sure the shoulders
are in a more neutral position, and that
there’s not too much external rotation
or extension happening during propulsion.
All of that comes into play when
you start talking about the trunk and
the pelvis. You’re reducing repetitive
stress and strain by having the best
biomechanics at the upper extremity.”

The stability and positioning of
the trunk and pelvis directly impact
upper-extremity function, Roesler said.

“I’m sure you’ve heard the old adage
that proximal stability promotes distal
function,” she explained. “So I think
that’s why there’s so much focus on the
pelvis and trunk: If I don’t have that
stabilized, I can position the arms the
best that I can, and [clients] still might
not be able to function with their upper
extremities properly.”

A stable pelvis and trunk, she added,
allows the wheelchair user “to initiate
control, to initiate movement at the
upper extremity without falling over or
being in an awkward position.”

And even when the arms aren’t being
used to propel or operate the wheelchair
— for example, with dependent
mobility, when a caregiver is pushing
the wheelchair — those upper extremities
still need to be supported, Romero
added. If arms are left unsupported,
“Now we have to talk about shoulder
pain management, because for the
longest time, somebody’s arms might
have been hanging, unpositioned. So
now you have joint pain.”

Lower-Extremity
Positioning Goals

The need for functional upper extremities
seems pretty obvious: Arms and
hands perform many activities of daily
living, and they often operate the wheelchair and seating functions. But why is lower-extremity
positioning so important?

“That’s one of my pet peeves, when I see someone come into a
seating clinic or I watch them in a wheelchair and they don’t have
their feet supported,” Roesler said. “I can do as much positioning
as I want to with the trunk, the pelvis, the upper extremities:
If my lower extremities aren’t supported, I no longer have that
closed chain.

“I always use the term closed kinematic chain, which is a biomechanics
term. When you’re seated with your feet supported —
your trunk and your pelvis, all the way down to your feet and
all the way up to your head acts as one closed chain or one
unit. Whatever I do to one of those segments impacts the other
segments. If my feet are dangling and pulling me forward, it
impacts my entire trunk, my entire pelvis, my entire head, my
upper extremities and my ability to control all of that.”

Footplates often get a bad rap: Depending on their placement,
they can add to a chair’s length and raise the risk of running into
walls during turns. They can get in the way during transfers.

Still, eliminating the footplate usually isn’t the best option.

Roesler said she’s “never [heard] a good explanation” when a
footrest is missing from a wheelchair. “Maybe it was easier for the
caregiver, and they didn’t realize the implications from a postural
standpoint,” she said. “If my feet are dangling and my legs are
dangling off the chair, it changes my postural position. It tends to
pull me into a posterior tilt. It can also cut the circulation off at
the back of your legs.

“Dangling feet are going to affect everything else you tried to
do in the rest of that chain. It’s a closed chain as long as your feet
are supported. Once you open up that chain, it’s like a noodle:
shear, friction, posture abnormalities, posterior tilt. It can cause
permanent postural abnormalities, like permanent plantar
flexion or rotation. And then you have even a more difficult time
when you try to support the lower extremities.”

Roesler pointed out how uncomfortable high barstools can be
when legs dangle for any length of time. “Are you comfortable in
that position?” she asked. “The only time I would ever say that
dangling feet are okay is if someone, for example, has a severe pressure injury on the bottom of their foot. Other than that, the
feet should always be supported in some way for stability.”

Building Movement Into the Seating Strategy

One of the challenges of positioning extremities is that wheelchair
users move — intentionally as well as unintentionally —
within seating systems. They reach and lean when performing
daily activities or operating their chairs. They can also experience
tone and spasticity that moves them within their seat.

That’s why extremity support is particularly important, Roesler
said. “Especially when you have someone with tone, they need
to be supported at their feet, but also supported correctly so
it doesn’t initiate more tone, say, when they go over a bump,”
she said. “That’s where you see more use of secondary postural
supports: With a lot of pediatric clients, you see the use of
ankle huggers to help keep their feet in place. Or a calf support,
either posterior or in front of the lower extremities, can really
help while the person is trying to function. So maybe their tone
doesn’t negatively impact what they’re doing, and maybe they can
utilize their tone to help increase function as well.”

Some wheelchair users actually use their tone to perform activities.
“You’ll see a lot of people initiate their tone increases, and
sometimes that helps them do functional tasks, like driving a power
chair,” Roesler said. “You might see their tone increase in their lower
extremities as they try to reach the joystick, for example.

“When I first started in seating and positioning, it was You
want to control the tone and stop it. As we’ve learned more and
really looked at what we’ve been doing, we’ve realized that sometimes
that tone that might be abnormal is helping them do some
activities. We want to minimize the negative impact of it, but we
don’t necessarily always want to eliminate it.”

That’s when dynamic postural supports can be helpful.

“I think that’s where secondary postural supports are different
than seatbelts, for example,” Roesler said. “A lot of [Bodypoint’s]
chest harnesses have a dual stretch so that they stretch when
they need to. If you need to lean forward, you can. But because
of the stretch, it’s also going to help you return back, because it
does want to return to its original position. It’s not like a spring;
it’s not that strong. But it gives you enough movement to be able
to use your upper extremities or move within a range and then
help you come back to the original resting position.”

Roesler added that dynamic supports can be adjusted per each
client’s needs: “You can make a postural support be pretty tight
and not have a lot of dynamic motion, but it’s always good to
have a little bit. You don’t want so much that the pelvic belt or
chest harness starts to slip, because that can become dangerous
over time. But you do want it to have some motion. Even the type
of buckle you use can impact how much or how little motion you
get, depending on the configuration.”

Dynamic supports can be particularly useful for pediatric
clients. “The example I always use is for kids,” Roesler said. “A
lot of times we’re using postural supports with kids because one,
we do want them to be safe. But we also want to give them some
postural support. We also know they tend to move around a lot
more, so we don’t want to restrict that too much.

“We have a [Bodypoint] swivel buckle that allows the harness
or belt to move laterally and rotate a little bit as the person moves
in the chair. So it still has a firm hold and tries to keep your
position, but it allows some movement in different directions,
whereas a straight rehab latch or push-button buckle is pretty
much fixed. You’ll still be allowed a little movement from the
stretch in the belt itself, but it doesn’t move with you. So it may
not be as comfortable, and if you have someone who’s asymmetrical,
it may not be as comfortable, either, because it might not
distribute pressure the same way.”

Adapting Strategies to Get the Best Function

That’s the greatest challenge for upper- and lower-extremity positioning:
Each client needs a unique approach.

“Especially when it comes to driving a power chair for an
individual with cerebral palsy — maybe they have to elicit tone to
reach the joystick,” Roesler said. “It may not be normal, but they’ve
developed it for function. Sometimes if we apply too many postural
supports or correct it too much, we take that away.

“I’ve seen that happen before: ‘Oh, look how nice and straight
they’re sitting, and they have this nice belt and chest harness.’
And now they can’t drive their power chair for some reason. So
it’s really important to look at that and realize tone isn’t always
a bad thing. Some people have learned to live with it and make
it useful for them. You don’t want tone to be so strong that it’s
causing postural deformities or limiting what someone can do.
But that’s where postural supports come in. If I have someone
who has a lot of lower-extremity tone when they push a manual
chair, for example, maybe use an anterior support on the lower
extremities or a good pelvic positioning belt. Although they still
might get tone, the belt helps them maintain lower-extremity
position so they can still propel easily or more easily.”

Romero praised seating teams who take the time to fine-tune
postural components for each client: “There are great ATPs that
take their time and get adjustable armrests that can rotate in if
they need to, or troughs that can rotate in. Sometimes it’s for
comfort and positioning. It becomes critical for them because
now they can be in their chair longer, which again is the ultimate
goal for everyone.”