UPPER EXTREMITY POSITIONING: THE MISSING SEATING INTERVENTION

Presenter: Bart Van der Heyden, Superseating, Belgium (photographed)

In July 2023, I had the privilege of attending a two-day conference hosted by the Posture and Mobility Group (PMG) at The International Centre in Telford. The conference was highly informative, featuring case studies, the latest research, and industry technology. Moreover, it provided ample opportunities to connect with experts in the field of wheeled mobility and posture. I am deeply grateful to PMG for extending this invaluable opportunity to me.

The following report is a summary of my personal reflections on Bart Van der Heyden’s presentation titled Upper extremity positioning: the missing seating intervention.

During the seminar, Bart highlighted the incidence of gleno-humeral subluxation, shoulder pain, and upper extremity contractures following stroke and traumatic brain injury. Wheelchair users with diagnoses such as multiple sclerosis, Parkinson's disease, and muscular dystrophy often also demonstrate neurological involvement of the upper extremity. These presentations can negatively affect an individual's quality of life, hinder rehabilitation, and increase institutionalisation rates. Bart, therefore, emphasised the importance of evaluating a client's upper extremity postural and functional deficits during a seating assessment, and understanding the link between upper extremity posture and seated posture.

He provided an overview of the pathomechanics and risk factors of upper extremity contractures and gleno-humeral subluxation, as well as seating considerations/interventions to reduce shoulder pain and subluxation, and manage contractures of the upper extremities. He used case examples to illustrate and share his expertise in managing gleno-humeral subluxation. From the examples provided, the following considerations were made to manage gleno-humeral subluxation: stabilizing the trunk and pelvis, supporting the posterior pelvis, accommodating for kyphosis, adjusting the armrest height to provide support for the elbow, hence supporting the gleno-humeral joint, avoiding excessive shoulder adduction and internal rotation, and adjusting transfer techniques.

Bart explained that the current interventions to manage upper extremity contractures utilise either closed and/or open kinematic chain movements. Closed chain movements (e.g. splints) provide distal stability but result in a proximal loss of control at the elbow and gleno-humeral joint. Open chain movements allow the distal aspect of the extremity to move freely and are not fixed to an object (e.g. gutter armrest, pillows).

To conclude his presentation, Bart introduced the Moduform Dynamic Arm Support, an innovative option for positioning the upper extremities on wheelchairs, which incorporates both closed and open chain movements. This arm support provides three points of support (elbow, distal forearm, and fingers) with dynamic distal movement of fingers. It is used to reduce the risk of upper extremity dysfunction (e.g. contractures, shoulder pain, and shoulder subluxation). Bart’s description of the development process and Bodypoint’s efforts to further develop this product left me inspired. It encouraged me to reflect on how we as clinicians can influence and shape product development in the market to bridge the gap and to address unmet needs.

Many thanks to Bart for his informative presentation. It reminded me of the importance of evaluating upper extremities, management, and positioning and how these factors play a crucial role in preventing contractures, range of motion deficits, shoulder pain, and gleno-humeral subluxation. Moving forward, when completing wheelchair assessments, I will evaluate clients’ upper extremity postural and functional deficit, and take on a multi-disciplinary approach (e.g, medications, positioning on wheelchair, positioning in bed, passive movement etc) to support the client’s needs. 

I am eager to observe the practical application of the Moduform Dynamic Arm Support among wheelchair users. Last but not least, this presentation reaffirmed the importance of upper extremities positioning, which I will share within our service.