Upper Extremity Protection

Posted by Nurse Linda in Life After Paralysis on October 13, 2021 # Health

Man in blue and white striped shirt using exercise equipment with his right armThe arm and hand are parts of the body that are used for specific types of work. This includes eating, dressing, bathing, typing, actually doing a rather lightweight sort of endeavor. The arms and hands are not designed to perform repetitive heavy lifting. Yet, with paralysis, arm and hand function can be challenged. Both arms and hand function can be affected after spinal cord injury or diseases that affect the spine. With stroke or brain injury, one arm and hand can be affected. Therefore, learning to protect your upper extremity is important for long-term health.

One of the joints in the arm that can be affected by paralysis in the arm is the shoulder. This joint is a ball and socket consisting of the top of the humerus bone (the bone above the elbow) shaped like a ball. This bone fits neatly into the shoulder socket. Because the joint is a ball fitting into a socket, it can rotate in all directions. This range of movement provides a lot of function. The bones and muscles of the shoulder allow movement of the arm in combination with other arm joints to be quite effective. But it can place a lot of strain on the shoulder joint.

One of the jobs of the shoulder is to hold up the entire arm. However, your body is not built to carry the weight of your arm through your shoulder joint alone. If the muscles and nerves around the shoulder joint are weak, the weight of the arm can cause the shoulder to sub lux or pull out of the socket. The movement to your shoulder or someone moving your shoulder joint will be restricted. If you have sensation, this is painful. If you have issues with sensation, you may not feel pain, but your body may react in other ways through referred pain to your jaw, by increasing tone (spasticity) in the muscles or episodes of autonomic dysreflexia (AD). You may not be able to move your shoulder as you once could when stretching or exercising; it may pop when moving, or you might hear a grinding noise. You may notice a decrease in strength.

Check with your healthcare professional as always if there are changes in your body. Report any of the above symptoms. Look at your shoulder, especially at the top of the shoulder where your arm meets your torso. If there is a little dip in the skin, your shoulder may be subluxated, meaning the ball has slipped out of the socket joint. You can also carefully place a finger at the top of the joint. You may feel a separation. Do not press hard to find it as you do not want to cause a subluxation through examination. If you do feel a little dip between the bones, the width of the dip is measured by finger widths, one finger wide, two fingers wide, three fingers wide. The wider the dip, the more severe the subluxation can be.

Prevention is the best treatment for shoulder subluxation. When discovered early, treatment can be the best prevention. If you have a high-level spinal cord injury or stroke with weak muscles on one or both sides of the body, a shoulder sling will assist with keeping the joint in place. Here is an example randomly selected of a shoulder sling. Notice the upper arm is supported with the weight of the arm distributed along the back. This type of device is great for those with ambulation skills or during therapy when your arm might be unsupported.

More commonly prescribed are arm troughs. This positions the arm with a reduction of weight through the shoulder joint. These can be attached to a mobility device. They can also have an elevating feature for the treatment of arm/hand edema.

Another alternative is electrical stimulation applied through electrodes placed on the skin to activate the muscles. This can hold the arm in position as well as build strength in the shoulder muscles.

A rotator cuff is a group of four muscles that stabilize the shoulder. Tears in the rotator cuff from overuse of these muscles can be large or a collection of small tears over time. This usually begins with a dull ache, especially as the arm is extended away from the body. This type of injury occurs more often in older age or due to the use of the arm for mobility. It is a repetitive use injury. Small tears can be treated with rest and exercise for strengthening, but a large tear is typically corrected with surgery. Rotator cuff surgical repair can be quite an interruption in life for an individual with paralysis as the use of the arm is prohibited during recovery. Resting the shoulder must be done after surgery. This stops independent mobility during the recovery period if you are using your arm for transfers and turning. The exercise regimen to rebuild the shoulder muscles is extensive. However, the outcome is beneficial. One type of surgery for this condition is a reverse repair where muscles are realigned to improve functional use, particularly for transfers or wheelchair mobility. After complete recovery, you are ready to be independent again.

Scapular winging is another issue where the shoulder blade does not lay in the correct position in the back. The shoulder blade bone should be flat on the back. The protrusion is called winging. It is again from weak muscles and nerves which do not support the shoulder. Although technically not part of the arm, the causes can be the same as with shoulder subluxation. This condition is extremely painful if you have shoulder movement and sensation because moving the shoulder is out of its natural pathway. It not only can cause spasticity and AD but also is an extreme risk for pressure injury. The treatments include strengthening exercises and electrical stimulation to strengthen the muscles and nerves. A customized pressure dispersing back support and pressure releases will be needed to avoid pressure injury.

Moving down the arm, repetitive motion can lead to nerve entrapment at the shoulder, elbow, and wrist. Most individuals are familiar with carpal tunnel syndrome, where the passageway for the median, ulnar or both nerves are constricted by the tunnel that they run through at the wrist. There are other nerve tunnels that guide nerves through the body, typically at joints, to protect them. Another is a nerve tunnel at the elbow. When this tunnel becomes tight, cubital tunnel syndrome is diagnosed. There is also a tunnel by the shoulder at the thoracic outlet.

The tunnel syndromes are typically diagnosed by nerve pain through a variety of symptoms, most commonly tingling or shooting pains and weakness. But also, symptoms may be burning, numbness or decreased function. At the carpal tunnel in the wrist, if numbness is in the thumb, first finger or body side of the middle finger, the median nerve is affected. If the numbness and pain are in the little finger, ring finger or outer side of the middle finger, ulnar nerve entrapment is diagnosed. If you have reduced sensation, an EMG (electromyogram) and/or NCS (nerve conduction study) will provide a diagnosis. The treatment is the same for both. Resting the wrist until the swelling subsides can lead to improvement if the injury is not too severe. Otherwise, surgery to release the nerve by enlarging the tunnel is done.

Cubital tunnel syndrome occurs when the ulnar nerve becomes entrapped in the nerve tunnel passageway at the elbow. The radial nerve can be entrapped there as well. Most individuals know this experience in a temporary issue of hitting your funny bone. Although a tap to the funny bone resolves, nerve entrapment at the cubital tunnel does not. Symptoms include numbness or pain in the ring and little finger, decreased ability to pinch and/or hand grip, muscle wasting and hand clawing. Like carpal tunnel, cubital tunnel syndrome can become progressively worse. Immediate treatment is not to tightly contract the elbow but to stretch it out. Tone (spasms) or contractures add to the risk of developing cubital tunnel syndrome. A release of the tunnel at the elbow is a surgical procedure for correction.

There are a variety of reasons for the development of these tunnel syndromes. Medical causes include pregnancy, where the issue resolves after delivery when increased circulation and swelling within the body diminish. Diabetes is another source. With paralysis, tone (spasticity) is a culprit. The most common cause is repetitive use of the extremity. Individuals who use their arms to lift their bodies or propel a wheelchair are subject to this sort of injury from overuse of the arms. This nerve injury is not necessarily from the spinal cord or brain injury but appears as a consequence after a time of heavy use of the arms for mobility.

There are some life decisions you can make to help avoid issues with the overuse of your arms.

Exercise or stretch your arms daily to maintain your level of muscle strength. This should include a regular exercise program developed for you by your healthcare professionals. The program you use might not be quite like the one a friend does because of differing needs. Ask about electrical stimulation to help build your muscles.

Obtain transfer equipment if you need assistance. You might be able to transfer a time or two during the day outside of your home, but to do more transfers within your home, ask for equipment that will reduce the workload of your arms.

Power assist devices are available to help you propel your wheelchair. It reduces arm exertion, so you do not have to do the bulk of the work. In addition, these require less energy on your part as they will provide more movement to one push.

When you do push your wheel, begin with your arm straight down. The temptation is to reach back behind you to give that wheel a strong push, but that is overextending your shoulder each time. Starting with your arm straight down along the line of your body will provide close to the same power.

Utilize assistive devices such as a reacher for extending your arms to obtain items.

Look at yourself in the seated position and when in bed. Do the same when using a computer, at work or school, or in other activities. Use a mirror to get a good view. Notice if you are sitting upright or leaning if your body is supported, including your arm position. When in bed on your side, be sure the weight of your body is not resting directly on your shoulders or arms. Discuss your positioning with your healthcare professionals to see if there are any adaptations now or over time to help protect your joints and body.

Do not let anyone pull your arm to move or position your body. Your arm cannot support the weight of your body when someone pulls on it.

This is broad coverage of upper extremity protection and issues. More information can be found at:

Learn more about Shoulder Exercises from the Model Systems.

Read PVA Guidelines here.

Nurse Linda

Pediatric Consideration:

Many individuals think children are lightweight and their bodies are smaller, so their arm joints should be fine. However, proportionally, their bodies are heavy compared to their arms. As a result, their muscles and nerve can be weak in arm support without recognizing it.

A small child might not have the developmental or language ability to express a change in their arm function. As adults, we must notice changes in behavior that could be medical issues. A problem could be brewing if a child stops using their arm, protects it, or has increased spasticity, episodes of AD, increased weakness or pain. Adolescents might not want to be bothered with medical assessments or treatments, thereby sometimes hiding or diminishing symptoms. All ages, even adults, can demonstrate behavior changes due to health concerns.

As parents and guardians, it is our responsibility to check out symptoms. Be vigilant in noticing those subtle signs of pain and discomfort in addition to positioning and exercise. Children grow out of their equipment so quickly. Notice if their supportive equipment is no longer supporting their growing bodies.

Keeping your child healthy with good habits in the early years will help protect them for years to come. Nurse Linda

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

In our community, Nurse Linda is a blogger where she focuses on contributing functional advice, providing the "how-to" on integrating various healthcare improvements into daily life, and answering your specific questions. Read her blogs here.

And if you want more Nurse Linda, sign up for her monthly webinars here. Don’t worry, we archive her answers so you can refer back and sift through her advice. Consider it Nurse Linda on-demand!

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.