Download sed properly, splinting and casting tech

Article and photos by Linda Pearson, O.T.R./L.
sed properly, splinting and casting techniques are an effective way to help neurologically involved patients regain their freedom of movement earlier-and facilitate
their return to normal daily living activities.
Early therapeutic intervention often makes
the difference in how soon people with neurological conditions regain their independence
in daily living skills and ambulation.
Providing patients with proper joint alignment
at an early stage is essential for controlling
abnormal tone and preventing contractures.
For people with head injuries, strokes, spinal
cord injuries and other neurological conditions, splinting
and casting is often a part of
the initial therapeutic process.
Lack of intervention often
leads to severe joint deformties, contractures and muscle
imbalance-all of which
involve enormous amounts of
time, money and patient discomfort to overcome them
later on. For these reasons,
case managers, insurance representatives and health care
professionals alike should
understand issues related to
controlling abnormal tone.
Starting Out Right
When considering splinting or casting a
neurologically involved client, it is essential to
evaluate and treat the person’s entire body.
Early bed positioning and range of motion are
critical in maintaining joint integrity, muscle
length and movement.
Occupational and physical therapy must
April 1995 21
begin early in the patient’s acute
care stay. Education for the nursing staff and family members
regarding proper bed and wheelchair positioning and range of
motion can go a long way toward
preventing deformities and promoting normal tone. Initiating
these programs early on may prevent the need for splinting and
The antispasticity ball
splint positions the wrist
in slight extension while
gently spreading and
extending the fingers.
Mike’s Story
ike, an 18-year-old male who sustained a traumatic brain injury as a result of a car accident,
was admitted to our rehab unit six weeks post
injury. At that time he was able to follow simple
commands consistently and exhibited fair trunk and
head control. He had full passive range of motion in
his left upper extremity, with some active movement
present. His right upper extremity was severely contracted at the elbow, wrist and fingers, with very
minimal active movement present.
In the weeks immediately following his injury,
Mike kept his arms
flexed up to his chest and
his legs were extended.
S
This position, known as
decorticate posturing, is
a typical pattern for tone
in people with head
injuries, and often leads
to contractures.
Although Mike received daily range of
motion by the nursing
staff and his family
early on, his tone was so severe that it was nearly
impossible for them to fully straighten out his arms
and fingers. Once it was determined that his lost
motion was primarily due to contractures, we were
able to begin our interventions. An aggressive splinting and casting program was instituted for his right
upper extremity, and aggressive passive range of
motion combined with tone-inhibiting techniques
were used for his left upper extremity.
Because Mike’s right elbow was lacking 85
degrees of extension, a drop-out cast was applied to
increase his elbow extension while preventing flexion.
The casting process involved a series of four casts
which were applied straighter each time, until we
achieved close to full passive motion. Once the cast
was removed, we used the last cast as a splint to maintain the motion at night and provided therapeutic tone-
inhibiting programs during the day to maintain motion.
With the elbow straight, the hand and wrist were
still problems. A wrist cast was applied down to the
base of the knuckles joints and a finger shell was fabricated to gently provide a prolonged stretch to the
long finger flexors. The cast was left in place for
approximately five days each time, with a series of
two casts used. Beginning motion at the wrist was
zero degrees of extension, with ending motion at 15
degrees of extension. Through the natural healing
process of the brain and the use of tone-inhibiting
principles such as splinting and casting, we were
A the splintingand casting
process evolved, Mike
gradually became stronger,
his tone decreased and his
active motion improved.
22 TeamRehab Report
~~~~eas~“the ~~~~o~~~
to allow for dynamic finger extension splinting in
;;i; t;i;;~r st~;;~z
improving the wrist and
finger extension.
In addition, a dynamic finger extension splint
was fabricated and worn
during the day for two hours on and two hours off.
Once the finger flexors stretched, we tightened the
tension to further provide a stretch. Mike wore this
splint for approximately six weeks and gained
almost full wrist and finger extension.
As the splinting and casting process evolved,
Mike gradually became stronger, his tone decreased
and his active motion improved. By the end of the
splinting and casting process, he was able to use his
arm to assist with his activities of daily living. He
was weaned to a program of gentle passive stretching to maintain range of motion and today uses both
of his arms functionally. Had this aggressive program not started early he may have ended up having
surgery-or, worse, not be able to use his arm
because of limited motion
0.
-L.P.
casting down the road, except in severe cases or instances
where splints are used to facilitate normal movement.
At times a person’s tone may be too severe to be controlled by positioning alone. In addition, other factors, such
as medical problems, resistance on the part of the patient or
family, lack of funding or unavailability of a therapist, may
prevent early initiation of such therapeutic programs.
Typically, the occupational therapist or physician will
recognize the need for a splint. There are many types of
splints, and many ways of using them to control tone;
however, the most common method is using one to spread
the client’s hand and prevent it from being held in a fist.
The therapist typically fabricates the appropriate
splint from a flat piece of splinting material, which is
heated and formed to custom-fit the patient. The therapist then monitors the splint and educates staff and family on proper wearing. If a therapist is not proficient at
making splints, commercially prefabricated splints are
available. However, these should be applied by a qualified occupational therapist following the principles of
splinting and tone management.
Splints may be applied to the elbow, wrist, hand or
all three areas if necessary. The ultimate goal is to prevent deformities caused by prolonged immobilization of
a muscle in a shortened state, while giving the nervous
system feedback as to what is normal.
Proper education in fabricating and applying splints is
essential. Often therapists or nurses apply splints to
patients without fully understanding the basic principles
necessary to control abnormal tone. In many cases splints
are overused when a simple bed positioning or range of
motion program would work best. Additionally, it is critical that the therapist understand the physiological principles of muscle and skin, since overstretching can cause
tearing of tissues which leads to inflammation, pain,
guarding of the limb and thus further increased tone.
Splints are often divided into two categories: preventative
and therapeutic. Preventative splints are used throughout
the hospitalization period and often after patients are discharged. These splints prevent deformities while helping
to control abnormal tone. Therapeutic splints are used to
provide a prolonged constant stretch to lengthen muscles,
tendons and soft tissue. Many splints are both preventative and therapeutic. These include:
1 Elbow hinge (with or without hand attachment)used to position the elbow in extension. A hand attachment can be fabricated if tone is severe enough that the
wrist and hand still flexes even though the elbow splint
is in place. This splint is typically custom-made using
commercially available hinges.
2 Antispasticity ball splint (with or without wristhinge)-used to position the wrist in slight extension while gently
spreading and extending the fingers. This position tends to
decrease abnormal flexor tone in the hand. The antispastic- The elbow drop-out
ity ball splint with a wrist hinge is often used if mild fin- ~C~~~~~~~~~o~”
ger flexor tightness is present in addition to flexor tone. extension.
These splints can be custom-made by the therapist, and
are also commercially available.
3 Resting pan splints with a dorsal shell-used to position the hand in a tone-inhibiting position while providing counterforce to aid in full finger extension in the
presence of finger flexor tightness.
4 Thumb loop-made from cotton webbing or neoprene,
this splint is used to position the thumb in slight abduction.
Thumb abduction tends to promote relaxation of the hand.
Although thumb loops tend to work best if they are custommade, they are also commercially available.
In addition to the splinting techniques above, casting and
dynamic splinting are often necessary to stretch shortened muscles and tissues. These techniques are usually
very effective in regaining motion lost through immobi-
Splints may be applied to the elbow,
wrist, hand or all three if’ necessary.
lization, and are a conservative and cost-efficient alternative to surgery.
These splints and casts are applied only with close
supervision and direct physician monitoring as the
potential for circulatory and pressure problems is great.
Therapists wishing to use these techniques should have
specific, intense training on these methods.
One cast that is very effective in increasing elbow
extension is the elbow drop-out cast. This is applied by the
therapist using fiberglass or plaster casting material over
the elbow joint. As the cast is applied, the arm is positioned
as straight as possible without causing pain. After the cast
CONTINUED ON PAGE 27
April 1995 2 3
CONTINUED FROM PAGE 23
The ultimate goal of splinting is to prevent
deformities caused by prolonged
immobilization of a muscle in a shortened
state, while giving the nervous system
feedback as to what is normal.
sets up, the bottom portion of the elbow is cut out, allowing the arm to straighten out while preventing it from
bending. Once the arm relaxes, the cast is removed and
reapplied with the arm straighter, with the ultimate goal
being full extension. When the casting process is finished,
it is critical that it be followed by daily range of motion,
and often splinting, in order to prevent shortening again.
Tone will typically continue to be present.
At times, dynamic or stretching splints are used to
stretch shortened muscles and tissues. These splints are
much like the ones used for tendon injuries or surgeries. Application of these splints must be considered
closely as these types of splints can increase tone and
cause skin breakdown.
Used properly, splinting and casting techniques are
very effective and cost-efficient. They allow patients the
freedom of movement earlier, thus facilitating their
return to normal daily living activities. Casting and
splinting are taught as a basic part of the occupational
therapy curriculum; however, this area is highly specialized and techniques are changing constantly. It takes
someone with a thorough understanding of anatomy and
a lot of creativity to apply these successfully. It is essential for therapists to practice and keep up-to- date on the
latest techniques, materials and time-saving tips.
In the end, however, the most important way to learn
about the effectiveness of splinting or any therapeutic
program is to be in tune with the patient. Even though
the person may not be able to respond verbally, their
body language and physical reactions to therapeutic
processes provide the most important feedback of all. W
Linda Pearson, O.T.R./L., is the director of occupational
therapy at HEALTHSOUTH Lakeshore Rehabilitation
Hospital. She has specialized in treating head injuries and
strokes for the past nine years, and spoken at many conferences on splinting and casting. She has completed the threeweek Neurodeveloumental Treatment Course for Adult
Hemiplegia.
HEALTHSOUTH Lakeshore Rehabilitation Hospital, 3800
Ridgeway Dr., Birmingham, AL 35209; 205/868-2435.