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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.