Splinting

targets of orthotic intervention

immobilization

mobilization

protection

pain-relief

positioning

substitution

improve function

articular

crosses a joint

non-articular orthoses

does not cross a joint

static othoses

no moving parts

serial static orthoses

remolding of a static orthoses

allows tissue remodeling which allows a joint to gain ROM

places tissue in a comfortable tension

remolded when appropriate

goal: progressively get move movement- elongate tissue over time

progressive static orthoses

inelastic

patient controlled tension

prevent over-stressing tissue

use of hooks and loop, turnbuckles, and outriggers.

typically elbow or knee.

does not allow movement, but can modify the position that the joint is stuck in

dynamic orthoses

1+ moving part

elastic tension

dropout splint

allows motion in one direction but blocks in another

nothing on the splint is moving

splinting for acute stage healing

static orthotic

serial static

splinting for proliferative stage of healing

dynamic orthoses

static progressive

serial-static

splinting for chronic condition

static progressive

serial static

general relationship between healing stage and splinting

in acute: want to hold in place. no movement as things heal

in proliferative: as things start to heal, allow more movement

for chronic: may need to substitute for impairment

goals for mobilization orthoses (dynamic)

substitute for loss of muscle function

provide controlled motion

facilitate scar remodeling during later stages wound healing

correct deformities due to PROM joint limitations via static progressive orthoses

two things that determine billing (L Codes) for splinting

type of splint

body part splinting

potential benefits of static progressive orthoses

patient controlled therapy

shorter Tx time

custom fit to each client

bi-directional stretch options in a single device- leads to decreased cost and increased efficiency

caveats to static progressive orthoses

patient compliance is really important for success

bulky

hard to put on

need to be strong to support the orthoses

cognition needs to be strong to know if orthoses is in the correct spot, etc

why is it important to know where the palmar arches are for splinting

they are good indications of where the orthoses should stop because they indicate the natural movement of the hand

general questions to ask clients to get understanding of social/cultural contexts

describe your typical day

how do you think splint will help?

anything that may hinder wearing it?

job, roles, etc

*** in general, regulat occupational profile

LEARN model

Listen with sympathy

Explain your perception

Acknowledge and discuss differences and similarities

Recommend Tx

Negotiate agreement

ETHNIC model

Explanation (how do you explain your illness)

Treatment (what have you tried)

Healers (have you sought advice)

Negotiate (mutually acceptable options)

Interventions (agree on)

Collaborate (with patient, family, healers, etc)

positive outcomes in occupational performance are the result of _______________

successful client-centered intervention

orthotic intervention as a facilitator of therapeutic outcomes

create or promote health

establish or restore skill or ability

maintain performance capabilities

modify context or activity demands via compensation and adaptation

prevent disability

What % of amputations per year are UE

14

goal of a prosthesis

provide appropriate appearance and function to increase independence with ADLs and increase QOL through participation in desired activities

socket

connection of residual limb and prothesis

types of sockets

silicone

polyethylene

acrylic

flexible socket

socks

gel liners

gentle and most natural socket

silicone

materials for flexible sockets

silicone or plastic

type of prosthetic that is considered standard of care

body-powered

oppositional/passive functional prothesis

provide opposition

normalize anatomical length

no active motion

often little maintenance

lightweight

good cosmesis but not completely normal

body powered prosthesis

poor cosmesis

can be less expensive

can be heavy duty

requires harness

limited functional envelope

externally powered prosthesis

battery system

controlled by various input devices (switches, electrodes, etc)- myoelectric

good pinch and grip

minimal energy expenditure

can be heavier

prosthesis noted to have limited pinch and grip

body powered

prosthesis noted to have good pinch and grip

externally powered

myoelectric prosthesis

externally powered- prosthesis responds to EMG signals picked up by electrical signals of muscles.

pattern recognition/directional control

array of electrodes to capture patterns of mvmt (think muscle memory but for prosthesis)

AMI procedure

Agonist-Antagonist Myoneural Interface

mechanically link antagonist and agonist muscles

allows patients to control bionic prostheses simply by thinking about moving their phantom limbs and capturing the electrical signals

hybrid prosthesis

balance when considering weight and cost

allows greater choice of components for higher level amputation

goals of AMI procedure

proprioception

pain management

improved prosthetic control

what to consider with hybrid prosthesis

expectations of both body powered and externally powered devices

#1 issue with prosethesis

overuse syndrome

A therapist fabricates a circumferential device applied to the humeral shaft that does not cross the elbow or shoulder joint. How should this orthosis be classified?

non-articular

client is 3 weeks post-flexor tendon repair and is in the proliferative phase of healing. Therapist wants to gradually remold orthosis over successive visits as tissue length increases, applying comfortable end range stretch each time. What type of orthosis is best?

serial static

what decade is most closely associated with introduction of thermoplastic materials for orthotic fabrication?

1960s

wrist orthosis with hook-and-loop turnbuckle. client tightens themselves to progressively increase wrist extension over time without elastic components

static progressive

what prevents FDS and FDP tendons from bowstringing?

annular pulleys

the central slip tendon inserts at the base of what structure?

middle phalanx

what deformity is caused by disruption to central slip tendon?

boutonniere

A client with a transradial amputation reports wanting a device that requires minimal maintenance, provides good passive cosmesis, allows normalization of anatomic limb length, but does not require active grasp/release function. Which prosthetic option best matches these stated goals?

oppositional/passive functional properties

deformity caused by damage to Terminal Tendon

malleT finger

deformity caused by stretching of the volar plate

swan neck deformity

basic prosthetic management

independently donning and doffing

changing terminal device

cleaning

charging

focus of phase 1 prosthetic training

basic operation of each component

phase 1 details

start with least cognitive demand: seated and at midline

add more planes of motion and situations: right/left of midline, up and down

standing

walking/dynamic movement

basic control innterventions

repetitive drills and tasks to bulid control patterns

progress to alternating components

examples of phase 1 repetitive drills and tasks to bulid control patterns

cone stacking

flipping blocks

repetitive ADL components

examples phase 1 alternating components

mirroring activities

grasp cone then flip to stack

phase 2 prosthetic training focus

gaining control =

repositioning terminal device

proportional control

repositioning TD

phase 2: place TD in most optimal position

minimize compensatory strategies at trunk, elbow, shoulder

proportional control TD

how soft/hard grip item

start with harder items then progress to softer (ie plastic club to paper cup)

partial arc control of components

rotating wrist part way

opening hand only as much as needed

position elbow at right level

phase 3 prosthetic training

bimanual skills training

longest and most challenging phase

patient directed- identify goals important to patient

allow pt to problem solve- may learn more from them than can teach

repetition and practice

break down tasks into components and practice each component until the full task is able to be done

What precautions should a therapist keep in mind when designing and fabricating an orthosis?

pressure areas

decreased sensation

client-centered wear schedule

edema

what does an orthosis referral include?

purpose

body part

how long

when observing a hand, look at

atrophy

edema

creases

joints

alignment

bone/finger rotation

arches

top down approach for hand therapy

usually when someone comes in with a complaint they cant do something

occupational performance analysis

client-centered frame of reference

bottom up approach for hand therapy

usually when someone comes in with a diagnosis

evaluate how the pathology impacts function

goals of orthosis for nerve conditions

protect nerve

decrease edema

control pain

amount of immobilization for nerve condition is determined by

procedure

location nerve

amount of nerve movement

concomitant procedures

pt. or surgeon related factors

nerve repair is

slow- needs to be immob. longer than grafts or transfers

take a month or so to initiate

then 1mm per day

main symptom of radial n injury

wrist drop

radial n injury in axilla symptoms

weakness

numbness / tingling from back arm to hand

radial n injury spiral groove symptoms

weak brachioradialis

interferes with ability to bend wrist back and straighten fingers

radial n injury posterior interosseous groove symptoms

weak muscles

cannot extend fingers

potential causes radial nerve injury

saturday night palsy

honeymoon palsy

crutch palsy

humeral fracture

entrapment in elbow

elbow fracture

entrapment in wrist

goals orthosis for radial n injury

position for healing, comfort, function

facilitate extension

fabrication considerations radial n injury

lack motor control

positioning to assist in fabrication

provide "just right" tension

wear schedule radial n orthosis

static- comfort and positioning

dynamic- function

precautions radial n orthosis

dorsal pressure areas

decreased sensation

client-centered wear schedule

potential causes ulnar n injury

fracture at medial epicondyle

fracture of olecranon process

compression at epicondylar groove

compression at wrist

provocative test for ulnar n injury

froment's sign

thumb IP flexes- compensation by median n for weakness in adductor pollicis, deep head of flexor pollicis, and 1st dorsal interosseous

purpose ulnar n orthosis

prevent compression

support function

cubital tunnel orthosis

45 degrees flexion

claw hand orthosis

90 degrees MCP flexion

cubital tunnel orthosis wear schedule

at night

claw hand orthosis wear schedule

to assist with function

potential causes median n injury

humeral fracture

elbow dislocation

distal radial fracture

carpal tunnel**

provocative test for median n injury

Phalen's

+ test = tingling in thumb, index, middle, lateral half ring finger

purpose/goals median n orthosis

prevent nerve compression

assist with function

median n orthosis fabrication considerations

CTS= want a normal orthosis

pronator syndrome- prevent pro/sup

wear schedule for median n orthosis

night time or activities that aggrevate

want to splint in _________ to prevent stretching of median n

neutral

first known use of an orthosis

14th century

dr brunnell made and sold first commercial orthoses (WWII influences)

1940s

polio lead to need for orthoses to help with ADLs

1950s

low temperature thermoplastic materials

1960s

therapists interested in researching and rehabing hand injuries

1970s

american society of hand theraoy established

1977

certifications in hand therapy

1991

low temperature thermoplastic materials softens between

135 and 180 degrees