The splinting issue Pages 95-96 Caroline W. Stegink Jansen, Gail N. Groth Preview PDF (121 K) | Related Articles


A History of splinting: To understand the present, view the past Pages 97-132 Elaine Ewing Fess Preview PDF (3870 K) | Related Articles


Lessons from hot feet: A note on tissue remodeling Pages 133-135 Paul Brand Preview PDF (42 K) | Related Articles


Outcomes, treatment effectiveness, efficacy, and evidence-based practice: Examples from the world of splinting Pages 136-143 Caroline W. Stegink Jansen Preview PDF (106 K) | Related Articles


Plaster of Paris: The forgotten hand splinting material Pages 144-157 Judy C. Colditz Preview PDF (1644 K) | Related Articles


A proposed decision hierarchy for splinting the stiff joint, with an emphasis on force application parameters Pages 158-162 Kenneth R. Flowers Preview PDF (81 K) | Related Articles


Static progressive splinting, Pages 163-178 Karen Schultz-Johnson Preview PDF (3007 K) | Related Articles


The effect of the forearm support band on forces at the origin of the extensor carpi radialis brevis: A cadaveric study and review of literature Pages 179-184 Nicholas J. Meyer, William Pennington, Barb Haines, Roger Daley Preview PDF (100 K) | Related Articles
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The effect of corrective splinting on flexion contracture of rheumatoid fingers Pages 185-191 Cecilia W. P. Li-Tsang, Leung Kim Hung, Arthur F. T. Mak Preview PDF (101 K) | Related Articles


Minimalistic splint design: A rationale told in a personal style Pages 192-201 Paul Van Lede Preview PDF (1772 K) | Related Articles


Splinting materials old and new , , : Origins and application of bark cloth in upper extremity splinting Pages 202-204 Gail N. Groth, Julius Kamwesiga Preview PDF (571 K) | Related Articles


Introduction to a new method for inelastic mobilization, Pages 205-209 Nelson Vazquez Preview PDF (806 K) | Related Articles


The Splinting Issue
Edited by Caroline W. Stegink Jansen, PT, PhD, and Gail N. Groth, MHS, OTR, CHT

Splints have been in use for millennia. Medical workers in Egypt were crafting them during the reign of the Pharaohs. Even so, to catch a glimpse of a splint in public is, even now, always a little startling. It may evoke empathy and curiosity from a friend or cool appraisal and valuation from a health professional. What is it designed to do? Is it holding up well? Does it look comfortable, even artistic, or is it strictly functional and not at all attractive? Even if a splint has great artistic appeal, its creation, utilization, and anticipated effectiveness must be based on evidence. The topics selected for inclusion in this special issue are intended to advance the artistry of splinting toward an evidence-based practice approach. Therapists have been charged with the “responsibility . . . to examine the theoretical grounding and evidence underlying” the techniques we use.1 Working to establish an evidencebased approach will not smother our artistic creativity and freedom. Rather, increasing our base of evidence will ensure that the utilitarian objects we create and prescribe will gain greater appreciation. The illustration on this page expresses our commitment to an evidence-based path, to an underlying science and theory of splinting, and foremost to improving the well-being of our individual patients. The intent of the artwork becomes clear with a bit of interpretation. The picture in the lower left corner of the triangle represents the path to evidence-based practice. The vertical line represents the neutral dividing line between a positive and a negative outcome of treatment. The horizontal lines represent individual pub-

lications that attempt to provide evidence of the effectiveness of the treatment. The judgment involved in evidence-based practice lies in the relationship between the horizontal lines and the vertical line. The farther the horizontal lines fall away from the vertical line, the more certain one can be of a statistically significant effect of the treatment, either positive or negative. If the horizontal line bisects the vertical line, the effect is not great enough to be of statistical significance. The starred line at the bottom of all horizontal lines depicts the effectiveness of all the horizontal lines combined. Figuratively, the left hand picture shows that our goal in delivering this

issue to you is to increase the available number of effective horizontal lines at your disposal. The picture in the lower right corner represents the underlying science of splinting, be it biomechanics, tissue response, or theoretic models of clinical reasoning. The triangle indicates that all elements are connected and that, ultimately, the rational base components serve the individual patient -- represented in the top corner by the photograph of the young man. Dr. Paul Brand exemplifies these triangular linkages in his description of the lessons he learned in India from hot little feet! Eleven authors volunteered to contribute their work to this issue of the


April–June 2002 95

Journal. This enormous wealth of talent has provided a true potpourri of splint articles. Elaine Fess gives us a thorough review of the history and development of splinting. Caroline Jansen seeks to stimulate debate on the evidence for splinting. Theoretic algorithms for splinting choices are proposed in separate papers by Ken Flowers and Karen Schultz-Johnson. Clinical practice is also well represented. Cecilia Li and her colleagues provide experimental evidence for the efficacy of splinting for patients with finger contractures. Nicholas Meyer and colleagues present a study of the efficacy of the mechanism of the counter-force braces used for patients with lateral epicondylitis. The practice of splinting is further enriched by Judy Colditz, who describes the use of plaster of Paris, and Gail Groth, who shows how bark cloth is used. Nelson Vasquez describes a new technique to provide a measured static stretch in a splint

design. Paul van Lede introduces an algorithm that promotes the concept of “minimal” splint design. The flow of the articles is such that papers with a theoretical orientation alternate with papers that have a more direct practical orientation, so that the reader can see clearly the close links between clinical practice and theory. As guest editors, we claim no special honors as splint makers. We feel humbled and privileged to have been given this chance to stimulate the creation of this special issue of the Journal. Ken Flowers’ foresight and gentle persistence have provided vital support in the composition and completion of the issue. We also want to thank Rebecca Robinson, ELS, at Hanley & Belfus, for her skillful and dedicated work. We hope that this issue will stimulate therapists in clinical and research capacities to apply the theory, evidence, and art of splinting to the care of current and future

patients entrusted to us. An evidencebased approach will only support our artistic creativity and freedom!—

The editors thank Alex McLaughlin, OTR, Lewis Milutin, and Josue Andrade, from Shriners Hospitals for Children, Galveston, Texas, and Hollie Hackett, University of Texas Medical Branch, also in Galveston, for their contributions to the illustration that appears on the previous page.

1. Harris SR. How should treatments be critiqued for scientific method? Phys Ther. 1996;76:175–81. 2. Fess EE, Philips CA. Hand Splinting: Principles and Methods. 2nd ed. St. Louis, Mo.: Mosby, 1987. Correspondence and reprint requests to Caroline W. Stegink Jansen, PT, PhD, University of Texas Medical Branch, School of Allied Health Sciences, Dept. of Physical Therapy, 301 University Blvd., Galveston, TX 77555-1144; e-mail: <cjansen@utmb.edu>.



Seattle. 113). as you know. Rebecca Robinson. OTR. MD Clinical Professor Emeritus Department of Orthopaedics University of Washington Seattle. but their opinions were based on individual trial-and-error observations. So Denis Browne would put his large thumb under the full length of the sole of the foot to preserve the arch of the foot while he pushed the foot up into a right angle position or higher. has an aluminum soleplate and. With Dr. enjoy. This letter is not exclusively about correcting clubfoot problems. for fear he would break the mid-foot. contemplate!—ELAINE EWING FESS. I realized that it would be a great disservice to bury this important account in the middle of my history article. MS. FAOTA. BRAND WRITES:—In 1944. It is the base on which splinting endeavors are founded. Historically. Caroline Jansen’s support. His straightforward teaching style and exceptional ability to translate difficult biomechanical and physiologic constructs into easily understood concepts facilitate learning for surgeons and therapists alike. advocated slow. Dr. Brand’s work is closely entwined with contemporary splinting theory and practice. CHT Correspondence and reprint requests to Paul Brand. This lack of organization and scientific validation made their teachings vulnerable to contradictory. I had heard Dr. and for this correction it was important not to use the foot as a lever to stretch the tendo achilles. for centuries. His method was to correct the three deformities of each foot. and I soon received a beautifully written narrative. It is relevant to all those who work with healing tissues and seek to influence the soft tissue remodeling process. He willingly agreed. but we used the Denis Browne splint— which.Lessons from Hot Feet: A Note on Tissue Remodeling Paul Brand. Then. when the foot was straight in a length-wise direction. gentle tension to effect change in soft tissue. Read. as I watched him. Dr. His idea was that if the child was seen early. Paul Brand. Denis Browne had become quite famous for his management of clubfoot. an aluminum sidepiece that April–June 2002 133 . However. Brand transferred his vast clinical experience and empirical understanding of soft tissue response to stress to the biomechanics laboratory to provide a foundation of knowledge based on scientific inquiry. he would correct the varus deformity of the hind foot to bring the os calcis directly under the ankle. so we got a very large number of these cases. His subsequent work has served as a foundation for expanding understanding and investigation into the histologic and biomechanical basis for soft tissue response to stress. opposing practices that promoted harsh manipulation to effect soft tissue change. In contrast to early practitioners. and most of the patients he saw were within days of being newborn. it did finish up with a foot in a normal relationship to the leg and the sole of the foot in the right position for walking in shoes. in that both truth and process are better appreciated. However. Dr. WA 98116. Washington Few persons have contributed more to our understanding of biomechanics and soft tissue response to stress than Dr. particularly talipes equinovarus. In all these maneuvers. enlightened physicians and brace makers have. Brand’s permission. at that early stage we did not put shoes on the foot. Confusion flourished for centuries. he would correct the equines deformity. 1026 California Lane SW. because it seemed to me that it was just too violent. Distinguishing the insights that such events bring has two-fold importance. The skin on the medial side of the foot had to be stretched. DR. Innovators often are able to identify watershed experiences that forever changed their thinking. at right angles to that. and sometimes little cracks appeared in the skin. On reflection. he would correct the deformity completely the very first time the child was seen. First he would correct the metatarsus varus at the level of the mid-foot. Finally. I did not like watching this manipulation. one deformity at a time. Denis Browne was a large man with large hands. I worked as First Assistant to Sir Denis Browne at the Great Ormond Street Children’s Hospital in London. and the creativity of the Hanley and Belfus editor. Brand describe the sequence of events that altered his understanding of soft tissue remodeling and asked him if he would write about these experiences for my article on the history of splinting (see p. it was obvious that he was breaking little ligaments and causing at least minor cracks in bones like the talus. MD. Brand’s letter is presented here as a stand-alone piece in this special issue of the Journal. I was responsible for the follow-up clinic.

that meant the manipulation was too strong. The newly manipulated foot was strapped onto the soleplate with adhesive strapping. I hoped that the improvement gained by moderate correction at the beginning of the week would loosen up and allow further improvement that would be maintained by the next cast. This meant that I had to handle these feet and feel them and feel the mobility. All this time. I had several doctors to assist me at the clubfoot clinic. even though the ones in England were straight and in a better shape. and the Denis Browne splint thrust the feet into inversion and eversion because of the bar that connected the two feet. compared with the feet of children who had been through Denis Browne’s treatment. When both feet had been strapped to their own section of the Denis Browne splint. I remember being astonished at the contrast between the texture and temperature of the feet I was now seeing in children aged 10 or 12. but no attempt had ever been made to correct them. I was able to get plenty of aluminum sheathing from the wings of an airplane that had crashed a few miles away from Vellore. the baby had been kicking its legs. and then to the lateral upright plate. As soon as each baby’s name was called. and any part that was not covered bulged out. When I went to India in 1946 and started a clubfoot clinic. some babies cried for no reason other than the strange atmosphere of the clinic and the white coats of the doctors. my hands became very accustomed to feeling the feet and became aware of those who were doing well and of those who perhaps did not do so well. However. However. the mother would take it to the treatment room and sit herself on a stool opposite the doctor. among the patients who came to my clinic in India (and unlike the patients whom I saw in London). even though the range of motion was from a deformed position and was not enough to correct the deformity. manipulate a little more. I taught my assistants to do the manipulation and correction just as I had been taught by Denis Browne. but the foot as a whole remained straight and rather rigid indefinitely. and then by using total contact plaster casts to hold the partially corrected position for a week or so. as any baby will do. Then we would remove the cast. The old plaster casts had been taken off. and apply a new cast. and I taught each of them the technique of little-by-little manipulation and plaster casts. and as one foot kicked downward. and we also had to be gentle. As these young children grew and as they learned to walk freely. How do you measure gentleness? We were not using anesthetics for the manipulation and plaster casting. So we tried saying that if the baby cried. at which stage I would be seeing them about every 6 months. I had to see the baby at the followup clinic and take off the old strapping and reapply it in the same position. which were corrected in position but so stiff and so hot compared with the untreated feet I was seeing in India. at least part way toward full correction. I had to follow these babies up to the stage when they were ready to begin standing and walking. To my astonishment. Having become very accustomed to observing hundreds and hundreds of these baby clubfeet at all stages of development. I hoped that we could achieve this by a gentle contact manipulation keeping within the limits imposed by pain. Now. I felt at once that the Indian feet were better feet than the ones we had treated in England. I began by trying to manipulate the feet. they were able to move a little at the ankle joints and some at the subtalar joint. but I found it very difficult to explain exactly what I meant when I said they had to be gentle. Anyway. there were several teenagers who had been born with clubfoot. They came to me walking either on the lateral side of the foot or even on the dorsum of the foot. I was required to keep track of these feet until the children were 12 years old. I felt that we had to be slow. This undoubtedly kept the subtalar joint and the ankle joints in congruity with each other. and now the baby . and then they had to be fitted with little boots. I wondered whether we could treat the Indian patients in a way that would not cause the inflammation and the damage to ligaments and to some bones that had been thrust upon the babies in London. we went on reattaching the splint with fresh strapping every week for a few weeks and then every two weeks until the swelling had gone down. The reason for doing the strapping over again was that the foot had swollen grossly inside the first adhesive strapping. I felt convinced that there was something fundamentally wrong about all those patients in London. but these were the only joints that kept moving. then the two feet were each attached separately to the crossbar that held the two feet parallel to each other.goes up to a little above the ankle. So the waiting room where the mothers and the babies were waiting for their turns for treatment was full of screaming babies feeling hungry and not being allowed to go the breast. I hired a mechanic to use this aluminum sheathing to make Denis Browne splints. The mid-tarsal joints were constantly kept in the same relationship to each other by the soleplate of the splint. I found that these untreated clubfeet of the older children felt cool to the touch and had surprising range of motion of all the joints. the other foot was being withdrawn. We had to develop an answer for that as well. Within a week. I was interested to know whether 134 JOURNAL OF HAND THERAPY one could do manipulation on these late older cases or whether one would have to operate on them. We told the mothers not to feed their babies in the morning before coming to the clinic. and everything seemed to be going well.

Not only were our feet in India in a normal position (as the London feet had been). and we switched from plaster casts to Denis Browne splints as soon as a full correction had been achieved by serial casting. On the other hand. and it turned its eyes and looked at the doctor without letting go of the nipple. We used Denis Browne’s methods of correcting the three deformities in sequence. April–June 2002 135 . I told the doctors that if the baby remained happy having its meal.was allowed to go to the breast and start sucking. if they pushed much harder. The ideal moment for the manipulation was when the baby showed it recognized that something unpleasant was happening to its foot. everybody can hear it. and the other doctors would know that the doctor dealing with that baby had gone too far and used too much force. that meant that they hadn’t pushed hard enough on the foot to correct the position. At that moment. and that meant that they had used too much force. This allowed the doctors to begin feeling the foot and moving it gently into its best new position. For a time the baby’s whole interest was to satisfy its hunger. when I was able to compare the feel of the 6-year-old and the 10-year-old feet with my memories of the feel of same-age feet in London. But the real joy and satisfaction came after a few years. but they were mobile and they felt cool and soft to the touch. because when a baby yells. the baby might let go of the nipple and start to scream. the doctor should hold the position and apply the plaster cast. This resulted in some teasing among the doctors.

1.” “treatment efficacy.” and “treatment outcomes” relate to one another? Is evidence-based practice even useful for practicing clinicians. The objectives of this paper are to 1) review the structure of outcome reports and research.” and “evidencebased practice”. Efficacy. It is concluded that health care is being reviewed on an increasingly more systematic and grand scale. outcomes are results measured after an intervention. by controlling for the effects of other relevant material. and 4) provide some reflections that place these terms in the context of scientific inquiry and clinical practice. The objectives of the paper are to 1) review the structure of outcome reports and research. 2) describe the background and discuss the terms “treatment efficacy. 3) discuss these concepts as they apply to selected studies found in the literature that report the use of splints for patients with ailments that affect the use of their hands. calls for outcome studies and evidence-based practice leave many therapists bewildered. studies involving smaller numbers of subjects can contribute greatly as well. “treatment efficacy. The goal is to isolate the relationship between the outcomes of interest and the treatment provided. and Evidence-based Practice: Examples from the World of Splinting Caroline W. Texas ABSTRACT: Calls for outcome studies and evidence-based practice leave many therapists bewildered as to the meaning of various types of terminology.” “effectiveness. PT. Treatment Effectiveness.edu>. 3) discuss these concepts as they apply to selected studies found in the literature that report the use of splints for patients with ailments that affect the use of their hands. PhD.4 The outcome approach aims to describe the outcomes of everyday practice. not to provide a comprehensive review of the current state-of-the-art of the effectiveness of splinting for hand rehabilitation.5 Investigations may include topics of quality assurance. or is it just an additional administrative burden? The purpose of this paper is to review terms related to outcome research and evidence-based practice in the context of the practice of splinting used in hand rehabilitation.2 when accountability for treatment procedures was advocated in an effort to stem rising health care costs.” and “evidence-based practice”.5 An outcome approach is a prospective activity of data collection. 2002. e-mail: <cjansen@utmb. Stegink Jansen.Outcomes. contrasting outcomes in different treatment settings. and 4) provide some reflections that place these terms in the context of scientific inquiry and clinical practice. J HAND THER. of Physical Therapy. so long as they are performed with the highest level of study design and use standardized outcome measures that are valid for answering the designated research questions.3 However.15:136–143. The splint examples were chosen as illustrations. University of Texas Medical Branch. urged members of the society to present outcome studies to demonstrate physician accountability to the public and support the historical trust between the patient and treating physician in a contemporary way. The movements of outcome research and outcomebased management of health care and the cry to arms for evidence-based practice arose in the 1990s. in his presidential address to the American Society for Surgery of the Hand. 2) describe the background and discuss the terms Correspondence and reprint requests to Caroline W. such as contrasting the outcomes when different devices are used. Galveston. PhD University of Texas Medical Branch School of Allied Health Sciences Galveston.” “treatment effectiveness. or even different health care providers. different health care disciplines. 136 JOURNAL OF HAND THERAPY . TX 77555-1144. While studies that include large numbers of subjects are needed to substantiate the effectiveness of splinting. What constitutes the evidence for evidence-based practice? How do such terms as “evidence-based practice. PT. Dept. Urbaniak. School of Allied Health Sciences.” “effectiveness. Stegink Jansen. but it encompasses more than just the gathering of all possible data that may affect a patient’s response to interventions. 301 University Blvd. STRUCTURES OF OUTCOME RESEARCH In their simplest form..

The surgical repairs were performed by junior surgeons. For the mobilization program. scientifically less well controlled study design. function. and wrist splints (93% of patients). Because of the proactive nature of outcome research.10 reports results for patients who were treated by a program of protective range of motion after flexor tendon surgery in zone II of the hand. participating parties proactively reach a consensus about the conceptual model of the data gathering. These authors divide the model into three categories—structure of the care (delivery system characteristics.6 The parties focus on the data collection and decide what data among a myriad possible data points are crucial for describing the outcomes. duration. All these conclusions were opinions of the authors based on their empirical judgment. and outcomes (symptoms. occupation).8 included 250 subjects in their outcome reports of patients with distal radius fractures. This is the reason a consensus is needed to determine the conceptual model that is valid to describe the outcomes in the most efficient way. including how to analyze and use the acquired data. quality of life. the symptom severity and functional status scale. Unfortunately. An informative study that was performed prior to the outcome movement shows what opportunities may be missed if outcomes are collected without a plan for analyzing contributing factors. elegantly describes the various forms that measured outcomes may take. living far from the hospital. and patient satisfaction with the care). and outcomes of care (clinical end point. The hands of the patients were placed in dorsal plaster splints.11 and measures of quality of life. Had the authors prospectively planned to address these issues in their study and planned statistical analysis of their data. such as perceived symptom severity. patient clinical characteristics. patient demographic characteristics.7 The organization of outcome studies can be a daunting task. functional status. Twenty-six surgeons performed the carpal tunnel releases. The authors praised this treatment program because it allowed the patients to be more independ- ent. With the organizational challenges of completing a study of this nature. they could have reported the effects of the service delivery in a more scientific way. Would it not have been useful if we had evidence that an early motion program not only improves motion of the injured hand but also makes the patient less dependent on the care delivery system? Kane 5 describes the basic model of an outcome study as a mathematical formula. and work status. treatment. The Maine carpal tunnel outcome study 9 included 467 subjects eligible for surgical treatment and 240 subjects eligible for non-surgical treatment. published last year (April/June 2001). such as proactive random assignment of study subjects. Following the model of disablement described by the World Health Organization. The authors concluded that their results were similar to those of published studies. the metacarpophalangeal joints in 40° to 60° of flexion. with the wrist in 60° of flexion. The nonsurgical treatments included medical treatment with anti-inflammatory medications. in their simplest form.During the outcome approach. A Steinmann pin was embedded in the cast to serve as a palmar bar for the achievement of full finger flexion when rubber-band traction was applied. outcome measures may include such measures as grip strength and range of motion (impairment) and measures that reflect the opinions of patients. despite the fact that the patients lived in rural areas and had limited access to followup care. treatment factors (which may include a combination of treatments and treatment setting). and the interphalangeal joints in a neutral position. performed in South Africa by Edinburg et al. patient satisfaction. etiology. no control group or other comparison group was included in the study. The Outcome Issue of this Journal. and patient characteristics). Kane categorizes contributing factors. An example of structured outcome research is the Maine carpal tunnel study by Katz et al. less effort is wasted on the collection of data that will not be used later.5. But the available number of patients limits the number of factors that can be included in the model if the statistical analysis is to be meaningful. The question arises about what outcome measures to use to conduct an outcome study. The outcome measures included patient self-reports in survey format. could not be applied in April–June 2002 137 . Scientific controls. corticosteroid injections. process of the care (technical style. including the provided treatment and interpersonal style). scar tenderness. comorbidity. requiring fewer hospital visits and less supervision by therapists. as clinical factors (severity of disease.6 include characteristics of the patient and the caregiver alike. a regression analysis can be performed to analyze the contributions of each factor. The 42 participating patients were manual laborers. provider characteristics. complications). namely: Outcomes = function of (baseline. the authors used a cast rather than a thermoplastic orthosis.9 This study compares outcomes after open and closed carpal tunnel release surgeries and compares surgical and nonsurgical treatments of carpal tunnel syndrome. gender. Tarlov et al. This prospective outcome study. Treatments may be applied in randomized clinical trials but are often delivered in a more natural.. it is crucial that only pertinent data are selected. MacDermid et al. because many outcome studies include large numbers of subjects. setting of care) Statistically. general well-being. and baseline status). patient factors (age.

because all forms of nonsurgical treatment were lumped together. such as fractures.12.16 Existing groups of subjects were included over 2 years. The postoperative treatment and the positioning of the Orthoplast splint were described in detail. factors that were not under the control of the therapist or the physician may have contributed to the results.1 early leading authors in the field. The study concluded that surgical treatment resulted in optimal patient outcomes. increased variability among subjects.14 In a study of efficacy. all conditions are optimal.this case. and no analysis was performed to analyze the interactions between the nonsurgical treatments and the methods by which they were provided. so that the study would include only patients with clean-cut flexor tendons and no concomitant injuries. then. Sackett et al. does a practicing clinician gather evidence that a chosen treatment is the best current option available for a specific patient and that it is within the realm of the skills of the therapist? Two issues play a role—the efficacy of treatment and the effectiveness of treatment. The subjects were 37 patients with 50 injured fingers. Studies of the effectiveness of treatment look at the effects of an intervention on measured outcomes in ordinary clinical practice. and other confounding factors may make it more difficult to reach statistical significance to substantiate the benefits of the intervention. from the randomized study design to the skills of the therapists and the characteristics of the subject sample. For instance.13 This example illustrates the strength of outcome research in reporting many patient characteristics. The aim of such a study is to demonstrate the capability of the intervention to benefit the described patients. who referred patients to a private clinic. and . The efficacy of an intervention is its effects in the best possible circumstances. The data were collected in the 1980s. The study elaborated descriptions of patient characteristics to indicate the equivalence of surgical and nonsurgical groups. The selection criteria for the subjects were stringent. The authors stated that the groups were the same at the beginning. because the effects in reallife studies may be less dramatic than those in idealcondition efficacy studies. Because of the lack of random assignment. made the treatment choice according to their clinical preferences. even though wrist angle may significantly affect intracarpal canal pressure. Random assignment would have meant that other. uncontrolled patient characteristics could have been similar between the two groups. so no systemic difference in patient characteristics was observed. but they did not describe how the patients were assigned to the two treatment groups (immobilization and early controlled mobilization). EVIDENCE-BASED PRACTICE Justification and Definitions Evidence-based medicine is a movement that started in Canada at McMaster University. quite a few physicians still preferred treatment with immobilization to early mobilization. and a variety of treating therapists chose the manner of splint fabrication and the rehabilitative treatment. The results showed that. The rater was not blinded to the treatment group. A variety of treating physicians. under the ideal treatment conditions. At that time. and may include the effects of the treatment. defined evidencebased medicine as the conscientious. and patient characteristics. Because of the broad description and possible variability in the technical performance of treatments by the many participating health care professionals. no conclusive evidence could be provided to support the effectiveness of the use of splints.2 138 JOURNAL OF HAND THERAPY An example of an efficacy study is the study by Strickland and Glocovac15 on the efficacy of a passive early mobilization program for patients after surgical repair of flexor tendons in zone II of the hand. the skills of clinicians. cost effectiveness. An example of an effectiveness study on the same topic is the retrospective cohort study by Jansen and Minerbo in which the effectiveness of early mobilization using the Kleinert and Duran technique was compared with the effectiveness of treatment with immobilization in a cast or splint for patients with surgical repairs in zone II of the hand. as was the passive motion program. In this real-life context. the position of the wrist in the splints was not described. The potential of an intervention to benefit a patient under ideal conditions should be tested before the effectiveness of the treatment is tested under a variety of treatment conditions.. the effects of clinicians’ skills. the patients in the early motion group regained better active range of motion than did the patients who were treated with immobilization. as well as the interaction of various splint designs and medical treatments. In real life. The same experienced surgeon performed all the surgeries. the quality of service delivery. However. explicit. the model may have been biased against nonsurgical treatments. and existing groups of patients were used. EFFICACY AND EFFECTIVENESS OF TREATMENT How. but it also shows the limitations. in comparison with a control group of patients who receive no treatment or standard treatment. the range of motion attained by patients treated with early mobilization was found to be better than the range of motion attained by the immobilized patients.

If that type of evidence is not available. However. a number of such studies all in agreement in support of a treatment. consequently.17 The concept of evidence-based practice has been expanded to include “evidence-based health care. and so on).1 TABLE 1. or the earlier in the alphabet the ranking letter. Some practitioners fear that third-party payers may misuse evidence-based practice by equating lack of evidence with ineffectiveness of treatment. but not all carry the same weight in the ranking system. the definition retains its simplicity but adds an important dimension: Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values. Sackett et al. or report of expert committee *The lower the number of the study level. A is stronger than B. the gold standard being the double-blind randomized clinical trial. The strategy for seeking evidence to support a treatment is to find the highest level of evidence. but it does mean that work still needs to be done to provide evidence of the benefit of the treatment. Grade of Recommendation Grade A Grade B Grade C All levels of clinical study designs can provide evidence for a clinician. a well-designed single-case study can provide evidence about treatment effectiveness. and 3 show rank order definitions of the quality of research and the strength of treatment recommendations. the health care provider will continue down the path of available evidence to find the best current external evidence for the treatment. contemporary controls.2: Well-designed cohort or case control analytical study Level II. and those who did read them spent less than an hour a day doing so. Tables 1. descriptive study or case report. non-randomized.2 Definitions vary for ranking the quality of treatment evidence and. some systems require more than one double-blind randomized trial and. the stronger the recommendation for use of the intervention (e. What if evidence cannot be found? This does not mean that the treatment cannot be efficacious. The lower the ranking number. for ranking the strength of recommendations to support treatment for clinical practice.judicious use of current best evidence for making decisions about the care of individual patients. 2. practice. level I evidence is strongest.1. the more confidently the study results can be included as evidence. Grading the Strength of the Treatment Recommendation*. Relationship Between Rank Order of the Level of Evidence and Grade of Treatment Recommendation18 Level of Evidence Level I: Large randomized trial with clear results (low risk of error/high power) Level II: Small randomized trial with uncertain results (high risk of error/low power) Level III: Non-randomized. April–June 2002 139 .1 report results of a survey of participants in medical rounds. so that we cannot safely base our practice on our old knowledge. The constant effort by clinicians to obtain the best available evidence and incorporate this evidence into daily practice is a preferred mechanism to ensure that the advances in health care will reach the patient through clinicians who use the best current treatment. Sackett et al.. Quality of Evidence* Level I: Properly randomized controlled trial Level II. management. Traditional continuing education models may not been able to stem this tide. B is stronger than C. no controls. purchasing. as highest evidence. Most systems rank the findings of the doubleblind randomized clinical trial as the highest evidence. For instance. An important feature of evidence-based practice is that systems exist18. and patient choice. the stronger the quality of the evidence19. In the second edition of their book Evidence-based Medicine: How To Practice and Teach EBM. which showed that many failed to read clinical scientific materials.1: Well-designed controlled trial without randomization Level II. but its evidence is not as strong as the evidence provided by a double-blind randomized trial. case series only TABLE 2.g.”2 with components such as evidence-based policy. Our current knowledge and practice patterns thus deteriorate with years of practice.19 to grade the quality of evidence and the strength of treatments recommended on the basis of that evidence.3: Time series with or without the intervention or dramatic results in an uncontrolled experiment Level III: Opinion of respected authority.1 justify the need for evidence-based medicine on the following basis: The growth of new evidence for treatment effectiveness (beneficial or harmful) is exponential in our time. historical controls.19 A: Good evidence to support recommendation for the use of the intervention B: Fair evidence to support recommendation for the use of the intervention C: Insufficient evidence to support recommendation for the use of the intervention D: Fair evidence to support recommendation against the use of the intervention E: Good evidence to support recommendation against the use of the intervention *The closer the letter grade to the start of the alphabet. TABLE 3.

and the diamond represents the combined results of all seven studies. Second.21 Evidence-based journal clubs. The first advantage of a systematic review is that the effectiveness of a treatment as expressed in multiple studies is summarized in one manuscript.14 In 1989. however.14 The official logo of the Cochrane Collaboration expresses the advantage of pooling the effects of many studies in systematic reviews of treatment effectiveness (Figure 1). Systematic reviews may be performed by individual authors.S.. both in print and on the Internet. prevent the loss of evidence.. three applied blinding for most outcomes. Dissemination of the Evidence For a clinician. statistically significant support for the treatment was substantiated. Results displayed are based on a study by Chalmers et al. making review difficult and the pooling of results impossible. in formats that are acceptable for inclusion in a systematic review. (Courtesy of The Cochrane Collaboration. the U. Many review databases now exist. The study is entitled “Orthotic Devices for Tennis Elbow. Where the horizontal line touches the vertical line. treatment may be found to be harmful. with the Forum for Quality and Effectiveness in Health Care operating under its wing. even when not all participating studies reach the level of statistical significance. that studies be performed at the highest possible design level.FIGURE 1. though. obtained by a variety of computer searches of medical and allied health databases as well as by hand searching.19 the opinion of experts is included in the ranking. the more certain the results). These authors also recognize that. government established the Agency for Health Care 140 JOURNAL OF HAND THERAPY Policy and Research. With the enormous amount of information available in published form. because an effort must be made to locate all literature that investigates the topic. even when each study by itself does not have a large sample size. such as comparison of different types splints. but they are often described in a mathematical.20 Each horizontal line represents the results of one trial (the shorter the line. including a wrist splint. narrative way. forearm .) In the ranking provided by Pinsky et al. but organizations like the Cochran Collaboration have established teams of reviewers who collaborate to complete systematic reviews. Performing a systematic review is a labor-intensive task. A nice example of a systematic review is a metaanalysis study published by Lacasse et al. This illustrates the strength of pooling results when multiple studies ask the same research question. and they provide the ranking for a recommendation system that includes the beneficial and harmful effects of treatments. Only one completed systematic review was found that involved the use of splints. on investigation. how can a clinician stay abreast of current evidence? Archie Cochrane. The position of the diamond to the left of the vertical line indicates that the treatment studied is beneficial. including the Cochrane Library and the Database of Abstracts of Reviews and Effectiveness. and two did not blind the rater from the group assignment. and in eight studies findings did not reach statistical significance. or they use nonstandardized outcome measures. Various questions were addressed. The studies in which findings did not reach statistical significance did. uniformly accepted outcome measures are used that are valid for answering the research question. and when the results of all 11 studies were pooled. The combined studies. Each study had a small number of subjects. also facilitate the sharing of results. Many studies are performed in ways that are not scientifically controlled. Six studies used blinded assessment of all outcomes. like that published by the American College of Physicians. in a meta-analysis study. ranging from 7 to 32.22 Study results may be systematically reviewed in a qualitative.20 found that pooling the effects of many studies in a systematic review can statistically support treatments. Official logo of the Cochrane Collaboration. it means that that particular trial found no clear difference between treatments. The pooling of results does require. quantitative way.23 which evaluates the pooled effects of 11 studies of respiratory rehabilitation for patients with chronic obstructive pulmonary disease. only 17 eligible studies were found that met the inclusion criteria for the systematic review and only 5 randomized clinical trials were found. realized the need for professionally performed reviews to collect evidence. Chalmers et al. included 309 subjects! All but one study had a concealed randomized design. and convey the evidence in the most time-efficient way to clinicians. and identify those studies with the most scientific strength for the review. show a mathematical effect. Three studies showed statistical benefit of the intervention. MD. rank the studies. and that standardized. the issue of the demands of daily practice comes to mind. The vertical line indicates the position around which the horizontal lines would cluster if the two treatments had similar effects.”24 Of 788 studies addressing the treatment of tennis elbow. however.

are concerned with the end results of interventions and do not emphasize significant developmental hallmarks along the way. How would this early motion best be applied. but the line of research includes basic science by Gelberman et al. the subsequent definitions of the quality and the strength of evidence do not include animal studies and rely solely on clinical studies of patients. April–June 2002 141 . The authors suggested more well-designed clinical trials and the development and acceptance of standardized outcome measures. and lateral epicondylitis clasp. Where. for example. Bunnell31 dramatically stated the problem that plagues the field of tendon repair in the hand. but can we say that the other authors did not seek evidence for their practice? Figure 2 shows an organization model of the relationships between clinical expertise and scientific efforts to form the basis for treatment interventions. and patient values and pref- FIGURE 2. To review the entire rich development in detail would go beyond the scope of this paper. and the scientific approaches that help make it all happen. DISCUSSION This paper reviews outcome studies—studies of efficacy. effectiveness. all contribute to the health and well-being of the world’s population? Where is the place for theory development28 in a published format.25 Outcome research and evidence-based practice. such as access to health care.36 in patient reports.27 Even though Sackett18 indicates that our best evidence may be derived from animal studies. or for projects that demonstrate the mechanism of an intervention?29. A model of relationships between clinical practice where it all happens. As a result. Duran and Houser 32 hypothesized that a gliding of the repaired tendon between 3 and 5 mm would be sufficient to prevent formation of these adhesions.35 However. which shows that micro-occurrences on a cellular level as well as issues of societal impact. only a few studies use control or comparison groups15. no decision could be made on the effectiveness of splinting as a treatment for it.26. electromyelographic testing of the finger flexor and extensor musculature during the splint regimen30 and placement of metal markers in the repaired tendons of patients to measure actual achieved tendon excursion33 to support the mechanism of the treatment. The authors stated that they could not pool the effects of the studies because of the heterogeneity of study designs and outcome measures. and how much load should be placed on the healing tendon? The use of a cast or splint regimen in postoperative early motion treatment has been an ongoing focus of study since then. He reported failures of surgical repairs in the area between the distal crease of the palm and a line just past the middle crease of the finger. Different outcome measures were included in the review. can rankings be found for information gleaned from animal studies that investigate mechanisms of disease or treatment?26.30 An example of this predicament is the elegant line of research that runs through the history of the treatment of flexor tendon injuries in zone II of the hand. The failures occurred not because the tendon was not solidly repaired but because adhesions formed around the repair and surrounding tissues. The definitions and the practice of evidence-based health care are still developing.27 showing the superior quality of healing of the tendon in dogs after application of an early motion program. no tendon excursion took place and finger movement failed to occur. few studies may be eligible for inclusion in a systematic review. Science. In the end. from this rich research line. In 1948. How results from the entire field of research are incorporated in the ranking of evidence is not clear. clinical expertise. as the phrases imply.34. such as pain-free grip strength. and evidence-based practice— and provides examples from the world of splinting to illustrate the topics. despite the enormous number of publications about the treatment of tennis elbow. and various descriptions of results.band. Thus. Where is the unifying concept from the disablement model of the World Health Organization.

In: Geyman JP. The outcome issue [editorial]. et al. 1998. J Bone Joint Surg. 1997. Burke DT. CONCLUSION Health care is being reviewed on an increasingly grand and more systematic scale. 1997:1–15. Digital function following flexor tendon repair in zone II: a comparison of immobilization and controlled passive motion techniques. Bloom T. FAOTA.18A(3):379–87. So Y. legislators. 2001. Great contributions to standardization of measurements have been made by the ASHT in publications like their Clinical Assessment Recommendations37 and the Journal of Hand Therapy. Mike25 places a burden of responsibility on all health care professionals and at the same time alleviates a sense of despair we may feel because we still seem to have so far to go. the needs of the injured tissues. and well-informed patients delineate the roles and importance of all aspects of scientific.: Saunders. 1993. Perrin B. CHT. Keller RB. J Hand Surg. Evidence-based Health Care: A Practical Guide for Therapists.” We need to accept that we can never provide evidence for every detail of our practice. Rosenberg W. Arch Phys Med Rehabil. Bury T. Splinting for carpal tunnel syndrome: in search of the optimal angle. 142 JOURNAL OF HAND THERAPY Scientific evidence cannot replace the excitement a therapist feels when a splint is completed.5(6): 537–43. Walker J.75A:1585–92. Sackett DL. 14(2):154–69. and use the best possible scientific evidence as a basis for every phase of medical decision making. J Hand Surg. Urbaniak JR Physician accountability: winning the public trust [presidential address]. It will make the entire splint treatment “just right. as indicated by the double arrows in the model. Critical Evaluation of Research in Physical Rehabilitation: Toward Evidence-based Practice. Ware JE.” The second is “to increase the awareness of.14(2):61–2. JAMA. 9. Tarlov AR. 125–41. 5. 1998:4–42. Deyo RA. Greenfield S. Richardson WS. Our work is being reviewed systematically even if we are not aware of it. Using outcomes to improve quality of research and quality of care. MS. 11. 7. The first is “to create. 1987.” she proposes two imperatives for the ethics of evidence. Roth JH. paying communities. Augusta ME. We still have work to do to substantiate our interventions and to publish results so that they can easily be found on computer searches. Gaithersburg. McHale Burke M. PhD. Glocovac SV. and come to terms with. providing the opportunity to combine technical expertise and scientific evidence. Kane RL. as in the Journal of Hand Therapy. Nelson EC. the Journal of Hand Surgery. 12. 2000:65–72. for critical comments on the paper. Koris MJ. et al. Edinburg M. 6. Future debates will decide how the clinicians. Widgerow AD. and other demands of care. J Hand Surg. for critical comments and references of splint examples. Maine carpal tunnel study: outcomes of operative and nonoperative therapy for carpal tunnel syndrome in a community-based cohort.12A:34–8. Simmons BP. chapter 1. 10. 1980. Biddulph SL. Gordon L. 1995. Philadelphia. Katz JN. 15. 1994. Weiss ND. Md. Woburn. 1989. scientists. Ramsey SD (eds). Science can help us with the first imperative. Strickland JW. Levine DW. and Elaine Ewing Fess. Early postoperative mobilization of flexor tendon injuries using a modification of the Kleinert technique. Mass. MacDermid JC. is of great importance for posing questions relevant to the field of rehabilitation of the upper extremity and for making a team of reviewers aware of the state of the art of outcome measures in our field. Understanding Healthcare Outcomes Research. applied inquiries and clinical practice.: ButterworthHeinemann. Woburn. J Hand Surg.: Aspen.: Butterworth-Heinemann. and others. Distal radius fracture: a prospective outcome study of 275 patients. Zubkoff M. Evidence-based Medicine: How to Practice and Teach EBM. J Bone Joint Surg. Cambre A. when it meets the requirements of the patient. practitioners. J Hand Ther. 14. 13. Our hand therapy community includes practitioners in all areas of hand rehabilitation—theoretical thinkers. Mass. and with awareness of both imperatives we may have the patience and persistence to make the best choices for each individual patient. our AOTA and APTA scientific publications. and trained researchers—and we thus have the expertise to collaborate as members of review teams. 2.23A:697–710. But studies involving smaller numbers of subjects can also contribute greatly so long as they are performed with the highest level of study design and use standardized outcome measures that are valid for answering the designated research questions. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. 2001. Mead J. Pa. the extent and ultimately irreducible nature of uncertainty. Helewa A.erences are mutually influential factors. Richards RS. The inclusion of hand therapists in review teams. Minerbo G. 8. Seeking to demonstrate the evidence for such a masterpiece should enrich and satisfy every clinician. 16. REFERENCES 1. such as those of the Cochrane Collaboration. Deyo RA. MacDermid JC. Haynes RB. 4. A comparison between early dynamically controlled mobilization and immobilization after . Evidence-based Clinical Practice: Concepts and Approaches. New York: Churchill Livingstone. Stewart GW. Studies that include large numbers of subjects are helpful. Position of the wrist associated with the lowest carpal tunnel pressure: implications for splint design. so taking the lead by conducting high-quality studies and disseminating the results of our studies to the world of health care at large is crucial. The medical outcome study.77A(11):1695–9. OTR. disseminate. J Hand Ther. 3.75:1241–4. Rempel DM.” Acknowledgments The author thanks Kenneth Ottenbacher. and when its appearance and fit and its smart and skillful construction are just right. Stegink Jansen CW. 1993.262(7):925–30. In her paper entitled “Outcome Research and the Quality of Health Care: The Beacon of an Ethics of Health Care. 2000:80.

Outcomes research at the Agency for Health Care Policy and Research. Outcomes research and the quality of healthcare: the beacon of an ethics of evidence. acpjc. Lothringer K. Cochrane Database Syst Rev. Healing of digital flexore tendons: importance of the interval from injury to repair. Philadelphia. 1997. Sanson MS. 21.1:72–80. Silfverskiold KL. Woo SL-Y. Orthotic devices for the treatment of tennis elbow (Cochrane Review). 25. 35.17A:122–31. Clinical Assessment Recommendations. Assendelft WJ. Eval Health Prof. Buchbinder R. 33. 23. Sackett DL. van de Berg JS. Oxford. Cook DJ. J Hand Surg. UK: Oxford University Press. Effects of early intermittent mobilization on healing canine flexor tendons. May EJ. Pinsky EL. Pierce TD. Foster A. 2000:1–12. Available at: http://www. Keagy RD. 36. J Hand Surg. American Society of Hand Therapists. Ill. 28.7:171–82. 19. 1989. Citron ND. 1994. 1989. Woo SL-Y. Goldstein RS. 31. Pa. 20. Guyatt GH. Akeson WH. Siegel DB. 2000:65–72. Symposium on Tendon Surgery in the Hand. Chicago. 22. Dijk v VA. J Hand Surg. Lister GD.19A:53–60. 1999. Flexor digitorum profundus excursions during controlled motion after flexor tendon repair in zone II: a prospective clinical study. Lippincott. Bunnell S: Surgery of the Hand. Wong E. 1987. Tornwall AH. 24. J Hand Ther. Haynes RB. New York: Churchill Livingstone. ACP Journal Club. 1975. Deyo RA. Rizzo F. DMCO. Chest. 1992. Rosenberg W. 26. J Hand Ther. Meta-analysis of respiratory rehabilitation in chronic pulmonary disease.22(1):3–32. Eisenberg JM. Primary flexor tendon repair followed by immediate controlled mobilization. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Mass. J Bone Joint Surg. Richardson WS. Takai S.: ASHT.: Butterworth-Heinemann. 1948:626–30. April–June 2002 143 . 2nd ed. Silfverskiold KL. Arola H.(1):CD001821. Philadelphia. 1992. 1990. King D. Houser RG: Controlled passive motion following flexor tendon repair in zones 2 and 3. 18. 1982.: ACP-ASIM. Gelberman RH.3(1):20–5. American College of Physicians– American Society of Internal Medicine. Ramsey SD (eds). Swanson AB. 1994. J Hand Surg. 2nd ed.73A(1):66–75.2(6):441–51. Coale EH. 1975:105–14. Lancet. 1991. Lee D. In: American Academy of Orthopedic Surgeons. May EJ. Soutas-Little RW.12B(1):96–100. Enkin M. Clinical guidelines: a strategy for translating evidence into practice. St Louis. Mike V. 1977. Woburn.95(2):2S–4S.348:1115–9. Boozer JA. J Hand Surg. Atasoy E. Clancy CM. 34. 1994–present.17A:942–52.7(2):170–5. 2nd ed. 32. 2002. Flexor tendon repair in zone II with a new suture technique and an early mobilization program combining passive and active flexion. 30. Hamilton BB. In: Geyman JP. May EJ. Duran RJ. 27. 1996. 37. Dynamic splinting following flexor tendon repair. Gelberman RH. Evidence-Based Clinical Practice: Concepts & Approaches. Chalmers I.17. Kutz JE. Sackett DL. Effective Care in Pregnancy and Childbirth. Haynes RB (ed). 29.: Mosby. Evidence-Based Medicine: How to Practice & Teach EBM. J Hand Surg.56:304–8. Amiel D. KL Silfverskiold. 1992. Mo. Arch Phys Med Rehab. Orthotic research evaluation frame work. Controlled mobilization after flexor tendon repair in zone II: a prospective comparison of three methods. Lacasse Y. Deyo RA. Smidt N.org/. Struijs PA. Kleinert HE. Keirse MJNC (eds). flexor tendon repair in zone 2 of the hand: preliminary results. Pa. Comparison of the biomechanical motions and forces involved in high-profile versus low-profile dynamic splinting.

many hours of tissue elongation are needed to effect permanent tissue change. This review article intends to stimulate the reader to use plaster of Paris splinting or casting more frequently to solve clinical problems. A loss of motion in one direction usually occurs with plaster of Paris splinting or casting. and precautions for its use introduces the reader to this oft-forgotten material. skin and joint tightness. This information is intended to encourage therapists to introduce plaster of Paris more readily into their treatment armamentarium as a means of accomplishing tissue change. CHT. Inc.). NC 27608. In some chronically stiff 144 JOURNAL OF HAND THERAPY . and edema reduction. the ability to position joints to positively influence the dynamic remodeling properties of soft tissue. In addition. intermittent splinting can maintain the gains. its working properties. The idea of mobilizing tissue by immobilizing it seems contradictory. Colditz. North Carolina ABSTRACT: This article examines the concept of tissue adaptation in response to the application of plaster of Paris splints and casts. if intermittent splinting and manual mobilization techniques are the first choice. on removal of the splint. One must grasp the concept of positioning tissue and waiting until it has time to adapt to a new length and shape. The use of plaster of Paris to improve postoperative flexor tendon glide is also discussed. OTR/L. This article enumerates the advantages of plaster of Paris and illustrates its application in specific clinical situations. The current primary treatment to mobilize stiff joints and adherent soft tissue is the application of intermittent force via mobilization splinting. plaster slabs. The clinical goal is quickly converted from gaining motion to maintaining motion. The only possible response to continual positioning in a plaster of Paris cast is plastic deformation. a permanent change in tissue length due to the realignment of collagen fibers. is discussed. Because we know that prolonged periods of immobility have negative effects. J HAND THER. HandLab (a division of RHRC. skin tightness. Joint stiffness and tissue adherence that are mature and resistant to intermittent mobilization splinting and manual mobilization also respond to positioning with plaster of Paris casting. is often overlooked in the splinting of hand patients. The sustained positioning of joints and soft tissue with plaster of Paris provides a gentler and more precise means of tissue remodeling than does dynamic or static progressive splinting.Plaster of Paris: The Forgotten Hand Splinting Material Judy C. and contour molds. and think instead of Correspondence and reprint requests to Judy C. The unspoken assumption—that all joints should be allowed to move in all directions when regaining motion in the hand—must be abandoned if efficiency and precision in joint and soft tissue mobilization are to occur. tissue elongation can be regained and motion restored by a brief period of casting. Immobilization of uninjured joints must be prolonged. Inc. muscle-tendon tightness. Bell1 agrees that we must abandon the traditional concept of applying force. digital unpadded casts. arthritis. OTR/L. Removable splints create an elastic response in the tissues such that. If joint tightness or tissue adherence is present in a recently injured hand. CHT. The risk of losing motion (even temporarily) is so intolerable that plaster of Paris casting is avoided unless it is the last resort for gaining motion. In contrast. but clinical experience has proved this to be temporary. contracted joints due to spasticity. e-mail: <JColditz@HandLab.15:144–157.com>. 2615 London Drive. Raleigh. Colditz. the tissue returns to the previous position. developed by the author. FAOTA. a division of RHRC. Four designs are described for plaster of Paris application—circumferential padded casts. and the extremity kept immobile for the negative effects of immobilization to stiffen uninjured joints. The discussion of clinical application of plaster of Paris covers joint tightness. Thereafter. a new application called casting motion to mobilize stiffness (CMMS). a highly compliant material. WHY PLASTER OF PARIS? Plaster of Paris. A review of the history of plaster of Paris and its composition.2–14 many clinicians assume that short-term immobilization of joints and soft tissue is to be avoided. 2002. FAOTA HandLab. Raleigh.

Germantown. closely woven gauze) is highly recommended (Gypsona Gauze Type-Leno. France.hands. especially the small interphalangeal (IP) joints.18. 5) its retention of body heat. treated battle wounds in the Crimean War with cotton bandages filled with dry plaster of Paris. Plaster of Paris with minimal additives is called gypsona. This hydration process converts the weak and powdery plaster of Paris into a homogeneous. At about the same time. Smith & Nephew.19 Bunnell20–22 incorporated outriggers into plaster of Paris splints to provide dynamic mobilization.29 Manufacturers clearly label their products with the set-up time. 4) its porosity. thus giving up most of their kinetic energy in the form of heat. HISTORY Archives provide numerous reports of various substances being applied to splinted body parts to stiffen the part for fracture immobilization. As a result of these two developments.17 This somewhat awkward means of plaster application continued until 1927.30. photographs do not adequately convey this progress. Wisconsin). because of the increased conformity16. In the 1970s. plaster of Paris was the most readily available material both for immobilization of acute injuries and intermittent immobilization or mobilization splinting. April–June 2002 145 . and 7) its use in the construction of comfortable.19.24–27 COMPOSITION Plaster of Paris is derived from gypsum (calcium sulfate dihydrate). Later. Inc. Serial plaster splinting or casting was used to mobilize stiffened joints due to trauma20 and contractures due to arthritis. most of the water is driven off. When water is added to the dry plaster of Paris.23. When plaster of Paris is used for hand mobilization. resulting in a powdery substance commonly known as plaster of Paris. a Dutch army surgeon. nonremovable casts to facilitate tissue response. The infrequency with which plaster of Paris is currently used in hand therapy is reflected by the very brief mention of its use in recent hand splinting texts. Antonius Mathysen. In this article. Kolumban15 offers the only study to date that compares the effectiveness of serial plaster of Paris casting with the the effectiveness of mobilization splinting. dramatic change occurs without the application of external force. neutral warmth31–34.35. the water molecules incorporate themselves into the crystalline lattice of the calcium sulfate dihydrate.. constrained motion in a cast can direct active motion to the stiff joints.) In 1852. plaster of Paris came to be used less frequently by both physicians and therapists.29 For removal. lighter-weight and water-resistant synthetic casting materials replaced the traditional plaster of Paris casting materials used for acute injuries. depending on the additives. a cast made of gypsona may first be softened by soaking. which allows absorption of perspiration and prevents skin maceration23. Since the primary benefit of plaster of Paris is a more rapid change in the quality of the soft tissue. so that they regain both soft tissue glide and joint motion.23. (It is called plaster of Paris because it was first prepared from the gypsum mined in Paris. No objective means of quantifying these changes currently exist.30. other additives were incorporated to change the physical properties of plaster of Paris. Because the cast is not removable and all motion is directed repeatedly to the same tissue. use of plaster of Paris for serial positioning of joints. rock-hard mass. 2) the decreased possibility of pressure areas. low-temperature thermoplastic materials became available. gums. which could be quickly molded on the patient and easily altered. When gypsum is heated to 128° C. Since plaster of Paris casting is frequently used as a means of mobilization ”splinting.16 Unfortunately. Gypsona has a creamier consistency than the plaster of Paris with additives. which provides a gentle. Brand’s work23 in India with leprosy patients introduced the ADVANTAGES AND DISADVANTAGES The advantages of plaster of Paris as a splinting material are 1) its ability to intimately conform1. These materials. when binder ingredients (starches. 3) the lesser sheerforce (the movement of the splint or cast on the skin)1. no comparative studies of patients with joint stiffness due to trauma are available. These additives made the application of a cast less messy and more consistent. gypsona impregnated into leno-weave gauze (a nonraveling. Direct palpation is the only means of demonstrating the quality of change in soft tissue. which allowed standardized production. revolutionized mobilization splinting of the hand. It was not until 1852 that a technique was developed for applying plaster of Paris directly to an extremity.18. casting was clearly superior to dynamic splinting and resulted in fewer pressure areas. 6) its reasonable cost23. such as the setting time.” the words splint and cast become confusing in this context. although the latter is more durable and water-resistant.30. splint is used when the piece is removable (regardless of the material from which it is made) and cast is used when the design (usually made of plaster of Paris) cannot be removed by the patient.19 In the first half of the 1900s. a naturally occurring rocklike substance found in rock salts.28 The time required for the plaster to set up varies. In his study with leprosy patients. and resins) were added to improve the adherence of the plaster to the gauze.

2) the sensitivity of hardened plaster of Paris to water exposure.28 . over which cast padding is applied prior to the application of plaster of Paris. If the cast saw blade is held in one position. the greater the exothermic process.47 SPLINT AND CAST DESIGNS Plaster application to the hand has three basic designs—circumferential casts (padded over the hand. padded slabs. A wet roll of plaster of Paris is quickly wrapped around the padded part. can mimic the ability of plaster of Paris to conform.18. Practice is required to develop skill in cast removal.18.19. and 3) its heavier weight in comparison with thermoplastic splinting materials. unpadded over the digit).36–38 Disadvantages of plaster of Paris are 1) the skill required for precise application and safe removal of casts made from it.43. Because the period when a cast is worn full time is relatively brief. the patient should be instructed to avoid covering it until it is completely cool and dry. During cast removal. regardless of its molding properties. Synthetic padding will narrow as tension is applied. North Coast Medical. should be considered whenever an unpadded cast or splint is applied. Besides. so that saw movements are kept securely in control and the pressure is released as soon as the blade pierces through the plaster. Thermoplastic splints and plaster of Paris casts are estimated by the author to have similar material costs per application.40. with a thicker cast or splint generating more heat. Any attempted remolding will hinder the interlocking of calcium sulfate crystals and weaken the cast or splint. which may cause inconvenience in the performance of activities of daily living.39–41 Therapists should be fully aware of the multiple factors that influence the exothermic process in plaster of Paris.40.42 Wrapping material over the setting plaster of Paris or covering the cast or splint with pillows prevents the heat from dissipating and significantly increases the internal temperature. Other factors that affect the heat generated by the exothermic process are the humidity and tempera146 JOURNAL OF HAND THERAPY ture of the room40 and whether the immersion water has had previous plaster of Paris dipped in it. Synthetic padding also usually has more cushion. the cast will not be unnecessarily heavy if it is skillfully constructed and applied. preventing the possibility of excessively tight application. the saw technique must incorporate an up-and-down movement of the blade.42 The second most important influence is the thickness of the plaster of Paris. although these complications are far more common when plaster of Paris is applied to an acutely injured hand.17. with four to six layers applied for a non-weight-bearing circumferential cast. Synthetic casting materials are much stiffer than plaster of Paris. vibration from the oscillating saw blade generates heat.43 For each type of plaster of Paris used.42. The use of cotton cast padding (Webril undercast padding. whereas the cotton will shred apart before excessive tension is applied. California) rather than synthetic padding is recommended.44. The greatest influence on the exothermic process is the speed of the setting time: The faster the setting time. Pressure areas and circulatory constriction are possible.19.44 As soon as a complete roll of plaster of Paris has been applied. Circumferential Padded Cast Padded casts have a layer of tubular stockinette applied directly to the skin.17.40. Once the set point is reached. PRECAUTIONS Care must be taken in the application of plaster of Paris to prevent inaccurate positioning or stabilization.. Synthetic casting materials are about 2 to 2.40–42 As the cast or splint is setting.37. joints cannot be repositioned or the contour changed. the weight of the cast is rarely a problem. therapists should follow the manufacturer’s written recommendation for immersion water temperature. the layers are smoothed together until it becomes one mass. The primary concern in the application of plaster of Paris is avoidance of excessive heat from the exothermic process. plaster of Paris can be applied directly to the skin.38 Strength is a consideration only in weight-bearing casts and large casts over joints influenced by spastic muscles. To prevent this.42 The thickness of the padding is an insignificant factor in temperature alteration. with inappropriately displaced pressure.40 Recommended temperatures for the dipping water vary greatly in the literature.40. increased temperature of the dipping water also increases the heat generated. although rare. Contact dermatitis. and isolated contour molds.28.No thermoplastic material.40. Morgan Hill.or third-degree burns.42 Third. a friction burn or abrasion to the skin will result. Patients with asensate areas are most vulnerable to complications from inappropriate pressure. but the time cost for construction of a mobilization splint is much greater than for a plaster of Paris cast.45 If pressure on the blade is maintained after it has cut through the plaster. making the application of intimately molded plaster of Paris over the padding more difficult.17. overlapping by 25% to 50%. As discussed later. Inc.5 times more costly than plaster of Paris.46. which can cause second.36–38 although they are stronger. the heat generated by it may burn the patient.

Multiple layers of plaster of Paris are prepared. Top left. Prior to application. The slabs can be removed and reapplied by the patient (Figure 1). Circumferential casts require removal by cutting down two sides with an oscillating cast saw.1. both slabs can be removed and reapplied. it is the ideal April–June 2002 147 . If the padding and stockinette are cut on one side only. (Cast saws are never used on unpadded casts. digital casts can be applied directly to the skin and easily removed by soaking in water or cutting with scissors. to assist in repositioning joints. Slabs are immersed in water and then smoothed out over layers of cast padding.) The plaster of Paris adheres slightly to the underlying skin. one may be applied and allowed to harden slightly before the second is applied. When two slabs are used. The slab is then held in place on the extremity with an elastic bandage or gauze wrap. Plaster Slabs Plaster slabs are lengths of multiple layers of plaster of Paris applied to one or both sides of the extremity. Since the plaster of Paris contours well and does not cause maceration.FIGURE 1. secondarily. Left. Top right.16 Contour Molds Contoured plaster of Paris molds are used to apply positive pressure to scars and. Bell-Krotoski provides detailed descriptions of this technique. A volar slab is applied and wrapped in place. Digital Unpadded Casts Because of the tubular shape of the digits. the circumferential cast becomes a hinged removable cast (called a bivalved cast). The addition of circumferential hook-and-loop straps allows periodic reapplication of the cast during weaning periods. Multiple layers of 1-inch-wide plaster of Paris strips are wrapped around the digit and smoothed together while the joints are gently positioned. forming perfect contact for pressure distribution. a wet slab is placed on strips of padding material and smoothed out so that the plaster of Paris layers meld together and adhere to the padding. Above. Plaster of Paris slabs are used to serially position the wrist. and the wrist is held in extension while the plaster of Paris hardens. After identical application of a dorsal slab.

the common 148 JOURNAL OF HAND THERAPY response of the digit is decreased edema. When the patient can actively lift the wrist out of the volar slab. fixed swan neck deformities can be gently altered by first mobilizing the DIP joint into extension and then the PIP joint into flexion. greater flexion results from increased room to move into a closed pack position. these two molds sandwich the wrist and hold it in maximum extension (Figure 1). Arthritis Prior to the development of anti-inflammatory drugs. The PIP joint is then cast toward extension with the application of additional plaster of Paris. which also reduces edema. the elongation of scar impeding volar plate movement allows the volar plate to more readily fold out of the way during flexion. In an edematous joint. Serial Digital Casting Serial digital casts are frequently used to decrease IP flexion contractures. CLINICAL APPLICATIONS Joint Tightness The periarticular structures of the human joint adaptively shorten under any circumstance in which the joint is not carried through the full range of motion. until the desired size and shape are achieved. but these splints are now made from thermoplastic materials for ease of construction and greater durability. Concerns are often expressed that the circumferential pressure of the cast on a digit may cause ischemia due to increased swelling. After waking. The use of night resting splints19 has continued. In a contracted joint. serial plaster of Paris splints or casts were then applied to regain motion in the stiffened joints. especially if the skin needs to be held at length while the positive pressure is applied. The rest that the cast provides to the joint contributes to diminished inflammation. rather than working to regain the maximum achieved the previous day. Regardless of the design. There remains a large realm of appropriate application of plaster of Paris to minimize and in some . and it is detailed by BellKrotoski1. the most important aspect of successful use of plaster of Paris is the melding of the layers together. A few days of serial casting will significantly decrease joint edema while enabling the joint to regain the weaker motion of extension. somewhat fluctuant PIP joint with inflammation localized to one or more collateral ligaments is an ideal candidate for a short period of serial casting early in rehabilitation.16 and others. Conversely. Both edematous PIP joints and contracted PIP joints may gain greater flexion as a result of the extension mobilization casting. The plaster of Paris may be applied directly to the skin. Since the cast is never applied in the acute inflammatory stage and since the pressure of the hardened cast is static.1 Digital casts may also be used to mobilize an isolated tight joint while a thermoplastic splint with outriggers is applied to elongate a tight muscle–tendon unit. the DIP joint can be mobilized into flexion and the cast allowed to harden.19 Since the advent of anti-inflammatory drugs. immobilization splinting for control of synovial inflammation is rarely used in the United States. To prevent friction of the mold on the hand. A dorsal plaster of Paris slab is then applied to hold the wrist securely against the volar mold.1 Serial Plaster of Paris Slabs Plaster of Paris slabs are particularly useful for regaining wrist extension after distal radius fracture.49 Kolumban’s work48 has validated the superiority of serial casting for increasing joint motion in patients with leprosy. Those who hesitate to apply serial casting for a brief period early in the treatment of proximal interphalangeal (PIP) joint problems are missing a valuable opportunity. compared with both traditional physical therapy techniques and dynamic splinting. A bulbous.43 Immediately following mobilization of the wrist in therapy. The patient wears this for prolonged sessions during the day. An additional advantage of plaster of Paris digital casting is the ability to mobilize adjacent joints in opposite directions. Both recently injured joints and chronically stiff joints respond to serial casting. or one layer of padding may be applied underneath. Joint tightness is currently the most common clinical problem treated with plaster of Paris casting or splinting. In a fixed boutonniere deformity. This technique was developed by Brand23 and Kolumban48 in work with leprosy patients in India. When inflammation subsided. If trauma creates scar within the periarticular structures. One layer of wet plaster of Paris is applied at a time and is smoothed in place. the mold is applied with an elastic or self-adherent elastic wrap rather than with straps. the resistance to full motion becomes even greater. a new one is molded. When applied together.material for application directly over scars. to make a strong and wellmolded contour. In many cases. plaster of Paris immobilization splints or casts were used to decrease synovial inflammation and reduce pain in patients with inflammatory arthritis. the wrist is positioned in easy maximum extension and a volar slab is applied. the patient starts with the wrist at its maximum extension. and sleeps in it. reducing joint edema is as crucial to the resumption of normal joint motion as is decreasing the resistance of the periarticular structures.

and this position is sustained. Gentle. Plaster of Paris seems to be the ideal material in such circumstances. Even an obstinate joint with a pseudarthrosis can sometimes be slightly repositioned so that the deformed position is more functional. Deformities are likely to progress if there is no external influence in the opposite direction.31. This is the ideal way to mobilize such joints comfortably.59 The tissue response with plaster of Paris—the reduction of subtle edema. as advocated by some. and apply plaster of Paris to gently reposition the tissue. so long as x-rays show an absence of a fused joint. In a patient with severe contractures due to scleroderma. and dorsal ulcers are frequently present. maintenance of skin length in all directions is needed to avert loss of joint motion. allowing the ulcer to heal. these patients need long-term casting to retain the gains that have been made. the cast is bivalved and worn for limited periods during day. Serial casting to reduce digital deformities. to decrease spasticity and improve joint contractures. An additional smaller slab is molded to hold the thumb (Figure 2).50–53 Although reports of the use of plaster of Paris inhibitive casting are limited to single case studies or general observation. but the other bone is allowed to move only in the direction away from the contracted position. Skin Tightness Because both burns and skin grafts provide a large bed of contractile scar. Care must be taken that the cast is not tight enough to constrict even further the already diminished blood flow of the finger. the dorsal slab is molded. slow repositioning of the joints via serial plaster of Paris splinting or casting allows the soft tissues to resume their previous length.31. It is only when forceful serial casting is applied that concern for cartilage neurosis via sustained pressure is a consideration.cases reduce hand joint deformities resulting from arthritis and other connective tissue disorders. Patients with severely contracted PIP joints have ischemia of the taut dorsal skin. fear of stiffness from a reasonable period of immobilization from serial splinting or casting is unfounded. The volar slab is molded to position the wrist and hand in the desired position. This allows active muscle contraction of the desired (and weaker) muscle into a greater range of joint motion.57 When plaster of Paris slabs are used both dorsally and volarly. may be approached as in the hand with trauma. but it prevents the joint and muscle from resting in the fully contracted position. If only one component is used. These ulcers are hard to heal. Since rheumatoid arthritis is a collagen disorder that increases the laxity of the supporting structures of the joints. When the volar slab starts to harden. rather than being used only for patients who are noncompliant. Dropout casts are circumferential around either the proximal or the distal bone.31–34 The prolonged positioning also results in muscle lengthen- ing. Muscle–Tendon Tightness Tightness of the muscle–tendon unit of either the extrinsic flexors or the extensors is remedied by serial positioning of all the joints crossed by the muscle. because the position of the severely contracted joint places continual tension on the dorsal skin.31 After initial progress has been noted. and the prominent apex of the flexed PIP joint is prone to abrasion.32.34 The extremity is cast in a functional tone-inhibiting posture that theoretically reduces cutaneous input and spasticity by providing neutral warmth and even cutaneous pressure. only one position is available for all the joints. As one would expect. which over time allows movement of the hand joints in the splint.55 This concept of controlling the direction and extent of joint motion has been used by the author to develop a new approach to mobilization of the stiff hand— casting motion to mobilize stiffness (CMMS)—which is discussed below.31–34. the balance of the forces crossing the joints of the hand is altered. A carefully applied serial digital cast (with a thin layer of cast padding over the PIP prominence) will protect an ulcer from pressure or fiction and can slowly relieve some of the tension on the dorsal skin.56 the multiple joints of the hand and wrist can best be serially positioned using volar and dorsal plaster of Paris slabs. Therapists will do no harm if they discard any idea of force application in their approach to patients with such deformities.33. and its increased mobility in response to gentle presApril–June 2002 149 . This slab technique also provides a safe means of repositioning an acutely injured hand while providing gentle compression to minimize edema. to regain maximum length. Plaster of Paris conformed over an area can comfortably position numerous joints accurately and also provide perfectly distributed pressure with a breathable material.33 Most casting of these patients is used to mobilize large joints such as the elbow or knee. such as boutonniere and swan neck deformities. Contracted Joints Due to Spasticity Inhibitive casting is used as a treatment technique in patients with cerebral palsy and head injuries.58. As joint deformities or instability begins. a significant change in quality of movement and amount of joint motion is consistently reported. stability of the splint on the hand is dependent on the strapping or wrapping.43 Since each joint being positioned requires three points of pressure to be accurately immobilized. Both circumferential serial casts and drop-out casts are used. the flattening and softening of the tissue. the possibility of regaining joint motion is obliterated by the nature of the disease.54.

it allows unimpeded wound healing. Wounds with unhealed areas and immature scars intolerant of friction (such as burn wounds that easily blister) are ideal candidates for the gentle pressure that plaster of Paris provides. A serial cast is applied (dorsal view). With plaster of Paris. By use of plaster of Paris.FIGURE 2. The prolonged splinting or casting needed by patients with extensive burn or skin injuries is a challenge. One study of split thickness skin grafts to the lower extremity showed that in patients who received casts immediately after surgery. 150 JOURNAL OF HAND THERAPY . 100%). Right. Plaster of Paris can easily be applied in a design that allows for splint removal. and fewer therapy treatments were required than in an uncasted group. multiple joints often need to be positioned. all joints must be simultaneously positioned while the thermoplastic material is cooling. graft acceptance was better (72% vs. a contracted hand can be slowly coaxed into a more functional position. Such wounds are tolerant of plaster of Paris also because collection of perspiration and moisture–a negative aspect of thermoplastic splinting material— is avoided. the concurrent presence of skin and joint tightness is an absolute indication for the use of serial casting. or molded supports wrapped in place with self-adherent wrap or overlapping molded plaster of Paris slabs can provide welldistributed pressure but also can be removed for skin hygiene and exercise. Left. Then additional plaster of Paris can be added for careful positioning of the adjacent joint. The immobilization imposed by any type of splint or cast. The straps of thermoplastic splints can never stabilize a splint as accurately as can circumferential application of plaster of Paris or contour molds held in place with wraps. Dorsal and volar plaster of Paris slabs with a small thumb slab can slowly and safely reposition joints in the acutely injured hand while providing conformed compression to reduce edema. Middle. the long finger stump is contracted and the first web space is tight. This is espe- FIGURE 3. one joint can be precisely positioned and the plaster of Paris allowed to harden. Bivalved casts. Because skin scars can cover any plane of motion and any number of joints. splints. Following severe crush injury.59 If motion is lacking in both directions.35 Since plaster of Paris decreases friction of the splint or cast on the wound and absorbs wound drainage. When thermoplastic materials are used. sure59—is always superior to the tissue response with thermoplastic splints. Plaster of Paris is well tolerated over open wounds. whether made of thermoplastic material or of plaster of Paris. In the author’s opinion. Extension of long finger stump and elongation of first web are regained. wound closure was more rapid. plaster of Paris provides direct pressure to the scar while joints are mobilized with repeated repositioning. Rivers59 suggests using alternating flexion and extension casts to prevent significant loss of motion in either direction. Skin and Joint Tightness If joint tightness accompanies skin shortness due to scarring. is difficult to balance with the need for joint movement.

where the many directions of motion and planes of skin movement make mobilization difficult.63 Only active motion is used to gain both active and passive joint motion. facilitates lym- Edema Reduction Traditional hand therapy techniques for edema reduction are elevation.68. skin loss in the first web. and the possibility of excessive force. there is no danger of a constrictive force. Patient following severe crush injury with multiple fractures. and compression with either elastic gloves or wraps or the application of massage. immobilization that prevents pumping of the venous and lymphatic system.62.(Dorsal view. The movement of the stiffest joints maintains lubrication within the collagen cell matrix. No passive force is applied to any joint during the casting.61 Active finger movement while in a wrist cast causes the skin on the palmar and dorsal surface of the hand to move. generalized joint stiffness results in joint tightness with a hard end-feel and constraint of soft tissue movement. and open wounds has thin circumferential cast applied to mold palmar scar and position thumb stump. cyclic active motion mobilizes the tissue in both directions. Recent increased awareness of the anatomy and physiology of the lymphatic system has caused many hand therapists to adopt gentler approaches when using these techniques. since we have learned that excessive pressure can prevent lymph fluid from entering the initial lymphatics. After a few days of casting edema is significantly reduced. on the other hand.69 These factors and the intermittent nature of mobilization splinting often make mobilization splinting ineffective in the chronically stiff hand. Since the cast redirects the muscle–tendon excursion constantly to the joints where it is most needed. Chronic Edema. FIGURE 4. The advantages of using active motion to mobilize stiffness in the CMMS technique far outweighs any negative effects of temporary immobilization of proximal joints. The hand is simply positioned so that the muscle and joint movement needed is the only motion that can occur repeatedly over a long period of time (Figure 5). Use of such a thin cast over the metacarpal area and around the base of the thumb may in some cases be a preferable edema reduction technique in the severely injured hand. Since the cast retains its original size and shape.cially true in the thumb. Soft Tissue Adherence. Cast padding is taped between fingers) Middle. Joint Tightness. tendon lacerations. Right. active motion. and severe crush injuries to the palm—plaster of Paris is likely to be more useful than thermoplastic materials (Figure 3). all of which prolong the inflammatory response. such as that seen with proximal compressive wraps. In the chronically stiff hand. Pitting edema is present prior to casting. amputations. The presence of the thin padded cast over the metacarpal area resulted in a dramatic reduction of edema (Figure 4). In multiple tissue injuries with skin injury—such as explosion injuries to the palm. prevents abnormal cross-link formation. The soft constraint of the padded plaster of Paris around the metacarpal area provides a light massage to the skin that facilitates lymphatic flow. and Altered Pattern of Motion in the Chronically Stiff Hand Casting motion to mobilize stiffness (CMMS) is a technique developed by the author that uses plaster of Paris casting to selectively immobilize proximal joints in an ideal position while constraining distal joints so that they move in a desired direction and range. Left. A small cast was applied around the amputated thumb stump to contour the palmar scar and provide maximum abduction of the first metacarpal.65–67 Mobilization splinting. moves the tissues in only one direction.60. This response was highlighted by a dramatic reduction in edema in a patient with a severe crush injury.64 The active motion re-establishes the normal collagen cross-linking. Additional negative effects of mobilization splinting are constriction that contributes to edema. April–June 2002 151 .

Cast with dorsal hood over the fingers immediately re-establishes pinch. in which finger flexion occurs concurrent to wrist extension. strengthens muscles. and the dominant extrinsic flexion pattern with stiff MCP joints. reinforcing the stiffness in the IP joints. Therefore. Patient with diminished finger flexion following distal radius fracture is fitted with a cast with the MCP joints in extension to allow active IP flexion to mobilize the interosseous muscles.71. Almost all patterns of motion will cause a loss of the normal reciprocal balance of tenodesis. Active finger flexion of patient with multiple wrist injuries and 4-month chronic open wound shows abnormal posture and limited motion.70–72 neither laboratory nor clinical studies have demonstrated its usefulness for reducing stiffness once it is present. regaining motion in the stiff hand is both a complex mechanical and cerebral issue. FIGURE 6. left). Left. 152 JOURNAL OF HAND THERAPY FIGURE 7. The most common patterns are the dominant intrinsic flexion pattern. in which the metacarpophalangeal (MCP) joints flex before the IP joints.73 Abnormal patterns of motion are established as a result of the lack of tissue mobility (Figure 6. and re-establishes independent glide of tissue layers. The patient repeatedly moves the loosest joints. which encourages the somatosensory cortex to memorize this aberrant pattern. The mechanical problems are shown by the presence of deviate patterns of motion.FIGURE 5. Right. . in which the IP joints flex fully before MCP joints. A vicious cycle is established because the tissue stiffness prevents the normal pattern of motion. Child with severe lawn mower injury at the wrist is fitted with a cast to support the wrist and position the fingers in slight flexion to facilitate maximum tendon glide after flexor tenolysis. Although continuous passive motion has proved to be effective in the treatment of acute joint injuries. and without the normal pattern of motion the stiffness cannot be resolved. phatic flow.

One must be cautioned against blocking the MCP joints in full extension in the very stiff hand. Middle.79 With removable splints. If profundus glide is poor.” Neuroscience research shows that animals and human beings trained in movement combinations magnify the cortical representations of the motor areas used predominantly and that lack of use decreases the corresponding cortical area. This explains why mobilization splinting so often fails to reduce resistance in the very stiff hand or April–June 2002 153 . They showed that the normal pattern of digital flexion is initiated with IP flexion prior to any significant MCP flexion (hook position).78. a hand with the dominant intrinsic flexion pattern is cast with MCP flexion blocked. the author has not found this necessary. right). since tight interosseous muscles may provide too much resistance to active IP flexion in the initial stages of mobilization. This is the only mobilization technique by which motion can be gained in both directions at the same time. and repatterning of the cortex is defeated. the cast restrains all proximal (or other) joint movement. For example. the motor cortex learns this pattern of motion as the new “normal. Movement occurs only at the site of the greatest stiffness (Figure 9). Although casting or other immobilization of the IP joints might be considered to transmit all flexor force to the resistant MCP joints. The patient works on pulling the proximal phalanx away from the dorsal hood using primarily intrinsic muscles (minimal IP flexion) (Figure 8. The joints are simply positioned within the cast to optimize active motion. a dorsal hood is added to position the distal interphalangeal (DIP) joints in relatively greater flexion than the PIP joints. Cast that dictates active MCP flexion in end range. A second example is the hand with stiff MCP joints but flexible IP joints.75–77 For motor cortex repatterning to occur. Since stiffness produces an abnormal pattern of motion. the CMMS cast blocks and stabilizes the proximal joints. This quickly converts a nonfunctional hand to an assisting hand while digital motion is being regained. The dorsal hood extends only over the proximal phalanges (Figure 8).FIGURE 8. Depending on the dominant pattern of motion. the cast position is changed to full MCP extension so that IP flexion can mobilize the tight interosseous muscles (Figure 7). ensuring that the most likely muscle movement will be that of the the flexor digitorum profundus. When a greater range of MCP flexion is gained. Active flexion after casting. nor are joints held at the absolute end-range of motion. Third. supporting the wrist in extension and placing a hood over the fingers immediately positions the fingers so that pinch is possible (Figure 6. if isolated joints are stiff. middle). repeated motion in the desired pattern is needed over a period of time. This is particularly helpful with PIP joint stiffness in which both flexion and extension are lacking. The neurologic consequences resulting from the altered pattern of motion create an additional consideration in the rehabilitation process. a patient reverts to the aberrant pattern of motion each time the splint is removed. In hands with extremely limited motion. When reasonable profundus glide is regained. Patient with hard end-feel stiffness of MCP joints following MCP joint dislocations:. Arbuckle and McGrouther74 validated the use of the dorsal hood to position the IP joints in greater flexion than the MCP joints. Limited active MCP flexion. Right. even with joints with a significant hard end-feel. a new dorsal hood is applied to allow this active motion to occur in a greater range of flexion. Left. At no time is any force applied to any joint with the plaster of Paris cast.

which also allows effective muscle strengthening. Middle. Most therapists are uncomfortable with the temporary loss of motion in some joints and are likely to wean a patient out of the cast too early. shiny skin and diminished or absent joint creases.81 Because of the limited active motion. the application of a plaster of Paris cast to stabilize the wrist and allow only finger flexion may be the optimal postoperative approach.78 a few weeks in a cast can convert the pattern of motion even if the stiffness has been of long duration. Since the initial lymphatics in the skin are easily collapsed by excessive pressure. Cast to prevent motion at all joints but the PIP joint. Postoperative Mobilization of Flexor Tendon Glide In unusual circumstances. For progress to occur and be maintained. Placing the hand in a cast in which only flexor glide is possible assists the patient with accurate muscle pull-through. 13-year-old patient with unusual pattern of hyperflexion of both the metacarpophalangeal and distal interphalangeal joints with limited proximal interphalangeal (PIP) joint flexion following proximal phalanx fracture.FIGURE 9.85.60. In the chronically stiff hand. the neutral warmth may assist in general tissue relaxation and facilitate tissue elongation. Placing the hand in a cast with a dorsal hood over the fingers allows the patient to work in the end range of active finger flexion.60. joint. There is also a direct relationship between ambient temperature and the permeability of the initial lymphatics.12. In addition to effecting lymphatic flow.31. No other mobilization technique provides this stimulus so consistently. extension can be incorporated into the exercise program. Since original cortical connection patterns persist and can easily be reactivated.86 The insulation of the cast provides neutral warmth.61. while movement of the hand within the padded casts provides a facilitatory pseudo-massage to the skin. Stretching and intermittent splinting can help the patient regain the exten- . the lymphatic system becomes stagnant. the cast may be applied early after surgery.61. Left. Since the single most effective stimulator of the lymphatic system is active motion. The cast must be precisely applied with accurate molding to ensure well-distributed pressure. so that a period of recasting is often required. In flexor tenolysis.84 light pressure is required to facilitate lymphatic flow. The CMMS technique should not be used on patients who are claustrophobic or have acute injuries or in a patient whose anatomy is so altered that a balance of motion cannot be regained when the CMMS casting is discontinued. When this motion is regained. The tissues are firm to palpation and have decreased mobility. following flexor tenolysis or flexor tendon repair.80. mild pitting edema accompanies atrophic. If a patient has had limited flexor tendon glide for a period of time. The cast provides light pressure to the hand. Right. the patient must wear the CMMS cast for a significant period of time and wean slowly. retaining the body heat. Each case is unique. Final flexion. The excess fibrosis from the prolonged immobility and the presence of high-protein edema impede the flow of lymphatic fluid.32 Dramatic results have been seen in numerous patients with chronically stiff hands due to a wide variety of conditions.80. Therapists must let go of previous assumptions that motion must be gained in all directions simultaneously. the unimpeded intrinsic muscles will always be dominant. Limited proximal excursion of the flexor tendons means that the muscles have never been allowed to maximally contract.83 CMMS casting effectively facilitates lymphatic pumping by encouraging active motion.82. and the cast design must be specific to the altered pattern of 154 JOURNAL OF HAND THERAPY motion.

Amiel D. Tegenthoff M. St. 30. Simple Splinting: The Use of Light Splints and Related Conservative Therapy in Joint Diseases. Such questions should lead the reader to use plaster of Paris splinting or casting more often to solve clinical problems. 3. The reconstruction of the hand in leprosy. Therapeutic Hand Splints: A Rationale Approach. The addition of dynamic splinting to hand casts. Therapists who lack plaster of Paris handling skills should seek the assistance of a skilled practitioner and should apply and remove numerous casts before using these treatment techniques with patients. the cast is removed and the patient works on regaining extension while maintaining flexion. 2. Electroencephalogr Clin Neurophysiol. Antwerp. concurrent goals of gaining motion in all directions. Principles and Practice. 8. Akeson WH. 1977. Hunter. Pa.44:507. 1987. Handbook of Traction.: F. Callahan AD.110:158–61. Effects of postoperative immobilization on the reconstructed anterior cruciate ligament. 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St. The comparative properties of plaster of Paris and plaster of Paris substitutes. Burns Incl Therm Inj. 47. 45.41:323–8. Plaster splinting as a means of reducing elbow flexor spasticity: a case study.31:1210–6. Auckland. Eldredge P.71:310–2. Staniforth P. J Bone Joint Surg.191–5. J Hand Ther. Parsons TA. 1982. Efficient mechanics of PIP mobilisation splinting.13:465–8. 39. 2000. Ashcroft G. Lymphatics of the skin. Yasukawa A. 74. Serial casting as a technique to correct burn scar contractures: a case report.10:639–65. 77. Preliminary report of a new technique for casting motion to mobilize stiffness [abstract]. Ledingham WM.(287):292–303. The biologic concept of continuous passive motion of synovial joints: the first 18 years of basic research and its clinical application. 36. 1981. Brand PW. Phys Ther. Keenan MA. 55. 1995. 1981. Danger of burns from fresh plaster splints surrounded by too much cotton. Skirven TM. Effect of serial casting for the prevention of equinus in patients with acute head injury. joint position and continuous passive motion on intraarticular pressure in the rabbit knee. Law M.64A:907–11. 1997. 62. Montgomery J.34:33–7. J Rheum. 1980. Van Royen BJ. Salter RB. 79. Jenkins WM. Neurodevelopmental therapy and upper-extremity inhibitive casting for children with cerebral palsy. 35. Rivers E. Cadman D. 63. Management of spasticity. Hedeboe J. Heat generation in plaster-of-Paris and resulting hand burns. 1984:177. Serial casting for the management of spasticity in the head-injured adult. Arch Phys Med Rehabil. Contact allergy to benzalkonium chloride in plaster of Paris.10: 360–3.25:411–9. 59. 60. Kolumban S. Salter RB. 41. 1995. 57. Phys Ther. Dickstein H. Mortimer PS. Weigand G. J Burn Care Rehabil. Mo. 49. Dhert WJA. Kaas J. 32. 1984. Becker DJ. Am J Occup Ther. Walter S. Miltner WHR. 64. J Orthop Sports Phys Ther. 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Mo. 1989. Johannes S. Mackie T.21B:396–9. 38. Cherry D. Pascual-Leone A. Mackin EJ. 156 JOURNAL OF HAND THERAPY . Ash GJ. Goodman M. Modern splinting bandages. Arbuckle JD. Stroke. Christensen ST. 58. 1996. Pope MH. Katz RT. 72. 1986. Sullivan T. Pope MH. 1983:181. Wall J. Functional properties of knee ligaments and alterations induced by immobilization.12:67–72.36:671–3. Hallett M. 1991. Marshall PD. Rosenbaum P. John RJ.3:67–72.: Aspen. Cohen L. Bauder H. Mo. 69. 71.61: 1601–3. 52.47:508–20. 1980. Angiology.63:1960–6. J Hand Surg. 1982. Salter RB. 2000. Schneider LH. 1999. 43. 1977. Reduction of hypertonicity by early casting in a comatose head-injured individual: a case report. Merzenich M. 1980. Colditz JC. 68. Staniforth P. Clinical Mechanics of the Hand. Russell D. Mackin & Callahan’s Rehabilitation of the Hand.: Williams & Wilkins. Contact Dermatitis. Merritt WH. 50. 61.8:24–30. Mortimer PS. 40. 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University of California San Francisco In the treatment of stiff joints. such as Akeson et al. the periarticular connective tissue—specifically. He also showed that the primary tissue involved in joint stiffness was Correspondence and reprint requests to Kenneth R. AND COLLAGEN RESPONSES TO LOADING In 1966. PT. Inc. we need to reverse the process and apply the stimulus of activity or. This was the inspiration for the term TERT (total end-range time). observing that “soft-tissue (periarticular connective tissue) resistance may be in fact primarily responsible for clinical joint stiffness. e-mail: <kenflowers@peoplepc. that it is better not to use the word “stretch” for what should be long-term growth. This practice is supported by the observation of Brand that “every bit of tissue elongation accomplished by stretch will shorten again when the force is relaxed” 1 and by similar findings of Frank et al. Arem and Madden5 published a seminal report on the remodeling of scar in mice. hold the tissue in a moderately lengthened position for a significant time. gentle stress. Adjunct faculty. The literature provides no objective guidelines to determine the splint of choice. Flowers postulated that the amount of increased range of motion in these knees was proportional to the length of time the joints were held in the end-range position. with an Emphasis on Force Application Parameters Kenneth R. 875 La Playa #278. TISSUE CHARACTER OF THE STIFF JOINT.8 158 JOURNAL OF HAND THERAPY .6 reported that low-load prolonged stretch was more effective than high-load brief stretch in the treatment of stiff knees in human subjects. the ligament and capsule that were placed in a shortened position during the period of immobilization. In 1994. Not only did the Flowers and LaStayo paper establish the TERT principle. for use in planning a splinting program for patients with joint stiffness. Although this paper cannot offer research data to answer this question. better.4 have confirmed Peacock’s adaptive shortening concept. but the question of “which is the splint of choice” in each case has customarily been decided subjectively on the basis of a therapist’s clinical experience in the treatment of similar cases. PT. it also supported an oftenreferenced Brand concept that previously had not been substantiated by data—namely. its purpose is to present an objective decision-making scheme based on clinical assessment of tissue compliance. CA 94121.com>. that “ligaments return to pre-stretch length. San Francisco.. derived from a study of 20 proximal interphalangeal (PIP) flexion contractures in 15 patients.. Other investigators. California. In 1984. San Francisco. Flowers. CHT President. They demonstrated (at autopsy) elongation of the scar substance that had been subjected to prolonged.”2 Many splints are designed to increase permanent tissue elongation and hence improve passive range of motion (PROM). Extrapolating from Light’s data. Flowers and LaStayo7 published data to support the TERT principle. Light et al. Current Clinical Concepts. Flowers. Peacock3 demonstrated on a canine model that joint stiffness was the by-product of a period of immobilization following trauma. The scheme was devised to be consistent with the known biology of joint stiffness and with my clinical experience.” In 1976. Then it will grow. Their conclusion was that increase in PROM in stiff joints is directly proportional to the time the joint is held at the end range. If we want to restore normal length to a tissue that has shortened after disuse. hand therapists have traditionally used splints that position a joint at its available end range in preference to manual stretching techniques. CHT.A Proposed Decision Hierarchy for Splinting the Stiff Joint.

38 when the knees were in 30° of flexion and 0. I have not found the TAC analysis method to be clinically effective in my practice. At the end of the 20 minutes. A TAC is constructed by passively moving a joint through its available range and recording a series of goniometric readings at intervals. to suggest a splinting prescription that is based on time and intensity. the study was not able to validate Brand’s theory of assessing joint stiffness through the use of TACs. characterized by a gentle slope. Tension-elongation or torque angle curve (TAC). where the slope is defined as the rise over the run.11 reported poor inter-rater agreement in a controlled study in which experienced orthopedic therapists tested the play of the joint in a human knee model. perhaps my technique was poor. Because no significant joint stiffness resulted from this method of immobilizing uninjured joints. In 1994. stiffness. the sharper the slope. more objective method of assessing compliance or stiffness has long been advocated by Brand.. In my opinion. and a smooth line is drawn connecting the points. The interpretation of the TAC with regard to tissue compliance or stiffness is as follows: The more gentle the slope. Tissue compliance has been clinically assessed in various ways. a prescription for a dosage contains not only the element of time but also the element of intensity. noncompliant tissue. using procedures with varying degrees of assessment reliability. No definitive data are available to validate the Brand TAC measurement. A method for assessing stiffness that has been popularized by manual therapists and described by Cyriax10 is based on the concept of end-feel. McClure et al. Over time. Immediately following cast removal. The McClure TERT algorithm does not address the variable of intensity expressed by force or over-pressure. In 1985. The basis for tissue compliance can be found in the biomechanical principle of the stress–strain curve (Figure 1). Line AF is the curve for stiff. anticipating sharper curves for the stiffer joints. and I have abandoned its use. and the subject was encouraged to do AROM exercises. with FIGURE 1. PIP joint flexion was measured. Unfortunately. Based on “how it feels. McClure et al.9 published an algorithm for the use of the TERT principle in clinical splinting of the stiff joint. This series of readings is plotted on graft paper. characterized by the long “toe” section (AB) and steep slope of the terminal section (CD).12 This is the use of a torque angle curve (TAC).FORCE APPLICATION THROUGH SPLINTING Flowers and LaStayo7 suggested that TERT could be used to quantify the dosage of stress provided by splints when a low-load prolonged stretch protocol is used. Another. A more reliable method of assessing the compliance of a joint would be useful to clinicians who treat joint stiffness. increasing force (torque) being applied to the joint— e. Indeed. the therapist passively carries the joint to its available end range and manually applies a gentle over-pressure. The TAC is analyzed by applying the basic geometric tool of determining the slope of the curve. The kappa values were only 0. characterized by a steep slope. The period of immobilization varied from a minimum of 1 week for one group to a maximum of 6 weeks for another group. The investigators were hoping to plot TACs for each group. because the rationale has great appeal.00 when the knees were fully extended. no published data were found that adequately address the issue of overpressure in the splinting of stiff joints. the immobilized hand of each subject was placed in a whirlpool bath for 20 minutes.” the therapist determines the end-feel and assesses the stiffness. Line ABCD is the curve for normal tissue. the stiffer the tissue. April–June 2002 159 . much as longer application time results in greater gains in PROM as stated in the TERT principle. this method is highly subjective. Many experienced therapists suspect that the application of a greater force will result in greater gains in PROM. The decision hierarchy for splinting the stiff joint proposed in this article extends the quantification of the collagen responses noted in the TERT principle to include the element of force. Flowers and Pheasant13 reported the results of a study involving healthy physical therapy students who each allowed the PIP joint of their nondominant ring finger to be immobilized in a plastic cast in full extension. every subject had regained full flexion at the end of the 20-minute whirlpool session. Line AE is the curve for compliant tissue. The clinical guideline that I have developed is based on assessment of tissue compliance or the converse. The end-feel is that sensation imparted to the therapist’s hands as the restricted range is encountered. as previously described. 20° at 200 g. I cannot say for certain why I have not had success with it. in an attempt to substantiate Brand’s concept.g. the more compliant the tissue. Using this method. However. This smooth line is the TAC and is in actuality a form of a tension–elongation curve.

or lack of gain. to define “the splint parameters of choice. or rate. The gain. I opt not to splint the patient but to rely instead on an exercise program alone. First. This second reading is called the “preconditioned reading. gentle passive motion—but rather at the amount of creep shown in response to a sustained force over time. The objective of this instruction is to have the patient present to the therapist with a joint that has not been stressed.15 Preconditioning is the biophysical term for the joint when it is “all stretched out” and is not going to yield to further force without undergoing damage. the patient places the involved extremity in a thermal modality. the joint is passively taken to its end range with a given force application. Before performing the MWT in a specific case. Weeks and Wray14 describe a clinical method of assessing joint PROM using a defined force over a defined period of time. the patient is asked to manually position the involved joint at its available end range.” because it is presumed that. Before any modality of treatment or exercise is applied. The numeric result of the MWT is used as the guideline for splint selection. no matter which extremity joint is being evaluated: s The Decision Hierarchy The proposed decision hierarchy for splinting the stiff joint makes use of a modified Weeks test (MWT).” unlike the Brand TAC method.” I have adopted the following guidelines in my clinical practice to decide the splint parameters of choice. The patient is instructed to actively exercise in the modality for 20 minutes. Management of Acute Hand Injuries. its potential compliance—but they do so by looking at different characteristics of the joint’s response to passive force. In fact. Immediately on completion of the 10-minute overpressure session. a second ROM reading is taken. a plan of splinting after determining whether joint stiffness is a significant problem. the load is increased to a given amount and maintained for a sustained period. a static splint which by definition provides no over-pressure. and maintain that force for 10 minutes. Weeks and Wray advocate the use of this test to determine whether to “operate. this measure does not attempt to quantify the potential of the stiff collagen tissue to respond to interventions aimed at elongating the tissue. The objective of the MWT is to provide clinicians with a basis on which they can proactively formulate 160 JOURNAL OF HAND THERAPY s If the MWT results in a gain of (approximately) 20°. .Key Concepts s Elastic recovery of ligamentous length follows stretch Trauma and immobilization result in adaptive shortening and stiffness Gentle prolonged stress promotes tissue lengthening Tissue compliance or stiffness is predicted with the modified Weeks test Dosage of force application is determined with the splinting decision hierarchy Patient response is monitored to assess safety and effectiveness of splint program s s s s s In their 1978 textbook. does not look at the slope of the curve generated in the initial maneuver—when the joint is taken to its available end range in a single. Immediately following the thermal exercise period. the therapist must make an initial determination of whether joint stiffness is a significant problem. the gain is the indicator of the compliance or stiffness and is used to guide the therapist in selecting the treatment of choice—in this case. The Weeks method of testing. This first PROM measurement is called the “cold reading. It is important for a therapist to assess this potential for change so that a splint design can be chosen and tailored not only to the degree of stiffness but also to the responsiveness of the stiffness. after which the PROM reading is repeated. The patient is instructed not to do any exercise or wear any splint on the day the MWT is to be performed. apply a tolerable overpressure.” However. preferably one in which motion is facilitated. rehabilitate. If the gain is of (approximately) 15°. the two PROM readings are compared to establish the gain in PROM. such as whirlpool bath or fluidotherapy rather than a constricting hot pack. Next. the joint is measured passively using standard goniometric technique. As in the original test described by Weeks and Wray. the joint has met the definition of preconditioning described in Fung’s Biomechanics: Mechanical Properties of Living Tissue. which I have for years referred to as simply “the Weeks test. I consider the joint slightly stiff and go with the least stressful end-range splint. such as 10 minutes. in PROM is used as an indicator of the likelihood of success of further therapy. as a result of the exercise period and manual stretching. because of time constraints on the initial visit. such as microtrauma. but the MWT is typically not performed until the patient’s next visit.” After the cold reading has been taken. At this point. presumably through end-range splinting. This first determination is typically done during the patient’s initial evaluation. Both the Weeks method and the Brand TAC method were proposed to assess the same characteristic of the stiff joint—namely.

The patient wore the splint for 30 minutes that day in the clinic to test for tolerance to the splint. to assess reactivity and effectiveness. in that they are straightforward to perform and both time. this indicates a static progressive splint that delivers unremitting overpressure at the very end of the stress–strain curve. considerable variation as to “how much tension” should be employed in the use of dynamic splints.s If the gain is (approximately) 10°. a second measurement of the PROM of extension was performed. At the end of the whirlpool session. This joint probably requires a dynamic splint. This system is based on actual degrees of change in PROM. s TABLE 1. In many instances. If the gain is on the order of 5° or less. s s s Case Presentation The following case presentation illustrates how the MWT was applied clinically. the MWT and its interpretation are user-friendly. ROM. the stiffness analysis of the MWT will indicate that a certain level of stress is needed. such as covalent cross-links. but the April–June 2002 161 Passive ROM of elbow extension was measured and found to be 60°. The patient ‘s arm was immersed in a whirlpool bath at 105° F for 20 minutes. All experienced therapists know that there is. On June 1. Guidelines for Interpretation of the Modified Weeks Test PROM Increase About 20° About 15° About 10° About 0°–5° Splinting No splint Static splint Dynamic splint Static progressive splint s The change in PROM between the cold reading (the first reading) and the preconditioned reading (the second reading) was 9°. the patient returned to the clinic for the MWT. A home-wearing schedule was established to deliver an initial TERT dosage of one hour a day. clearly. Typically.16 The potential for adverse response to stress delivery must always be foremost in the therapist’s mind. swelling.”15 However. It is intuitively obvious that any adverse reaction calls for a diminution of the stress dosage. the patient presented for therapy on July 2. the patient was positioned with her arm resting on a table padded with a folded towel and was shown how to manually use her uninvolved arm to apply continuous over-pressure into extension up to her pain tolerance. The definition of stress relaxation is that if a tissue is placed under tension and the length of the tissue is held constant. repetition of the MWT is often helpful for deciding whether to go up the hierarchy ladder to a more aggressive splint. Following pin removal. s s s .and cost-effective. except to respect the patient’s pain. Her involved forearm was supinated. On termination of this manual stretching session. The viscoelastic behavior of stress relaxation must be borne in mind in the use of static progressive splints. a dynamic elbow extension splint was fabricated and fitted. The patient was instructed to actively flex and extend her elbow within her limits of pain throughout the whirlpool session. after a short time (perhaps 15 to 20 minutes). In my scheme. The reading was 51°. A follow-up visit was scheduled for July 5. The therapist is obligated to monitor the patient for any possible adverse reaction to the any low-load prolonged stress therapy. At the initial therapy evaluation. I am not aware of any objective guidelines for directing this decision. The patient was a 35year-old secretary. s These guidelines are summarized in Table 1. The fracture was initially managed by K-wire percutaneous pinning and plaster immobilization for 28 days. the amount of tension required to maintain that length decreases as the tissue “relaxes. she fell while playing volleyball and sustained a supracondylar fracture of the humerus of her nondominant arm. the joint is significantly stiff and in need of some over-pressure to increase the stress delivery. On July 3. Prudent application of stress to overcome stiffness requires considerations beyond the initial choice of splint as aided by the MWT. this phenomenon cannot be repeated many times in rapid succession. but a similar approach using percentage change might be as appropriate or better. which was performed in the following manner: s DISCUSSION In clinical practice. the joint is very stiff and will require the most aggressive intervention. hand therapists monitor pain. She used a palm-to-palm method to grip her involved hand with her uninvolved hand. the tissue length is maintained by the elastic restraints within the tissue components. When a patient appears to be reaching a plateau in PROM gains. because once the relaxation has occurred. and grip/pinch performance to assess adverse reactions. it was found that a flexion contracture was a significant clinical problem and that the patient would probably require splinting to regain functional ROM. Clinical scientific validation of these procedures is still in progress. This question would make excellent fodder for investigation. On the basis of this MWT result.

1985. Blackburn LG. 1976. St. St. such as choice of materials and fabrication. 3rd ed.164:1–12. St. Riddle DL. which was later substantiated by the TERT paper. Mo. Biorheology. Clinicians can be stimulated to try these untested hypotheses in their own clinical practice. The decision hierarchy presented here is purely theoretic. Data to substantiate the proposed model are lacking. the therapist must default to a lower level of stress that can be tolerated by the patient and should increase the stress only as tolerated. 16.. Mechanical Properties of Living Tissue. selection of the proper splint for managing joint stiffness has been empirical. Mo. The proposed splinting decision hierarchy for the stiff joint described here should not mitigate against or override a dosage consideration that is based on the TERT principle. Louis. The vision of Brand. Clin Orthop. because tissues are often too irritable to tolerate significant over-pressure. Frank C. Phys Ther. Mackin EJ. 1966.: Mosby. Biomechanics. 6. McClure PW. Some biomechanical and biophysical aspects of joint stiffness. s This paper proposes a new method of assessing joint stiffness or compliance called the MWT. Clinical Mechanics of the Hand. The two measures of dose are complementary. LaStayo P.20:93–102.: Saunders. Concepts related to this topic would make fertile ground for scientific investigation. increased over-pressure should not be substituted for long TERT doses. Akeson W. 11.: Williams & Wilkins. St. Intertester Reliability of Clinical Judgements of Medial Knee Ligament Integrity. Ann Surg. The MWT method is clearly only a model for assessing specific characteristics of joint stiffness and the application of forces in splint selection. 1985.: Mosby. 1985. Effects of stress on healing wounds: intermittent noncyclical tension. Dusold C. So TERT trumps over-pressure. The use of splints in the treatment of joint stiffness: biological rationale and an algorithm for making clinical decisions. We need data to support clinical impressions such as these. Peacock EE.: Mosby. 13. New York: Springer-Verlag. Weeks PM. Low-load prolonged stretch vs. # 4: 268-275. Brand P. it has not been substantiated by data obtained under controlled conditions. 2. J Hand Ther. 1984. 10. 1981:211. Rothstein JM. but both may be required. 1984:84–6. Management of Acute Hand Injuries.7(3):150–7. Philadelphia. clinical methods of assessing joint stiffness or compliance have not been shown to be valid or reliable. Hand rehabilitation: management by objectives. 1985:62–7. Guidelines are proposed for interpreting the MWT in the selection of the proper splint to manage joint stiffness. Arem A. Amiel D. 14. 69.1:69–75. The face validity of a model of testing or treatment often comes from the clinic before research data are reported to substantiate its use. 1984. Schneider LC. 15. J Surg Res.17:95–110. Wray RC. Mo. 1980. Peacock EE. However. Amiel D. In: Hunter JM. In such cases. not mutually exclusive. 1994. Cyriax J. Nuzik S. Baltimore. Personius W. Light K. Woo S. Rehabilitation of the Hand. Over-pressure is the intervention of last resort. McClure PW.patient will be unable to tolerate that level of stress. Madden J. Scientific validation can come later in the form of controlled studies that grow out of clinical impressions. 2nd ed. 1994. Brand P. Flowers K. 1978:434–8. 1989. 3. 12. 5. Brand P.74(12):1101–7. Wound Repair. Effects of total end-range time on improving passive range of motion. Louis. J Hand Ther.196:15–24. Textbook of Orthopedic Medicine. To date. s s REFERENCES 1. Louis. The use of torque angle curves in the assessment of digital joint stiffness. CONCLUSIONS s To date. Flowers KR. Phys Ther. Pa. Phys Ther. Pheasant S. 9. 7. s 162 JOURNAL OF HAND THERAPY . Fung Y. Md. 8. Louis. Callahan AD (eds). Normal ligament properties and ligament healing. 6th ed. Immobility effects on synovial joints: the pathomechanics of joint contracture. Woo S. Clinical Mechanics of the Hand. is an example. It is beyond the scope of this paper to discuss the many other nuances of splinting. high-load brief stretch in treating knee contractures. 2nd ed. MO: Mosby. 1975. Vol 1: Diagnosis of Soft Tissue Lesions. 64: 330-333. 4. 62-67.

OTR. Flatt. and reasonably priced.3–10 some clinicians still use dynamic or elastic forms exclusively. CHT Director. clinicians used low-technology. and many splint designs incorporating the static progressive approach are illustrated. Utah ABSTRACT: Static progressive splinting is the use of inelastic components to apply torque to a joint in order to statically position it as close to end range as possible. Rocky Mountain Hand Therapy. P. and the various methods of achieving static progressive splinting are compared. Static progressive splinting can achieve gains in PROM when other therapeutic and splinting approaches fail. progressive hinges. MS. Rocky Mountain Hand Therapy Edwards. Edwards. It offers many examples of static progressive splinting and makes clear that this approach can be used with any mobilizing splint design.O. As tissue lengthens in response to this carefully applied stress. For more than 20 years. noted surgeons Nirschl and Morrey 2 oppose the use of dynamic splinting to gain motion. e-mail: <handksj@ vail. This article discusses static progressive splinting indications. The variation in the gradability of the various force generators demands special attention. Recognizing the power of static positioning. It maximizes total endrange time. lightweight. grossly adjustable approaches to static progressive splinting. in the 1994 edition of The Care of Congenital Hand Anomalies. Director. “Static splinting yields better results than dynamic forms” to increase PROM.12–16 These components allow progressive changes in joint position as PROM changes. With the number of clinicians who understand the The author has a financial interest in one or more products mentioned in this article. Initially. Box 2145. thus increasing passive range of motion. principles and benefits of static progressive splinting reaching a critical mass. turnbuckles. and advantages as well as guidelines for a splinting regimen. clinicians have recognized the effectiveness of static progressive splints to improve passive range of motion (PROM).1 wrote.11 This article defines static progressive splinting and describes its advantages for improving PROM. Correspondence and reprint requests to Karen Schultz-Johnson. Offering high levels of patient satisfaction and compliance. Static progressive splinting is a time-honored concept—not a new one.) Discussing rehabilitation of the elbow.Static Progressive Splinting Karen Schultz-Johnson. and Table 1 compares component gradability. static progressive splinting has come to the forefront of clinical practice. this splinting approach has the potential to become the technique of choice for increasing PROM. the clinician or wearer adjusts the joint position to progress tissue at the new maximum tolerable length. without changes in the structure of the splint. In spite of such statements in the literature and the clinical success of static progressive splints. contraindications. The unique mechanics of this splinting approach are described. static line. low-profile. Adjunct Faculty Rocky Mountain University of Health Professions Provo. and gears—to apply torque to a joint in order to statically position it as close to end range as possible and thus increase PROM (Figure 1). OTR.15:163–178. 2002. CHT. (Here dynamic means “elastic/spring traction” splints. Static progressive splinting combines precision in joint position and torque application with patientcontrolled stress to create an approach powerful enough to succeed when no other treatment approach does. FAOTA. MS. FAOTA. J HAND THER. DEFINITION OF STATIC PROGRESSIVE SPLINTING Static progressive splinting is the use of inelastic components—such as hook and loop tapes.net>. April–June 2002 163 . Regimen guidelines for various aspects of static progressive splinting are provided. screws. It also clarifies the indications and contraindications for this splinting approach and explains the unique mechanics of static progressive splinting. Splint designers then sought a means to improve the technique with components that offer infinitely adjustable joint torque control and are easy to apply. Colorado. CO 81632.

However. Maureen Hardy noted that. it can limit the excursion of tissue when it spot-welds a moving structure to a nonmoving one. One such approach. static line. THE BIOLOGIC BASIS OF STATIC PROGRESSIVE SPLINTING The biological basis for using static progressive splints to increase PROM lies in the ability of lowload prolonged stress to reorganize tissue in a manner conducive to motion and function. the clinician or wearer adjusts the joint position to progress tissue at the new maximum tolerable length. Although the combination of elastic components with inelastic components does increase control over the force generated.16 s INDICATIONS FOR STATIC PROGRESSIVE SPLINTING The clinician applies a static progressive splint to decrease stiffness at a joint. Gradability of Static Progressive Force Generators. In her 1999 keynote address at the American Association of Hand Surgeons seminar on joint stiffness.19 Static progressive splints may require adjustment of the line or angle of pull as PROM progresses. Stiffness—the loss of PROM at a joint. The generated tension continues as long as the elastic component can contract. TABLE 1. the term “dynamic” is also used to describe a mobilizing splint—one that exerts forces on the involved joint or tissue to affect a change in joint motion. uses self-adjusting resilient or elastic components such as spring wire. A serial static splint positions the restricted tissue at maximum tolerable length.18 For purposes of clarity. such as hook-and-loop tape. To accommodate increases in tissue length and progress to a greater range of motion (ROM). its sheer bulk may create physical blocks to motion. it is not the same as static progressive splinting. the clinician must remold the splint to place the tissue at the increasing maximum tolerable length. even when the shortened tissue reaches the end of its elastic limit. Colorado) joint or successive joints. the static progressive splint holds shortened tissue at its maximum tolerable length and does not stress beyond it12 (Figure 2). screws. incremental hinges (change joint position to 10° to 30° increments) NOTE: The higher the level of gradability. The process continues until the patient achieves desired tissue length and range of motion.19 Both create formidable barriers to motion. the more the patient can take advantage of small changes in tissue length and excursion by repositioning the joint at the new end range. Potentially infinitely adjustable: s Progressive hinges have a continuous arc of motion and position the joint at any degree of range of motion(ROM) Physically difficult to progress joint ROM and torque exactly as desired s Grossly adjustable: s s Offer approximate adjustment in ROM Types of static progressive splinting components— hook-and-loop tape. to apply torque to a joint to increase passive range of motion. this article uses the term “elastic traction” to describe this type of splint. Scar limits motion by several mechanisms. from Most to Least Gradable Infinitely adjustable: s Can change the joint position by a fraction of a degree and torque by a fraction of a gram Types of static progressive splinting components— turnbuckles. joint stiffness continues to be a challenge. Edwards. and springs that create “a mobilizing force on a segment. and gears. while hand specialists have made great strides in hand surgery and rehabilitation. First. resulting in passive or passive-assisted motion of a 164 JOURNAL OF HAND THERAPY . Static progressive splinting is the use of inelastic components. and MERiT components (UE TECH. rubber bands. progressive hinges. Loss of joint flexibility has two major sources—scar formation and adaptive shortening.FIGURE 1. Clinicians apply other splinting approaches to increase PROM. Serial static splints are yet another splinting approach to increasing PROM at a joint. Clinicians often use the term “dynamic” for this type of splint. because scar consistently reorganizes in a denser form.”17 Such splints allow activeresisted motion in the direction opposite their line of pull. turnbuckles. Second. the resulting tissue becomes progressively more resistant to lengthening and has less viscoelasticity. the elastic traction splint. because it has moving parts and resilient components. gears. screws. coupled with the need for increases in muscular effort to achieve end range—continues to be a common reason that patients attend clinics for upper extremity therapy. As tissue lengthens in response to this carefully applied stress. Finally. Figure 3 illustrates this concept. When applied correctly.

(Photograph courtesy of Alimed. including scar. Static progressive splints allow adjustable tension and changes in joint position at any time. The scientific community has not yet quantified the exact amount of stress required to stimulate change in tissue length. (Artwork © Karen SchultzJohnson. The inelastic tape allows some variation in the amount of force the elastic traction generates. The stress stimulus of tension triggers an increase in the length of the tissue. in this author’s experience. The flexion glove uses elastic traction. The shortened tissue restricts joint motion. the clinician controls the environmental demands on the tissue and applies the mechanical stimulus of stress. This glove still uses rubber band elastic traction. splinting is the most powerful. As tissue remodels into a longer form. Left. (Photograph courtesy of Alimed.20 Clinical experience and the orthodontic and orthopedic literature support the use of low-load prolonged stress over any other combination of load and stress for achieving permanent increases in tissue length and. will reorganize and change in response to stress. a clinician faces the challenge of changing the length and density of the scar. the patient or clinician can immediately adjust the splint to capture this increased tissue length and thus increase passive range of motion. However. Inc. to flex the finger joints. Although the clinician has many devices in the therapy toolbox to control environmental demands on tissue and apply optimal stress. low-load prolonged stress appears to work by providing a mechanical stimulus that causes scar to biologically remodel into a form conducive to motion.20–24 Although the mechanism of action is unknown. but the rubber bands are attached to hook tape to traction the finger joints into flexion.) April–June 2002 165 . the amount of stress required increases as the maturation of the scar progresses. They establish a static tension that places tissue at maximum length but does not stress beyond it. (Photograph © Karen Schultz-Johnson. However. To reverse the motion-robbing effects of scar and adaptive shortening. Studies by Akeson et al. therefore.FIGURE 2. Living tissue. in which static force generators replace all elastic ones. to traction the finger joints into flexion. in PROM. To achieve these desired changes. in the form of rubber bands attached to the glove. scar adhesions. Splinting maintains tissue changes and elongation that have been gained during thera- FIGURE 3. Static progressive force generators use entirely inelastic components and do not combine elastic and inelastic components. This glove uses static progressive traction. or it may occur over several weeks or months.) Right. and adaptively shortened tissue.26 indicate that scar contracts and becomes denser as it matures. This can occur quickly in the presence of inflammation. in the form of inelastic splint line attached to hook tape.) Adaptive shortening decreases the length of a tissue when the tissue is placed in a slack position. This embodies true static progressive traction.25 and by Frank et al.) Middle. the combination still creates elastic traction. Inc.

19. heat. Edema. It is difficult. it positions the joint at end range over long periods of time. the key elements in increasing PROM are high time doses of low-load stress adequate to position the shortened tissue at or near the end of its currently available length. duration. and this tissue length remains the same until the clinician progresses the splint. it contracts and further limits PROM. With the advent of static progressive components that offer infinitely variable tension. achieving this exact relationship was one of the most difficult aspects of splint fabrication and was often impossible. a relationship exists between the goal PROM and the amount of force required to attain the goal. However. and stiffness indicate that micro-trauma has occurred. The clinician considers the effects of these three variables—intensity. only the wearer can truly set the precisely correct load. fibroplasia. it contracts and further limits passive range of motion. the more it increases in length.FIGURE 4. Elastic tension is not readily or precisely adjustable. Although this amount of tension might initially appear desirable. when elastic traction or gross static progressive methods were used. Stressing tissue beyond its available length causes pain and ultimately creates micro-tears and increased scar formation (Figure 4). This results in rapid gains in PROM as the patient takes immediate advantage of incremental PROM increas- . As this new scar matures. and might appear to be the logical solution to the problem of lengthening tissue. While a clinician may initially balk at giving this control to a patient. The elastic 166 JOURNAL OF HAND THERAPY component that can generate the amount of force needed to remodel mature scar may continue to shorten tissue to the point where it tractions the joint beyond its currently available end range. The micro-tears. Elastic tension splints. but it may cause further damage. (Artwork © Karen Schultz-Johnson. and in some cases impossible.21 Thus. to appreciate the benefits of patient-controlled tension. One need only imagine being placed in a splint with tension pre-set by a clinician who cannot know the physical experience of that level of tension. A static progressive splint delivers the type of stress that tissue requires to overcome these barriers and to achieve desired increases in PROM. pain. erythema.) py. especially over long periods of time.19 Research has supported the hypothesis that the longer tissue remains at maximum tolerable length. ADVANTAGES OF STATIC PROGRESSIVE SPLINTING Force and Range-of-Motion Adjustment The ideal amount of torque exerted on a joint will be the minimum necessary to achieve the goal point in the PROM—that is. Using low tension. to establish a tolerable elastic tension that places tissue at maximum length but does not stress beyond it. Of course. Force Control Static progressive splints introduced an important concept into splinting regimens: patient-controlled force. Stressing tissue beyond its available length causes pain and ultimately creates microtears and increased scar formation. this goal is now easily achieved. This over-pressure may initially appear to be a desirable and logical means of lengthening tissue. and frequency—as they mediate total stress delivery. clinical experience has shown the effectiveness of empowering the patient in this way. the maximum tolerable end range. An elastic component that can generate the amount of force needed to remodel mature scar may continue to shorten to the point where it tractions the joint beyond its current available end range. Although serial static splints create constant tension and joint positioning. As the scar matures. All forms of mobilizing splints base their effectiveness on the principle of stress application. In the past. through a patient’s home program. the patient cannot move from the end range established by the clinician. and maturation. in fact it is not. the clinician employs experience and data from repeated evaluation to determine optimal stress loads. Static progressive splints have the advantage of allowing the patient to instantly progress the splint rather than waiting for the therapist to do so. Typically. and by functional use of the hand. undergo the normal phases of wound healing—inflammation. The splint holds tissue at its current maximum length. in turn. The clinician can make an educated guess about force adjustment.

Each time clinicians fabricate circumferential casts. The speed with which static progressive splinting succeeds in conjunction with the option for patient-controlled tension results in a reduction in the number of treatment sessions. and also help control edema. and Time Dosage Because a static progressive splint positions the joint precisely at end range with the appropriate amount of force. Removability The patient can remove a static progressive splint for periods of exercise. With an elastic traction splint. Efficacy. “Serial casting immobilizes the arm.” 4 Static progressive splints offer most of the benefits of serial static splints while permitting AROM. for definitions of soft and hard end-feel joints. (See Splint Indications Algorithm: Applying Static Progressive Splints.29 Motion promotes nourishment of cartilage30. below. the patient exerts final control over a splint that exerts too much or too little tension: The patient simply removes it. By wearing the splint at night. interferes with the performance of home exercise and activities of daily living. Many static progressive components are reusable. to hold the tissue at its maximum length for long periods of time. Such proven efficacy demands that clinicians seriously consider this treatment approach. Static progressive splints accommodate increases in joint mobility without the need to remold the splint to progress PROM. they deprive the splinted joints of active range of motion (AROM). Although serial casts maximize compliance. saving the time for remolding or refabrication that serial static splints require. necessitating additional expense. the patient receives approximately 8 hours of therapy during a period when little is usually accomplished therapeutically. This thwarts the entire purpose of the splint—that is. because springs and elastics deform over time. AROM encourages functional organization of scar tissue and facilitates lengthening of adhesions in both directions. which in turn provides increased PROM. The static progressive approach to splinting PROM limitations helps the clinician meet the managed care challenge. This reduces or eliminates the need for daytime splint wear when the splint would interfere with functional use of the hand and exercise.31 and helps pump high protein edema into the lymphatics. Clinical experience has shown that elastic traction splints often fail to improve the PROM of hard endfeel joints. distribute pressure. minimizing materials expense. (Guidelines for clinician-controlled tension appear under Static Progressive Splinting Regimen. they must use consumable materials.27.32 Bash and Spur state. the patient can also pull against the force and shorten the tissue on an intermittent basis. With good splint tolerance comes the possibility of splint wear during sleep.27 While many clinicians have found that static progressive splints demonstrate a high level of effectiveness with hard end-feel joints. elastic traction deprives both the clinician and the patient of control over force. and may cause stiffness in the opposite direction. Ultimately.) When allowing a patient to set the torque. Compliance. The value of empowering the patient to adjust the splint cannot be overstated. minimizing treatment costs and speeding the injured worker back to gainful employment are more important than ever before. Static progressive splints represent a potential cost savings in comparison with serial static splints.33 demonstrated that static progressive splinting improved PROM in cases in which no other treatment approach was successful. and Cost Effectiveness In this era of managed care.) . Efficiency. Physicians and therapists have described patients with contractures who were scheduled for surgical April–June 2002 167 Application by Joint End-feel A common misconception is that clinicians should use static progressive splinting exclusively with hard end-feel joints and elastic tension splints exclusively with soft end-feel joints. the clinician must assume responsibility for providing the patient with clear guidelines.28 they also find that static progressive splints often improve the PROM of soft end-feel joints faster than elastic tension splints.es. and because the patient can increase and decrease the tension. Splint Tolerance. the static progressive splint maximizes splint tolerance. the dosage of splinting that a patient receives is critical to achieving optimal outcome—the reorganization of tissue in a longer form. Bonutti et al. This fosters compliance in the form of consistent and multiple-hour splint wear. below. The patient who has cognitive problems or who lacks kinesthetic feedback will not be a good candidate for adjusting the splint tension independently. patients will change the type of rubber band or its length or will deform the spring in an attempt to control splint tension. The total end-range time directly affects the speed and amount of PROM gain. Even when the clinician thinks that the splint tension has been set.21 Thus. In contrast. This may be because of the splint tolerance factors described above and the inability of a patient with a hard end-feel joint to wear such a splint long enough to experience adequate total end-range time to achieve tissue remodeling. The patient remains at end range until the patient or clinician re-adjusts the splint to optimize the combination of range of motion and tension.

controlled approach to increase PROM. 33 At this point. such as those incorporating gears and screws. the tissue . With the infinitely adjustable static progressive force generators. the effectiveness and fiscal efficiency of the splinting become apparent. the patient’s temperament. A static progressive force generator has a wide range of load application. clinical use suggests that static progressive splints increase the range of motion more rapidly than other splinting approaches for this soft end-feel type of limitation. As the inflammatory phase progresses toward its end. the clinician uses decision-making techniques to identify the approach to motion restoration that best suits the patient’s many needs and characteristics. the clinician can employ a static progressive approach before considering elastic traction.33 At the beginning of the inflammatory phase. especially in complex injuries. Frequently. and can be renewed in response to even a relatively minor trauma. the therapist will have the sense that the joint the joint rapidly increases its passive motion arc. the size and collagen content of the scar stabilizes. a patient may be able to benefit from a static progressive splint 4 days after metacarpophalangeal (MCP) capsulotomy. For example. At this phase. It is up to the clinician to establish the correct amount of tension or load for the given tissue. Inflammatory cells invade the wound but do not immediately begin to form collagen. The clinician’s knowledge of the status of tissues relevant to the stage of wound healing forms the basis for the decision. The wound actively turns over collagen. Static progressive splinting has provided improvements in PROM similar to or better than those gained by surgery. without the risks. In the past. surgical procedure. destroying old fibers and placing them with new ones. As stated above. Not all patients will be able to tolerate passive torque in the late inflammatory phase. . and myofibroblasts stimulate wound contraction. Scar becomes denser in the maturation phase. Elastic traction splints and serial static splints will ultimately provide the desired result of increased PROM.release prior to application of static progressive splints. from extremely low to extremely high. although it may persist for days or weeks. Remodeling continues for many more months at an ever-decreasing rate. This makes static progressive splinting potentially applicable at the end of the inflammatory phase and during the fibroplasia phase. In addition. THE SPLINT INDICATIONS ALGORITHM: APPLYING STATIC PROGRESSIVE SPLINTS When evaluation reveals PROM loss. Thus. and it should be avoided with patients in some diagnostic categories. The presence of inflammatory cells and products leads to fibroblast recruitment and activity. Approximately 3 weeks after injury. because they considered it a high-load generator. the joint with limited PROM will often have a compliant feel when the clinician applies passive force to achieve end range. heat. fibroplasia (proliferative). The most active period of this phase lasts from 3 weeks to 6 months. creating increased edema. even when tissue is at the lower ranges of tensile strength. some clinicians delayed using static progressive splinting until the later phases of wound healing. Local vasodilation permits the leakage of blood and plasma into the injured area. when the 168 JOURNAL OF HAND THERAPY dynamic turnover of collagen provides for differentiation of scar to accommodate to the tissue type and the stresses under which the tissue is placed. This is a misconception. and pain. tissue inter-cellular bonds are fragile. Because of the success of static progressive splinting. Capillary in-growth supplies nutrition to the area. During the late fibroplasia stage and the early maturation phase. the clinician will choose a splint as part of the treatment plan. the classic signs of inflammation. the wound transitions to the maturation phase. surgery was cancelled. However. the fibroblasts synthesize collagen rapidly. The algorithm features the three phases of wound healing—inflammation (acute).33 Fibroplasia begins 3 to 4 days after injury. static or serial static splints may provide the only appropriate splinting approach. clinicians have developed various algorithms that match the type of splint with the phase of wound healing. When comparing the cost of static progressive splinting with the costs of surgical release of a joint. and maturation (chronic): The inflammatory phase of healing begins within hours of trauma and continues for at least 3 days. . the clinician must set up the splint appropriately and teach the patient how to use it. Soon outnumbering other types of cells in the wound. As a foundation for making the choice between the various splinting approaches. the clinician considers multiple factors before applying a splint. patient-controlled passive extension is contraindicated for the patient who underwent a zone II flexor tendon repair 4 days previously. However. . This compliant feel is often called a “soft end-feel. and the patient’s general health. Application of an appropriate splint always requires consideration of diagnosis. At this point in the healing continuum. redness. making the wound susceptible to rupture if it is exposed to excessive tension.” 34 When applying moderate passive force to this type of joint. Figure 5 shows one such algorithm and serves as a guideline only. the range of force—from low to high—is much more diverse than that achievable with a rubber band or spring. the clinician may apply a static progressive splint to begin a gentle.

However. They are: s s s s s s s s s s s The clinician must carefully consider the appropriateness of applying a static progressive splint when a patient’s status includes of sensory loss or cognitive impairment.” 34 In contrast to other splints. under “Splint Indications Algorithm— Applying Static Progressive Splints. These contraindications are the same as those for any type of mobilizing splint. As a foundation for making the choice between the various splinting approaches. A patient with Dupuytren’s contracture will respond to splinting only after surgery. or both.36 Because of the nature of Dupuytren’s tissue. it is important to know its contraindications. CONTRAINDICATIONS TO STATIC PROGRESSIVE SPLINTING Just as it is important to know indications for a static progressive splint. Static progressive splints can generate the appropriate forces and joint position in a way that patients can tolerate for adequate force dosage. Irradiated tissue is mostly fibrotic and does not possess the same viscoelastic properties as normal connective tissue. (See discussion of splinting during the inflammatory phase. static progressive splints are extremely effective with these types of joint rangeof-motion problems. clinicians have developed various algorithms that match the type of splint with the phase of wound healing. It lacks the number and type of live cells required to respond to the mechanical stimulus and to reorganize. Scar tissue will respond to the stresses that splinting imparts. Clinical experience and research33 have shown that static progressive splints can make improvements in hard end-feel joints when no other therapeutic intervention other than surgery can. the clinician must carefully consider the appropriateness of this splinting approach for them.”) These diagnoses are contraindications to the application of not only static progressive splints but also any type of mobilizing splint. Splinting of patients with hypertonic muscles always requires a great deal of assessment and clinical problem solving.FIGURE 5. The patient with compromised sensation or cognition requires a splint design that ensures skin integrity while minimizing the risk of vascular compromise and shear. Three special diagnostic categories require special comment. Dupuytren’s contracture will not respond to lowload prolonged stress. with its constituent myofibroblasts. a patient with spasticity may be dependent on caregivers to don and doff a splint. In addition. Irradiated tissue will usually not respond to lowload prolonged stress. This dependency may compromise splint effectiveness if the caregivers do not have adequate training in applying and adjusting the splint. They are: s s s Joint instability Avascular necrosis Acute inflammation* Infection Unstable fractures Marked demineralization Myositis ossificans Heterotopic ossification Exostosis formation Loose body in joint Stress across healing structures that lack adequate blood supply or that lack tensile strength to withstand tensile stress Dupuytren’s contracture Motion loss due to tissue irradiation Diseases creating fibrotic tissue *The contraindication to static progressive splinting in the presence of acute inflammation is diagnosis dependent and does not apply across the board. Some joints feel extremely limited and unyielding when the clinician applies passive force to achieve end range. because patients with hypertonic muscles often have sensory or cognitive impairment as well. it will not remodel in the same way as normal tissue or scar. April–June 2002 169 . because the surgery removes the unresponsive tissue and replaces it with scar. requires longer periods of end-range positioning and higher loads in order to remodel. These joints are said to have a “hard end-feel. The patient with spasticity may benefit from a static progressive splint.35.

Seldom does a patient ignore these warnings when the clinician states the precautions clearly and emphatically. will help the clinician establish an ideal splinting regimen. Powerful enough to sublux joints. high force will re-injure the tissue. tension. producing more scar and increasing the time before the joint moves as they would like. and by removing the splint. especially when there is any doubt about splint appropriateness or tolerance. sensation. When designing the splinting regimen. A careful assessment of whether the patient can make healthy judgments about splint tension and joint position will allay this concern. and other important variables. When designing a splint and instructing the patient in its use. the clinician acquires feedback regarding appropriate fit. the clinician explains the concept of low-load prolonged stress to patients. In this author’s clinical experience. It is especially important to rethink the rationale for splint application to be certain of its appropriateness. stage of wound healing. Making it clear that splints have the capacity to modify the tissue that restricts patients’ movement. Illustration with examples that people can relate to—such as braces straightening the teeth or pointy shoes deforming the foot—brings the concept home. creating deformity. During this trial period. a patient may also be able to wear a static progressive splint during sleep. who is compliant and well aware of splint precautions. a patient with a contracture that has a soft. the clinician should keep this basic principle in mind: The more time the tissues spend at end range. everyday language. a patient with a wellestablished hard end-feel contracture. In this author’s experience.21 The clinician adapts this principle for each patient. The responsibility lies with the clinician to provide instructions in a way that the patient can comprehend. the more quickly PROM will improve. cognitive status. This will help them with proper tension adjustment. which include (but are not limited to) acuteness of injury. STATIC PROGRESSIVE SPLINTING REGIMEN The clinician is responsible for establishing an appropriate splinting regimen for each patient. and patient acceptance of the splint. pain. by moving the hand in the splint. . PROM. Using simple. patient awareness of splint precautions. Clinicians will find it very helpful to make it clear to their patients that they will always experience stretch before pain. Patients must also understand that the use of too much tension will not increase PROM faster. Scleroderma may be one such entity. Although wearing a splint may not be easy. it must be pain free. Static progressive splints offer the option of having the patient set the splint tension. Clinicians who have no experience with patient-controlled tension may initially feel apprehensive about allowing a patient to adjust a splint independently.Some types of pathology create fibrotic tissue. wound status. among other factors. However. Once the patient can tolerate the splint for the trial period.12 Static progressive splinting generally follows the same regimen guidelines as any other type of splinting. and motivation. line of pull. The clinician using a splint to increase PROM in a patient with scleroderma must use great care and monitor the hand closely. Rather. general health status. and patients with minimal education—can learn to adjust splints properly. the clinician must rigorously check for the following signs and symptoms. time since surgery. the clinician must consider many issues. The patient may initially wear the splint for a brief trial period (the clinician sets the duration) to determine tolerance. Gains at a joint of 5° to 10° per week indicate splint success. As mentioned earlier. even patients from difficult populations—such as children. excel170 JOURNAL OF HAND THERAPY lent results. the clinician instructs patients to position each joint so that they experience a mild to moderate stretch sensation at the joint or in the tissue adjacent to the joint. which indicate a problem with the splint: s s s s s s s Pain Heat Redness Edema Decreased range of motion Decreased strength Decreased sensation If any of these signs and symptoms are present. patients with language barriers. At the other extreme. the fibrotic tissue contracts. Whenever a clinician applies a splint. Close monitoring of skin status. The splint wear schedule may require some experimentation before the clinician and patient discover the optimal one. This approach has successfully improved PROM when no other splinting approach did. Clinical experience suggests that fibrotic tissue does not respond to splinting. A range of splinting periods may be used to treat a given patient successfully. may be able to wear the splint 23. it should be kept in mind that patients wearing elastic traction splints self-adjust tension by changing or shortening rubber bands. and thus obtain 8 hours of end-range time that does not take away from function and movement during the day. the clinician must thoroughly check the splint for fit and pressure distribution. springy end-feel can wear the splint for 3 to 4 hours a day and obtain rapid. edema. the clinician may instruct the patient to wear the splint for longer periods of time. removing it only for hygiene. Patients must understand that gentle stress will give them the results they seek.5 hours a day.

Let the splints illustrated here stimulate ideas for unique designs to match each patient’s needs. Over time. of course. On a torque-angle ROM graph. Elastic tension wrist extension splint. Left. The clinician’s careful consideration of each of these factors often determines the final factor— patient compliance with the splinting regimen. Using range-of-motion evaluation. This wrist extension splint uses the same base and components. Clinical experience has shown that many patients will be able to tolerate such a position and still enjoy steady gains in PROM from splinting. When considering the ease of splint construction.FIGURE 6. the splint might position the joint approximately 5° beyond readily available end range.). or rental splint best suits the specific financial situation. the joint will “communicate” its needs and tolerances. prefabricated. observation of color.” The clinician applies torque to the target joint until she or he feels slight resistance. if the clinician judges a static progressive splint to be the splint of choice. A judgment error in any of these factors will often result in a patient’s failure to commit to the splinting regimen. Thus. splint cost is a critical factor. Another option is to position the joint by “feel. Static progressive wrist extension splint. the clinician should set the splint to maintain this desired position. Even when using a prefabricated or rental splint. and the position will be adjusted. the clinician will need to be able to modify and fit the splint properly to achieve optimal results with it. In such a case. (Photograph © Karen Schultz-Johnson. It is a common misconception that static progressive splinting can be used only with certain splint designs. While many patients are fascinated by the workings of a splint. April–June 2002 171 . It is always helpful to remember that the optimal splint design results when the clinician first asks “What does this hand need?” rather than “What splint goes with this diagnosis?”12 It is a common misconception that static progressive splinting can only be used with certain splint designs (Figure 6). the clinician determines joint position in the splint. (Photograph © UE TECH. only the force generator changes. The clinician and patient must decide together if a customfabricated. she or he must establish the splint tension. Although the nature of the PROM limitation controls most of the decision-making process with regard to the type and design of a static progressive splint. Using a light to moderate force. several other issues also come to the forefront. Certainly. As a general guideline. “Readily available range” means the range of motion that is easily achieved without dramatically increasing joint torque. Some patients may fail to tolerate certain materials and will require alternative materials. The clinician must evaluate each patient’s ability to tolerate the design and complexity of a splint. edema and temperature assessment. the clinician must determine whether he or she has the skills and the time to make a given splint. padding. or liners.) The patient without the cognitive skills or kinesthetic feedback to guide the splint tension presents a special challenge. The treatment team must also match the weight and bulk of a splint to the patient’s body and function. the patient’s “gadget tolerance” comes into play. others are undone by them. this point occurs just before the line begins to curve sharply upward. Compliance failure will significantly compromise ultimate outcome. Right. and only the clinician managing the individual patient can determine the optimal joint position. and an understanding of the type and duration of the pathology to guide the decision. These are: s s s s s s s s Ease of splint construction Cost Weight Bulk Stability on the arm Material tolerance “Gadget tolerance” Compliance SPLINT DESIGN The following pages present a wide range of static progressive splint designs that address PROM problems at each joint of the upper extremity. Every case is different.

and static progressive extension to hold the PIP joint at maximum tolerable end range (Figure 7. With two separate static progressive components. when the patient lacked MCP joint flexion and IP joint extension. left). Another exception is the final-flexion splint. Bell-Krotoski describes the combination of PIP joint serial casting with a mobilizing splint to increase MCP joint flexion to reverse the joint contractures often seen with combined median and ulnar nerve lesions. the size of the joint and the ability of the splint to distribute pressure along the skin surface. 172 JOURNAL OF HAND THERAPY Combining Static Progressive Splinting with Other Splinting Approaches Clinicians sometimes confront the challenge of a joint with limited PROM paired with the need for periarticular structures to undergo AROM. the splint acting on well-established contractures with fully healed tissue will be able to generate more torque without tissue damage. In addition. the results will justify the effort. The unique design of this splint distributes the torque of one static progressive component to position each joint at maximum tolerable end range.* Clinicians may also instruct their patients to alternate between elastic and static progressive traction during the day. the splint shown in Figure 9 puts a static finger extension platform together with static progressive MP joint extension. each splinted joint will require its own individual static progressive component. For this reason many of the splints pictured in this article feature rigid loops. is usually the “weak link” in the system. . Although this may seem a difficult request. In a like fashion. the patient may have PIP flexion contracture. which allows active motion when the patient pulls against the traction (Figure 7. The patient–clinician team can determine the duration of this nighttime regimen.39 The splint shown in Figure 8 illustrates the use. each joint will receive the correct amount of torque and can progress at to its own unique rate. With the lighter force. A splint design may also combine the serial static and static progressive or static and static progressive approaches. elastic traction for extension of the PIP joint. the more force is required to achieve the PROM goals. In such a case. the appropriate amount of torque will vary with the stage of healing. in one splint. larger joints require more torque than smaller ones. When AROM is essential and PROM is limited. The clinician must work to improve IP PROM in extension while focusing on active motion to allow free excursion of the tendon. An alternative design for the same problem. of serial casts for PIP joint extension with static progressive MP joint extension for a patient with extrinsic flexor tightness. An exception to this “one-joint. Colorado) to traction the wrist into *A clinician may instruct a post-tenolysis patient to set an alarm and get up once or twice a night to remove the finger sling of a splint set in static progressive mode.37 It is critical to understand that when mobilizing splints are used. To provide the optimum amount of torque. Figure 11 shows a static splint base positioning the thumb metacarpal in maximum flexion while the MP joint undergoes static progressive traction to increase passive flexion. With improved pressure distribution. and that the PROM of each progresses at a different rate. a clinician should consider combining static and elastic traction approaches (Figure 7).38 It appears that the longer the joint contracture has existed. the MCP and interphalangeal (IP) joints of the thumb— such as with extrinsic extensor tightness. the skin. because these distribute pressure better. The problems clinicians often face after flexor tenolysis exemplify this situation. The splint shown in Figure 12 makes use of a MERiT component (UE TECH. Clinicians may find that their patients can wear this splint in elastic traction mode during the day and in static progressive mode at night during sleep. the less stiff joint will not receive the correct amount of tension and may not benefit from the splint. and actively move the finger. The splint shown in Figure 7 illustrates how the patient can benefit from both approaches in one splint—specifically. the therapist designing an elastic traction splint uses a separate rubber band or spring for each joint. This guideline is based on the limitations of skin under a conventionally sized finger sling made of relatively soft material and not on the fragility of the target tissue. As described above. clinicians have cited a certain number of grams as the maximum torque to mobilize a joint. the tension the component generates will need to be lighter. Thus. The splint shown in Figure 10 effectively combined static IP extension with static progressive flexion after metacarpal fracture.Considering the Amount of Torque with Static Progressive Splinting For many years. scar becomes denser as it matures and seems to require more cumulative mechanical force to alter its structure. not the contracted tissue or scar. Assessment of two such stiff joints will almost always reveal that they do not have the same PROM in flexion. Edwards. The example of two adjacent MCP joints with extension contractures will help illustrate the reasons for this. when the tendon does not have the opportunity to move. right). To avoid overstressing the stiffer joint. however. one-component” rule is when the tissue restricting motion is not specific to the joint structure but rather the extrinsic soft tissue affecting a joint series—for example. The clinician can use multiple types of static progressive traction in one splint. that the amount of torque required to position each joint at end range differs.

The use of serial casts for proximal interphalangeal extension with static progressive metacarpophalangeal extension in a single splint. (Photograph © Karen Schultz-Johnson. This splint shows a MERiT component that tractions the wrist into ulnar deviation while hook-and-loop tape exerts pull on composite thumb metacarpophalangeal/interphalangeal joint flexion.) FIGURE 9. An alternative design for extrinsic flexor tightness. The indication for this splint was limited thumb flexion following deQuervain’s release when the extrinsic extensors of the thumb became adherent. Combining static splints with static progressive splints. This splint combines a serial cast for distal interphalangeal extension with static progressive proximal interphalangeal flexion.) FIGURE 11 (above right). Static progressive extension holds the PIP joint at maximum tolerable end range. Right. (Photograph © Karen Schultz-Johnson. when the patient lacked MCP joint flexion and IP joint extension. FIGURE 8. (Photograph © Karen Schultz-Johnson.) Middle right. This splint shows how the patient can receive the benefits of both elastic traction and static progressive splinting approaches in one splint with interchangeable force components. for a patient with extrinsic flexor tightness. (Photograph © Karen Schultz-Johnson. this splint combines a static finger extension platform with static progressive metacarpophalangeal extension. This design effectively combines a static interphalangeal (IP) joint extension splint with static progressive metacarpophalangeal (MCP) joint flexion following metacarpal fracture.FIGURE 7. (Photograph © Karen Schultz-Johnson. Left. (Photograph © Karen Schultz-Johnson. Elastic traction for extension of the proximal interphalangeal (PIP) joint allows active motion when the patient pulls against the traction.) April–June 2002 173 . A static splint base positions the thumb metacarpal joint in maximum flexion while the metacarpophalangeal joint undergoes static progressive traction to increase passive flexion.) FIGURE 10 (near right and middle right).) FIGURE 12 (left). Near right.

Splints can work to improve either flexion or extension of a single distal interphalangeal (DIP). when faced with PROM limitations in a patient. static progressive splints will also resolve soft end-feel contractures with great speed. PIP. In another example. Static progressive splint to increase proximal interphalangeal joint extension. the clinician has many options and splinting combinations available to treat a patient’s PROM problems. (Photograph courtesy of the Rehabilitation Division of Smith & Nephew. while specific diagnoses or patient characteristics may dictate specific approaches to splinting joints with PROM limitations. the span of the thumb web. The combined benefits of achieving precise torque and joint position with patient-controlled tension result in high splint tolerance. serial static) splinting approaches will successfully improve many hard end-feel joints. (Photograph © Karen Schultz-Johnson. A static progressive force generator has a wide range of load applications. and splint mechanics to support the advantages of this splinting approach. Static progressive splint to increase metacarpophalangeal joint flexion. Maximizing total end-range time will make it possible to achieve treatment goals. and patient satisfaction. and shoulder abduction and external rotation (Figure 23). The hook-and-loop tape kept the splint lighter and was adequate for the patient to create the gradations of force required to lengthen the adhesions. when the thumb extrinsic extensors became adherent. her therapist designed a splint that combined finger DIP/PIP joint flexion. Thus. The static progressive approach creates a highly effective means to deliver an adequate dose of total end-range time.e.. The principle “always use elastic splinting with soft end-feel joints and static progressive splinting with hard end-feel joints” is incorrect. Using creativity and expertise. The classification of static progressive splinting as only a high-force generator is a misconception.FIGURE 13 (left). any splintable joint limitation will respond to static progressive splinting. find that static progressive splinting is the technique of choice. from extremely low to extremely high. Many clinicians. the benefits of patient-controlled tension. 174 JOURNAL OF HAND THERAPY . This article reviews the literature. static progressive. Unfortunately. (Photograph courtesy of Pam Schindeler-Grasse and Pattie Paynter. or MCP joint (Figures 13 to 16) or a combination of the finger joints (Figure 17). MCP joint extension. FIGURE 16. the splint failed the “gadget tolerance” test. wrist extension. when a patient complained that she had too many splints to wear for her multiple PROM limitations after a serious motor vehicle accident. The indication for this splint was limited thumb flexion in combination with wrist ulnar deviation following deQuervain’s release. Static progressive splint to increase distal interphalangeal joint flexion.). elbow flexion (Figure 22) or extension. Some clever splint designs facilitate motion in alternating directions. FIGURE 15.) FIGURE 14 (right). Inc. Static progressive splint to increase proximal interphalangeal joint flexion. While it is true that only static (i. As described above. and the patient declined to wear it. Common goals of splints include increasing wrist flexion (Figure 20) or extension (Figure 21). (Photograph © Karen SchultzJohnson. and forearm rotation. Any tissue that can tolerate elastic traction can tolerate static progressive traction. a single splint may be designed to increase flexion at one joint and extension at another (see Figure 10). SUMMARY Clinical experience and research have supported the efficacy of static progressive splinting to improve PROM quickly and efficiently. such as flexion and extension (Figure 18) or pronation and supination (Figure 19).) ulnar deviation while hook-and-loop tape exerts pull on composite thumb MCP/IP joint flexion. compliance.) The clinician can use a static progressive approach with any joint in the upper extremity.

This design.FIGURE 17. Some clever splint designs facilitate motion in alternating directions.) Middle. (Photograph © UE TECH. called a final flexion splint. (Photograph courtesy of AliMed.) April–June 2002 175 . Static progressive splints that simultaneously flex more than one finger joint at a time. such as flexion (above) and extension (right). Left. Inc. (Photograph © Karen Schultz-Johnson. This splint uses a unique design with hook-and-loop tape. Splint to increase proximal and distal interphalangeal joint flexion.) FIGURE 18. here illustrated at the elbow. (Photograph © UE TECH.) Right. uses a MERiT component.

here illustrated at the forearm for supination (left) and pronation (right). Another splint design that facilitates motion in alternating directions. (Photograph © UE TECH. Static progressive splint to increase wrist extension using a progressive hinge. Static progressive splint to increase wrist flexion. Left.) 176 JOURNAL OF HAND THERAPY . (Artwork © UE TECH. (Photograph © UE TECH.FIGURE 19.) FIGURE 20.) FIGURE 21.) Right. (Photograph courtesy of the Rehabilitation Division of Smith & Nephew. Static progressive splint to increase wrist extension using a DigiTECH outrigger. Inc.

) Right. (Photograph reprinted. from Bash DS. J Hand Ther. Static progressive splint to increase elbow flexion. Inc. Static progressive splint to increase shoulder abduction and external rotation. (Photograph courtesy of Joint Active Systems. An alternative to turnbuckle splinting for elbow flexion.) April–June 2002 177 .) FIGURE 23. Static progressive hinge splint to increase elbow flexion (Photograph courtesy of Alimed. Above.FIGURE 22. 2000. Spur ME.13[3]:237–40. with permission. Inc.

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Orthotics in Rehabilitation. Static progressive splint designs run the gamut of a splint maker’s imagination. Bell-Krotoski JA. In: Skirven T. 178 JOURNAL OF HAND THERAPY . Splinting for the forearm contracture. Introduction to Splinting: A Clinical-reasoning and Problem-solving Approach. 25. A clinician can use static progressive force generators in place of elastic components in any existing splint design. Splinting the stiff wrist. 26. 2nd ed. Louis. J Hand Surg. 12. 2nd ed. Introduction to splinting. In: Morrey BF (ed). 14. 1987:453–4. In: Hunter JM. Fess EE. 39. Ables BA.196:15–24.: Mosby. In: Skirven T.20:93–102.: Mosby. J Hand Ther. 1987:449–66. 2001. Woo SL-Y. Atlas of the Hand Clinics.: Bailliere Tindall. Lohman H (eds). Bell-Krotoski JA. 2001. Mobilization splints.64:330–3. An alternative to turnbuckle splinting for elbow flexion. Splinting for thumb contractures.: Mosby.62A: 1232–51. 32. Coppard BM. Brand PW. St. Splinting to increase PROM [question-and-answer period following lecture]. Flatt AE.

Milwaukee.. CHT Department of Orthopaedic Surgery Medical College of Wisconsin Roger Daley. Each of these treatment modalities lacks definitive evidence to support or refute its use in the treatment of lateral epicondylitis. PhD Department of Orthopaedic Surgery Medical College of Wisconsin Lateral epicondylitis is a common problem. corticosteroid injections.15:179–184. Very little published evidence supports an actual effect on the forces at the ECRB origin.2 Application of this orthotic to the forearm has been hypothesized to decrease the tension of the extensor carpi radialis brevis (ECRB) origin on the lateral epicondyle with activity. While further clinical evaluation is necessary to determine the most appropriate clinical indications for use of a forearm support band. Meyer. Wisconsin ABSTRACT: The forearm support band is hypothesized to reduce force. Medical College of Wisconsin. stating that the bands were applied “snugly without pinching the skin. MD Department of Orthopaedic Surgery Medical College of Wisconsin Milwaukee. Meyer. treatment success is unpredictable.6 This study did not control for the force at which the two bands were applied. For clinical correlation. statistically significant reduction was shown only with use of the Aircast band. performed by Labelle et al. Jansen et al. WI 53226. Inc. Since tendinosis of the ECRB origin at the lateral epicondyle is thought to be the pathologic lesion of tennis elbow.g. Standard tennis elbow braces. and wrist extension braces have been proposed as continued conservative treatment of lateral epicondylitis refractory to initial therapeutics. The authors describe a cadaveric study in which forces at the ECRB origin were measured while various pressures were applied to the forearm support band and the ECRB tendon was loaded distally.3–6 An attempted meta-analysis of the literature on lateral epicondylitis treatment methods.edu>. In more difficult cases that are not responsive to these modalities. MD. its prevalence ranging from 1% to 3% of the general population. Aircast braces. The results reveal an increased effect with increased band pressure and a decreased relative effect with increased force applied distally. MD Department of Orthopaedic Surgery Medical College of Wisconsin Barb Haines. generally with a high clinical success rate.The Effect of the Forearm Support Band on Forces at the Origin of the Extensor Carpi Radialis Brevis: A Cadaveric Study and Review of Literature Nicholas J. OTR. specialized tennis elbow braces (e. 2002. This analysis concluded that the most important factor in treatment of lateral epicondylitis is the natural evolution of the disease and the placebo effect of its treatment. at the extensor carpi radialis brevis (ECRB) origin. and thus inflammation.7 found insufficient evidence to support any particular treatment.” thus rendering the results difficult to interpret. 9200 W Wisconsin Avenue. J HAND THER. the forearm support band (also known as the “tennis elbow band” or “counterforce brace”) has been widely incorporated into the treatment regimens of many patients with lateral epicondylitis. symptomatic relief would intuitively be expected if tension were reduced at the origin of the ECRB.1 Since its introduction in 1971. application pressure was also measured in nine patients using a counterforce brace. MD. however.. William Pennington. however. email: <nmeyer@mcw. Summit.5 reported an additional electromyographic study evaluating the effect of various wrist orthoses on the wrist April–June 2002 179 . Aircast. Conservative therapy usually focuses on stretching and strengthening exercises with concomitant activity modifications. Department of Orthopaedic Surgery. these results suggest that the forearm support band may be most effective when applied at a force of 40 to 50 mmHg and used during light-duty activities. increasing to 19% of men in the fifth decade of life.. An electromyographic study of the forearm extensors with the application of both standard and Aircast tennis elbow bands showed reduced electromyographic activity with both bands. Correspondence and reprint requests to Nicholas J. New Jersey).

extensor muscles. the weight re-applied. but not for the 10-lb trial.and 15-lb trials. Another study showed an increase in wrist extensor strength during rapid repetition activities with application of the brace in asymptomatic persons. 150 mmHg. The percentage force reduction with application of the forearm cuff reveals a trend as cuff pressure increases and as additional weight is applied distally. This was statistically significant for the 5. with a tennis elbow brace. No electromyographic difference was noted with gripping activities. the purpose of our study was to develop a cadaveric model using a forearm support band. the cuff was inflated to 50 mmHg. 10. or 15 lb). . and 200 mmHg and loads of 5. Experimental set-up. and the forearm support band cuff pressure regulated. The ECRB tendon was isolated distal to the intersection of the extensor pollicis brevis and abductor pollicis longus through a 3-cm longitudinal incision. 150. A #5 suture was placed 180 JOURNAL OF HAND THERAPY FIGURE 2. with the goal of measuring the percentage force reduction at the ECRB origin with application of a forearm support band at various pressures. To accurately correlate this cadaveric study with a clinical scenario. but this was not studied. The weight was removed. 100. that the brace may be effective for extended periods.Vertical hatching indicates 50 mmHg pressure. The clinical effect of the tennis elbow band has also been controversial.5 Regardless. force as a percentage of control (no cuff pressure) was measured and recorded. The recorded data consisted of voltage as measured by the force transducer attached to the ECRB origin. and 200 mmHg cuff pressure. white. 150. and a placebo brace showed no change in acute pain or strength. using Steinman pins through the distal ulna and proximal humerus. 50. The ECRB origin was isolated through a 5-cm incision over the lateral epicondyle. and the force again measured at the ECRB origin. 100. For the first trial. Standard deviation was calculated in standard fashion. Absolute force at the ECRB origin was not calculated. 5 lb was applied to the tendon distally and the force at the ECRB origin recorded. cuff pressure. This sequence was repeated through five cycles.8 This study acknowledged. 5. and 90° elbow flexion. nine patients currently being treated for lateral epicondylitis were studied. and 15 lb applied as well as with 0. Force reduction trends related to cuff pressure and force applied distally. 10. through and around the tendon at this point and passed through a low-friction pulley for application of weight. To determine the force at which an average patient applies the tennis elbow brace. 100 mmHg. The force transducer was initially calibrated with no weight applied to the tendon and the cuff deflated. the origin monitored by a strain gauge. This model would allow us to determine whether an actual mechanical effect exists. An attempt was made to duplicate these pressures in the cadaveric model. A blood pressure cuff measuring 5-cm in width was applied to the forearm and centered 5-cm distal to the lateral epicondyle (Figure 1). A Student t test was used to calculate p values for the comparison with force reductions at 50 mmHg cuff pressure. Schematic of cadaver model showing the ECRB tendon loaded by a fixed weight distally (0. the pressure at which patients routinely apply the forearm support band was also measured. 5. inserted into the pocket of an Aircast forearm splint. 200 mmHg. no studies have shown that electromyographic changes translate to clinical improvement in patients with lateral epicondylitis. A pediatric blood pressure cuff measuring approximately 5 cm in width was insufflated with a small amount of air. black. 10. A study measuring pain-free grip strength and pain scores in patients with lateral epicondylitis without brace treatment. however. and weight applied to the distal tendon.9 In light of this review of the literature. The voltage was recorded for all trials with 0. however. and applied by the patient in normal fashion to the same level of tightness that the patient normally METHODS Five cadaver arms transected at the mid-humerus were mounted to a support frame in neutral supination/pronation. horizontal hatching.FIGURE 1. A #5 suture was passed deep to and through the ECRB tendon origin and was subsequently connected to a custom force transducer. Similarly. This study demonstrated electromyographic changes in the wrist extensors exclusively during lifting activities. and 15 lb being applied sequentially to the tendon distally. the entire sequence and five trials were repeated with cuff pressures of 50. neutral wrist extension/flexion.

10. our study does support Nirschl’s April–June 2002 181 Force Reduction (%) SD SE p Value* NOTE: Data show the percentage force reduction achieved with 50. Thus. and the resulting cuff pressure and grip force were recorded.06 13 24 32 38 7 11 14 22 1. The average force at which the cuff was applied was 45 ± 25 mmHg (range. 100. the band decreases the magnitude of muscle contraction and thereby reduces tension at the musculotendinous unit proximal to the band. not be excluded from statistical analysis on the basis of this deviation (at the 10-lb trial) alone. Statistically significant differences were noted in all trials with 5 and 15 lb applied to the ECRB distally. More important. Review of the raw data revealed that one specimen in the 10-lb trial had statistically significant deviation from the other specimens in its group.13 Nirschl14 agrees that tension at the musculotendinous unit proximal to the band is reduced.6 dispersing stress away from the pathologic area by “broadening” the area of the common extensor muscle origin. This trial was discarded from statistical analysis. thereby decreasing the fulcrum effect that occurs at the attachment to the lateral epicondyle.5 5.04 FIGURE 3.8 – 0. This pressure rose to 86 ± 39 mmHg (range. This was applied and re-applied three times. the patient performed maximal grip.6. 10. As cuff pressure was increased. Since our model is a purely passive system (with no active muscle activity).8 – 0. we cannot comment on any electromyographic effect or reduction in muscle activity. Table 1 shows the percentage change in force compared with control values (no cuff pressure) for each amount of pressure and force applied distal to the cuff.5 – 0.8 4. *The p value for each series is derived from comparison with findings at 50 mmHg.01 10 14 19 28 8 11 11 19 2.and 15-lb trials. This pressure rose to 86 ± 39 mmHg during maximal grip and was independent of grip force.05 0. and standard deviation? .or 15-lb trial. and the average application pressure and grip force were recorded for each patient. RESULTS Four of the cadaver arms were used for experimentation.8 2. Standard deviation and p values derived from comparison with findings at 50 mmHg pressure are also included. and 15 lb. the percentage effect was less with higher loads). 150.02 0. 21–101 mmHg).0 2. however. Cuff pressure during rest and grip.11 Other authors propose additional benefits of minimizing exaggerated tendon movement.01 0. Among the nine patients experienced in the use of the tennis elbow band.8 2.8 2. the average force at which the cuff was applied was 45 ± 25 mmHg (range.applies the counterforce brace. DISCUSSION Many authors agree on a common theoretic mechanism of action for the counterforce forearm band.12 decreasing the force contribution by muscle fibers proximal to the band. Black indicates resting pressure.5. the percentage force reduction decreased (that is. these trials did show a consistent and logical trend. with increasing loads to the tendon distally. Presumably by inhibiting muscle expansion. This pressure was recorded. In addition. One arm showed abnormal adhesions of the tendon distally and produced inconsistent results.02 0. white. the trend appeared to fit as expected between the 5. and 200 mmHg pressure applied to the forearm cuff with applied weights (force) of 5.21 0. as related to grip force. but this was not found in the 5. 42– 150 mmHg) during maximal grip and was independent of grip force produced (Figure 3).8 3. but suggests that the brace acts by supplying the extensor muscle mass with a second origin distal to the radial head. the specimen could TABLE 1. Percentage Force Reduction Related to Cuff Pressure and Force Applied Distally Cuff Pressure (mmHg) At 5-lb applied force: 50 100 150 200 At 10-lb applied force: 50 100 150 200 At 15-lb applied force: 50 100 150 200 6 13 17 25 5 7 8 11 1. Clinical measurement of forearm band pressure in nine patients familiar with the use of the band showed high variability in resting pressure of application. However.3 1. However.0 2. 21–101 mmHg). the achievement of statistical significance for all trials is difficult. A trend was observed for the trials and is graphically represented in Figure 2. but not with 10 lb applied. gripping pressure. or directing potential stress overloads to healthy tissues and possibly the band itself. the percentage force reduction also increased. Given the limited number of specimens used in the trials.01 0.

muscular strengthening exercises. such as when there is no pain with daily activity. . whether reduced electromyographic activity correlates to clinical improvement remains to be seen. The armband has been shown to both increase and decrease wrist extensor strength in several contradictory studies. . but this was not statistically significant. A shortcoming of this series is the absence of a comparison control group with findings that would definitively support use of the band. Interestingly. but they suggest that patients be weaned from its use over the remainder of the rehabilitative program. Regarding the clinical effect of the forearm support band. Most authors do not address this issue sufficiently in their discussions and studies and instead simply report applying the brace so that it feels “comfortable. . Topical diclofenac has been shown to have a short-term effect on elbow pain related to lateral epicondylitis. use of the backhand stroke). but its result and long-term effects lack consistency.g. Groppel and Nirschl12 performed a biomechanical analysis of banded and unbanded tennis players using three-dimensional cinematography and electromyographic techniques in normal subjects.” 2. the forearm band may be used in conjunction with local anesthetic and steroid injections. . Froimson recommends using the band during activity for at least 1 year after pain relief is achieved. . secure it . as were 10 of 12 patients treated with the forearm band alone. Others have suggested that counterforce bracing be implemented when symptoms have resolved. Priest15 found that the backhand stroke produced lateral epicondylar symptoms twice as frequently as the serve in patients with tennis elbow. numerous other nonsurgical treatment modalities exist for lateral epicondylitis. Froimson2 first introduced the concept of a formal forearm support band to clinical use. they describe the tension at which the forearm band has been applied in the following ways: “. Other authors also recommend use of the forearm band in the acute phase of treatment. The standard band also caused a reduction in electromyographic activity. In acute cases.13 proposed that the effects of the armband in patients who have pathology may differ from those in patients without pathology. compared with control values and findings for the standard band. and not a replacement for. which may outweigh the benefits derived from their use. to avoid recurrence. compared with control values in normal subjects. during the strengthening exercise program.g. Snyder-Mackler and Epler 6 studied the effects of both standard and Aircast bands on electromyographic activity of the extensor digitorum communis (EDC) and ECRB proximal to the band. These findings suggest that tennis elbow is aggravated by both passive stretch at the ECRB origin (e. Froimson2 directs patients to use the band only during painful activities and to remove it during periods of inactivity. and Nirschl14 reported that the backhand initiates tennis elbow in 90% of affected tennis players..7 Although our study suggests a mechanical benefit. the armband may decrease strength by mechanically limiting maximal contraction. no referred pain.11 These authors also suggest limiting forearm band use to the early. “. They found that. Wadsworth et al. as evidenced by the reduction of force in this model.theory that the origin of the ECRB is broadened and transported distal to the ECRB origin. Finally.10 Counterforce bracing is felt to be a supplement to. In those with pathology. extremes of wrist flexion with serving) and active firing of the extensors (e.” For example. These designs range from a simple adjustable strap to a band with a small balloon (Aircast. Adding to the problem of contradictory information about the mechanism of forearm support bands. Once more. Priest15 recommends that moderately symptomatic patients wear the band during any activity and that highly symptomatic patients wear it at all times except at night. less acute. 23 of 28 patients treated with the forearm band plus steroid injection were relieved of pain. the literature again lacks definitive results. In his series of 182 JOURNAL OF HAND THERAPY 40 patients. Banding resulted in lower electromyographic activity of the extensor carpi ulnaris and extensor carpi radialis during serve and backhand strokes than in the unbanded controls. New Jersey) that concentrates pressure over the extensor wad. there are several designs of these bands on the market. the decrease in electromyographic activity due to the bands was more marked in the EDC than in the ECRB. . the review of literature has shown that recommendations regarding the timing and duration of application vary.. In those without pathology. but these carry the risk of side effects ranging from gastrointestinal upset and ulceration to renal damage. the Aircast band caused a significant reduction in electromyographic activity of the ECRB and EDC. so that a subject felt comfortable when relaxed but noticed tension when contracting his/her forearm . tension is adjusted to a comfortable degree with the muscles relaxed so that maximum contraction of the wrist and finger flexors and extensors is inhibited by the band . and full range of motion. Along with the forearm support band.16 Oral diclofenac and other nonsteroidal anti-inflammatory drugs have been reported to improve pain. Perhaps the most difficult measure to quantify is the tension at which the forearm band is applied. Electromyographic activity and muscle strength using the forearm support band have been tested in subjects with and without lateral epicondyle pathology. or less painful cases in which splinting or corticosteroid injection is not thought to be necessary. . . it may increase strength by lessening pain and thus permitting a more forceful contraction.

. Patients with lateral epicondylitis who have been using the forearm support band apply the brace to highly variable pressures (from 20 to 100 mmHg). Circles connected by a solid line indicate pressure difference. Second. . the patient developed deep forearm pain associated with weakness of the hand. the rise in pressure FIGURE 4. The data obtained from the clinical trials show a peak pressure effect at 40 to 50 mmHg resting pressure. minimizing edema. in higherdemand activities. The largest excursion in pressure was observed when the band was applied at 40 to 50 mmHg. Normal function returned 48 hours after the forearm band was discontinued. suggesting that the band does. In our series of nine patients. In this range. . In our model. In short.6. the pressure rises maximally during grip.” After 1 week of wearing the forearm band. since it decreases the force at the ECRB origin dependent on pressure of application (increased effect with increased pressure) and load applied to the ECRB tendon distally (decreased effect with increased loads). and true effect on symptoms related to lateral epicondylitis. “. . . the findings appear logical and applicable. and is the subject of.2 Enzenauer and Nordstrom17 reported a case of transient anterior interosseous nerve syndrome following treatment with a forearm band. in vivo testing). In this case. further investigation. since they are not taught to apply the band to a goal tension. .”15. the forearm support band in this model decreases the forces at the ECRB origin. independent of grip strength.muscles . a purely passive model. . In fact. cadaveric vs. One author recommends applying and adjusting the band with the forearm pronated.10 while most recommend application with the forearm in neutral position. . Pressure difference from rest to grip. April–June 2002 183 s s s s . it is almost impossible to apply the band to a consistent pressure. The positioning of the forearm band is. much discrepancy and little objective data exist regarding the optimal pressure of application. . Study of clinical efficacy is also required. at least in part. causing a rise to approximately 100 to 140 mmHg (see Figure 3). . The force reduction caused by the forearm support band is proportional to the pressure of application. wrapped snugly about the bulkiest portion of the upper forearm. period of application. Regarding the clinical use of the forearm support band. This suggests that a successful clinical effect may be more likely in lower-demand. the pressure ranged from 21 to 101 mmHg at rest and rose during gripping to 42 to 150 mmHg. and there is no regulator on the band itself. the patient had applied the band firmly and “overzealously. This effect may be analogous to the disease process itself: If the forces experienced at the ECRB origin are “overloading” the area by 10% to 20%.13 Potential side effects of use of the forearm band include venous congestion and edema. not adequately addressed in the literature. address several of the vague and ambiguous points mentioned previously. and “. Further study is necessary to determine an ideal pressure of application. While this study has many limitations inherent in cadaveric models (e. While this requires. it would suggest that an application pressure of 40 to 50 mmHg would offer the optimal mechanical benefit (Figure 4). create a second “origin” for the ECRB distal to the lateral epicondyle. Most agree that the band should be placed approximately 2 cm distal to the lateral epicondyle. repetitive activities but that use of the band has an effect. However. pressure of application. This resting pressure would be below diastolic blood pressure. The force reduction caused by the forearm support band in inversely proportional to the load applied to the ECRB tendon distally. . further study is required to determine the optimal period of application. and position of application to attain the desired effect.”13. if applied in the clinical setting. CONCLUSIONS s The forearm support band appears to provide a mechanical inhibition of force transference to the ECRB origin during activities that load the ECRB tendon distally. similarly. First.g.. The results of our study. the band reduces a larger percentage of the force in lower-force activities (13%–38% reduction) than in higher-force activities (6%–25% reduction) (see Table 1). however. patients do not consistently apply the band to a uniform tension. the support band may diminish the forces enough to allow the tissues to recover. no true clinical effect measured. during activity would create a 24% to 32% force reduction during low-demand activities. This suggests an optimal pressure of application in the 40 to 50 mmHg range. albeit diminishing.”6 Obviously. snugly without pinching the skin . this model suggests a mechanical basis for the forearm support band. squares connected by a staggered line indicate grip strength.

11:192–7. 10. Arch Phys Med Rehabil. Br J Gen Pract. Allander J. Prevalence incidence and remission rates of some common rheumatic diseases and syndromes.14:788–90. Lateral tennis elbow: “Is there any science out there?” J Shoulder Elbow Surg.8(5):481–91. 6. Priest JD. Gellman H. 1997. Hasson SM.Acknowledgments The authors thank Linda McGrady and the staff of the Biomechanics Lab at the Medical College of Wisconsin for their assistance in obtaining and analyzing the raw data. DH. Epler M. 13. Mangine R.74(B):646–51. Overend TJ. Snyder-Mackler L. 1989.3:145–53. Boyer MI.15(9):1089–96. Steadward R. Orthop Clin North Am. 1992. 1998. MacDermid J. J Orthop Sports Phys Ther. Anterior interosseous nerve syndrome associated with forearm band treatment of lateral epicondylitis. Bouter LM. Effect of the counterforce armband on wrist extension and grip strength and pain in subjects with tennis elbow. 1971. 1989. J Bone Joint Surg. The effectiveness of topical diclofenac for lateral epicondylitis. Newman N. Olson SL. Guibert R. REFERENCES 1. 1974. Froimson AI. Labelle H. Adshead R. 15. Lack of scientific evidence for the treatment of lateral epi- 11. 1984. Tennis elbow (lateral epicondylitis). Thompson CG.23:75–82. Groppel JL. 16.79:832–7. Scand J Rheumatol. 14.4: 787–800. Orthopedics.14:195–200. 1976. Am J Sports Med.46:209–16. Rehabilitative techniques in the treatment of medial and lateral epicondylitis. 184 JOURNAL OF HAND THERAPY . Clin J Sports Med. Burns LT. 1998. 17. 9. Tennis elbow. Orthopedics. Rivard CH. 8. Treatment of tennis elbow with forearm support band. Hastings H. Nirschl RP. 2. 7. Krull JD.10:283–9. Catlin PA. Wadsworth CT. Joncas J.8(2):78–81. J Bone Joint Surg. The effect of use of a wrist orthosis during functional activities on surface electromyography of the wrist extensors in normal subjects. The effect of a forearm strap on wrist extensor strength. 1999.53(A):183–4. DeMaio M. 1986. Galloway M. Corticosteroid injections for lateral epicondylitis: a systematic overview. Gregg R. Effect of standard and Aircast tennis elbow bands on integrated electromyography of forearm extensor musculature proximal to the bands. condylitis of the elbow: an attempted meta-analysis. 4. Minn Med. Enzenauer RJ. 1991. Nielsen. Am J Sports Med.17:278–81. Orthop Clin North Am.59:367–71. Strength and pain measures associated with lateral epicondylitis bracing. Nordstrom DM. 1996. Kramer JF. 12. 3. A mechanical and electromyographical analysis of the effects of various joint counterforce braces on the tennis player. Jansen CW. J Hand Ther. 5. Stonecipher DR. Nirschl RP. Tennis elbow: the syndrome and a study of average players.6(3): 184–9. Wuori JL. Fallaha M. J Orthop Sports Phys Ther. 1992. 1992. Assendelft WJ. Hay EM. Burham R. Healy P. 1973.

then extension in preparation for grasp is limited. but their sample size was too small to generalize the results.. depending on patients’ preferences and comfort. Department of Rehabilitation Sciences.11 Most occupational therapists are reluctant to prescribe corrective or dynamic splints for patients with rheumatoid arthritis. PhD Chair and Professor. MPhil.0005) but also in grip strength (p = 0. After a 6-week baseline measurement of hand function—including measurement of grip strength and range of motion and administration of the Jebsen Hand Function Test—the patients were randomly placed into two groups. or Correspondence and reprint requests to: Cecilia W. The Hong Kong Polytechnic University. The incidence of deformities at the interphalangeal joints and the wrist ranges from 63% to 85%. MSc. and those in the second group were given static (belly gutter) splints. Leung Kim Hung. Lack of PIP extension can also hinder other functional activities. shortening of the volar plate. J HAND THER.6–9 but very few studies have reported the clinical value of these resting splints in the prevention or correction of finger deformities in patients with rheumatoid arthritis.13 Fairleigh and Hacking10 reported the clinical application of dynamic splints in patients who underwent arthroplasty. MBBS.4 Provision of static resting hand splints has been found to be effective in the early stage of disease. If the PIP joint cannot fully extend.3 One of the most common hand deformities is flexion contracture of the proximal interphalangeal (PIP) joint. Twenty-four patients with rheumatoid arthritis and finger flexion contracture participated in the study. PhD Associate Professor. The PIP joint and its motion are among the most important factors in hand function.12.001) and hand function (p < 0.edu.5.10. flexor tendons. with its proximal lateral check-rein extensors. and of the collateral ligaments may develop. T.Hong Kong. 2002. sheaths may be associated components of flexion contracture. Associate Professor. Patients in the first group were given dynamic (Capener) splints. Department of Rehabilitation Sciences The Hong Kong Polytechnic University Hong Kong ABSTRACT: This paper reports a matched-pair experimental study to investigate the effect of corrective splinting on flexion contracture of rheumatoid fingers. to rest the inflamed joint and provide pain relief. but they did have better flexion than patients with static splints. causing flexion deformity at the PIP joint. P. Results indicated significant improvement in both groups. Li18 conducted a April–June 2002 185 . for fear that the stretching force might create further damage to the joints and thus cause pain and discomfort. Previous studies reported that the uses of elastic splints and traction have been proved to be effective in preventing and correcting finger deformities. joint destruction. Li-Tsang. OT(C). and deformity ensue. FRCS Professor. Both types of splints can be recommended for flexion contracture of rheumatoid fingers.P.The Effect of Corrective Splinting on Flexion Contracture of Rheumatoid Fingers Cecilia W.5 As a result of chronic inflammation.4. not only in the correction of the finger flexion contracture (p < 0.4 The PIP joint is the epicenter of the hand and is responsible for 85% of total encompassment when an object is grasped. instability. Tendon adhesions at the palmar skin.1 After several years of persistent synovitis in chronic arthritis. The hand function and activities of daily living of these patients with rheumatoid arthritis showed deterioration in a 5-year follow-up study. Patients with dynamic finger extension splints did not differ from those with static splints in extension gains. e-mail: <rscecili@polyu. PhD.11 also reported the application of dynamic splints in the early management of boutonniere deformity. Li-Tsang.2 The disease often begins in the hand.15:185–191. Hung Hom. and large objects cannot be gripped.4. Department of Orthopaedics and Traumatology The Chinese University of Hong Kong Hong Kong Arthur F. Kln.hk>. Palchik et al. and upper extremity function can be seriously impaired with progression of the disease.14–16 Wu17 found that static inelastic corrective splints for flexion contracture of the PIP joint might be more effective than dynamic or elastic splints with rubber band or coil-spring elements. Rehabilitation Engineering Centre The Hong Kong Polytechnic University Rheumatoid arthritis (RA) is the most common chronic inflammatory disease of joints characterized by remissions and exacerbation. Mak.0005). Hand function was re-assessed 6 weeks after the splinting program.

group 2 patients after 6 weeks of splint intervention. The third hypothesis was that the type of splint used would affect the hand performance after a 6-week period of splint use.18) 11 1 10 2 5 6 1 Group 2 (n=12) 9 3 5.METHODS Patients A total of 30 patients (22 women and 2 men) were recruited from three outpatient rheumatology clinics and selected for the study. On the basis of their degree of impairment. grip strengths (p > 0. Y3.7%) and other professionals (12.0) 37. would not change over a baseline period of 6 weeks. group 1 patients after 6 weeks of splint intervention.34 years). Twenty-four patients completed the study in 12 weeks. Year of Onset. The first hypothesis was that the hand performance of patients with rheumatoid arthritis.5 (2. This helped minimize the discrepancy in hand function assessments due to variation in severity of the disease processes. Key: X1 indicates patients with rheumatoid arthritis in group 1.5 (2. All the patients were right-hand dominant. Patients were housewives (45.0 (2. The initial mean degree of flexion contracture was 34. X2. 16.921) (Table 2). Patients with fixed. and dexterity. TABLE 1. However.6°) among the 24 patients. would such splinting be equally effective for patients with rheumatoid arthritis? This study examined the effects of the early application of corrective splinting on flexion contracture of rheumatoid fingers and compare the effects of two different types of corrective splints—a static splint and a dynamic splint—on the hand function of patients with rheumatoid arthritis. A. and affected fingers were paired into the two groups for comparison of the effect.631).0) 35.24) 22 2 19 5 10 12 2 RESEARCH DESIGN The study was designed to compare the effectiveness of two types of corrective splinting on flexion contracture of rheumatoid fingers. Most of these studies were conducted on joint contracture caused by traumatic injury. strength.19 There were even distributions of sex.524). Inclusion criteria were that the patients were between 15 and 65 years of age and had diagnoses of rheumatoid arthritis with finger flexion contracture less than 45°. and affected fingers in both groups (Table 1).17 (17. permanent deformities or with articular damage on the PIP joints were excluded from the study. as measured by ROM.25 (16. who had demands of light to moderate manual tasks during their daily routines. Distribution of Sex. same group of patients in group 2 after 6 weeks. using a matchedpairs control group design (Figure 1). 17 patients were rated functional class II and 7 were rated functional class III. splint intervention–dynamic finger extension splint (Capener splint).5) 34.71 (16. Age. Patients with PIP joints with differences in passive range of motion less than 10° were also excluded from the study. patients with rheumatoid arthritis in group 2. 186 JOURNAL OF HAND THERAPY . Group 1 (n=12) 8 4 6. and Jebsen Hand Function Test (JHFT) results (p = 0. not by chronic disease. biomechanical analysis of finger splints and found that the dynamic (Capener) splint is more effective than the static (belly gutter) splint in correcting flexion contracture at the PIP joint. Therapists have been concerned that the loading force of these corrective splints might cause pain and further damage to inflamed joints. The second hypothesis was that treatment with a splint of the PIP joint would change hand performance over a period of 6 weeks.05). if the corrective force is monitored closely and maintained within the pain threshold of each patient.5%). splint intervention–static finger extension splint (belly gutter splint). The average age was 37. students (16. sex. Y2. B. Pretest–posttest control group study design. Y1. X3.2° (SD. Patients with similar functional levels. but the remaining six patients could not continue the program because of the exacerbation of their disease. hand dominance.02) 11 1 9 3 5 6 1 Total (n=24) 17 7 6. Affected Hand and Affected Fingers of Two Groups Characteristics Functional class: II III Mean year of onset (SD) Mean age in years (SD) Sex distribution: Female Male Affected hand: Right Left Affected finger: Index Middle Ring FIGURE 1. same group of patients in group 1 after 6 weeks. There were three hypotheses. affected hands.8%). The groups showed no significant differences in the degree of flexion contracture on affected fingers (p = 0. age.08 years (SD. active flexion (p = 0. clerical staff (25%). 11.

Both instruments were found to be reliable tools for measurement of various hand grips.01). Third.03) 12. regardless of the splint design.08 (4. and those in group B. stacking chess pieces. pinch grip. A qualified therapist who was blinded to the study conducted the hand function assessments before and after treatment. A Jamar dynamometer and a pinch gauge were used to assess power grip. Patients were also reminded to exercise and mobilize the PIP joint during the day when the splint was off.30 (1. the active range of motion of the affected finger joints. The JHFT has proved to have high reliability in measurement of hand function. on both hands. Second. Patients in group 1 each received a custom-made dynamic (Capener) splint with coil length..25 (11. and picking up heavy cans. including the metacarpophalangeal (MCP). picking up small objects.21 the finger goniometer is a reliable and valid assessment tool in the measurement of joint range of motion. width.5 and 8 hours.75) 3.25 hours).350 0.22 Therefore. chuck grip. when all patients received regular medication and other therapy services. Each patient was asked to draw one of the two envelopes and was then assigned to group 1 or group 2.613 0.20. one with a “1” and one with a “2” labeled inside . with a mean value of 6. a pairedsample t-test was conducted to compare the initial assessment score and the pretest score.739 0.78) 2. PIP. each patient was asked to complete the seven subtests of the JHFT.Procedures All patients were informed of the study and told that they could terminate the study at any time.921 Measurements The hand function assessment included assessment of joint range of motion. Written consent was obtained from each patient prior to assessment. After the 6-week intervention period.5 (9.45 (1.43 (1. who used the static splint. simulating feeding. The investigator also examined the affected PIP joint regularly to adjust the loading force and to ensure that the loading force would not cause any joint damage. depending on the number labeled inside the drawn envelope.23 The patients used regular medication and therapy services. turning cards. included writing. If ABBREVIATION: JHFT indicates Jebsen Hand Function Test * p < 0. First.75 hours (SD.45 (2.38 (10. was measured using a finger goniometer. DATA ANALYSIS Three analyses were performed.22. Each patient was asked to use a diary to record the splint-wearing regimen and duration.75 (7.21) p Value 0.79) Group 2 (n=12) 31.08 (11.31) 86. Two envelopes were prepared.524 0. with a minimum of 6 hours a day.47) 3. and administration of the Jebsen Hand Function Test (JHFT). except splinting intervention. assessment of grip strength.09) 53. Each patient in group 2 received a custom-made static finger extension (belly gutter) splint.096 0. they felt any pain or discomfort on the joint after wearing the splint. For each patient in both groups. they should report this to the investigator.48 (13. The duration of wear depended on the tolerance of each patient. TABLE 2. Patients were also instructed to exercise the joint during the period of wear. who used the dynamic splint. According to Fess20 and Hunter et al.57) 88.44) 3. RESULTS Baseline Hand Function Performance of Patients A baseline comparison was conducted at the initial assessment and at 6 weeks (Table 3).10 ( 1. the paired sample t-test was used to analyze the pretest and post-test scores to determine whether there were significant differences before and after intervention. and circumferences adjusted to suit the individual patient. picking up light cans. The investigator provided the intervention program for all patients in the study.631 0. Dosage and types of medication depended on the medical conditions of individual patients but April–June 2002 187 . which was to be worn at rest a minimum of 6 hours per day.67) 2. There was no significant difference between two groups in the length of wear (p > 0. The patient was instructed to apply the dynamic splint four times a day.08 ( 1. 1.50) 3.84) 53.21 It has been suggested that the Jebsen Hand Function Test (JHFT) is a useful adjunct to evaluation of the hand in rheumatoid arthritis. The investigator explained the mechanisms of the splints and the wearing procedures to all patients. Hand Function Performance of Group 1 (Dynamic Splint) and Group 2 (Static Splint) Mean (SD) Measure PIP joint extension (°) PIP joint flexion (°) Power grip (kg) Pinch grip (kg) Lateral grip (kg) Chuck grip (kg) JHFT score (sec) Group 1 (n=12) 37. the recorded splint-wearing time among the patients was between 5. an independent t-test was used to determine whether there was a difference in the hand function scores between patients in group A. to indicate the stability of the hand performance of the patients without any intervention.49 (12.42) 10. and distal interphalangeal (DIP) joints.05. and lateral pinch grip of the affected hand of each patient.

the significant improvement in correction of flexion contracture for all patients showed that corrective splinting is effective in cor- The Effect of Corrective Splinting on Hand Function All patients were assessed before and after the splint intervention program (Table 4). pinch grip (p = 0.108 ABBREVIATION: JHFT indicates Jebsen Hand Function Test *p < 0.05) 3.23(8.46 0.42 (10.50) 52.95 (7.75° of improvement.36 –3.93) 3. There were also no statistically significant differences in power grip (p = 0.27+10. Hand Performance Measures for the Two Groups Combined (n = 24) Six Weeks after Initial Assessment Mean (SD) Initial assessment PIP joint extension PIP joint flexion Power grip Pinch grip Chuck grip Lateral grip JHFT score 34.9) 3. 188 JOURNAL OF HAND THERAPY FIGURE 2.268 0.50) 2.2 (11.0 (7. Results showed significant improvements for all patients in correction of flexion contracture at the PIP joints (p < 0. Hand Performance Measures for the Two Groups Combined (n = 24) Pre.8 t Value 0.71 Df 23 23 23 23 23 23 23 p Value 1.05 (7.268).6) 88.000 for PIP extension and p = 0.00 (8.05 (7.73 (2.0005) after the splint intervention.00 –1.158 0.67 5.32 (10.410 0.4) 53.05 TABLE 4. pinch grip (p = 0.44(1. improvements in power grip (p = 0.84 –0.20 (1.083) during this baseline period.9) 3.94) 2.20(1. Weekly attendance at a physiotherapy unit for mobilization and pain relief therapy was also required throughout the 12-week period to ensure consistency in intervention protocol before and after splint intervention.49 (12. In terms of grip strength.334 0.6) 87.5) 52.94) 2.82 1. Black columns show pre-splint values.0005* ABBREVIATION: JHFT indicates Jebsen Hand Function Test *p < 0.0005* <0.45 –4.90) Posttest 15.52) 95.72) 12.2) 11.61 –3. and lateral pinch (p = 0. No statistically significant differences existed in the active range of motion of the affected PIP joints (p = 1.72) 3.24(1.21 Df 23 23 23 23 23 23 23 p Value <0. hatched columns.0005).0005).001* 0.TABLE 3.6 (8.7) Pretest 34.and Post-intervention Mean (SD) Pretest PIP joint extension PIP joint flexion Power grip Pinch grip Chuck grip Lateral grip JHFT score 34.334). .61) 3. Mean hand function values before and after splinting intervention in group 1 (dynamic splint) and group 2 (static splint).7) 11.72) 3. chuck grip (p < 0.56 (1.6) 89. This served as a control period prior to the administration of splinting.86 (1.21) 2.94 0. post-splint values.56 (1.158 for PIP flexion) and the hand function test scores (p = 0.0005* <0.083 0. As mentioned earlier.62) 47.000 0. The mean difference among all patients was 18.6) 3.35 (1.08 (8.41).16 (1.12 –4. A significant difference was also noted between the hand function scores (as measured by the JHFT) for all patients before and after the splint intervention program (p < 0.002).108) among the 24 patients.001).0005) after splint intervention were noted.10 (10.74 –1.84 –6.002* <0.0005* <0. when no patients had any splint intervention.17 (11.66) 11.05 remained the same throughout the 12-week period of study. and lateral pinch grip (p < 0.36 (1. chuck grip (p = 0.17) t Value 13.2 (11.82 (1.0005* 0.

25 (5. The remaining 24 patients did not report increased pain during or after the splinting program. The major consideration in application of the corrective splints was whether signs of active synovitis were present.70 (2. contracture at the affected PIP joint were observed (p < 0.4. the force generated by the dynamic finger extension splint (the Capener splint) is proportional to the deflection angle of the joint. resting the joints.33 (9. There was no significant difference between the initial and 6-week assessments. Hand Function Performance of Group 1 (Dynamic Splint) and Group 2 (Static Splint) after Post-splint Intervention Mean (SD) Group 1 (n=12) PIP joint extension ((°) PIP joint flexion (°) Power grip (kg) Pinch grip (kg) Lateral grip (kg) Chuck grip (kg) JHFT (sec.14) 2.001). This indicated that the patients’ conditions were quite stable and that any later changes could be due to splint intervention. pinch grip. or lateral pinch grip (p > 0.05. improvements in the correction of flexion ABBREVIATION: JHFT indicates Jebsen Hand Function Test * p < 0. hatched columns. that static and dynamic splints promoted the same strength. There was no statistically significant difference between the two groups in active extension of the PIP joint (p > 0.922 DISCUSSION Most research studies have focused on the effects of resting splints for patients with rheumatoid arthritis in relieving pain. Findings from this study conflicted with those of the biomechanical analysis in Li’s study.rection of PIP joint flexion contracture.18 showing that. chuck grip. Mean proximal interphalangeal joint flexion values before and after splint intervention.75 (6.53 (10. It is extremely important to monitor this force.92 (1. very few researchers have studied the application of corrective splinting to overcome joint flexion contracture in patients with rheumatoid arthritis. Patients selected for this study were fully aware of the pain-controlled mechanisms and were asked to wear their splints within their limits of pain during the 6 weeks of intervention. April–June 2002 189 . had to be accepted.11 (10.644 0. which are common among patients with rheumatoid arthritis.343 0. The bilateral coil at both sides of the PIP joints helps provide the continuous torque force to extend the finger. FIGURE 3.59) p Value 0.73 (1. These patients were withdrawn from the study because of deterioration due to the disease process. static and dynamic corrective splinting regimens could reduce flexion contracture of the PIP joint equally well.47) 3. especially for patients with rheumatoid arthritis. No significant difference was noted between the dynamic splinting group and the static splinting group in power grip. The flexion contractures were caused mainly by chronic edema and stiffness.81) 3.58) 91. The force can be adjusted (by modifying the dimensions of the coil) to provide the best stretching force tolerable by the patient.04) 2.37) 98.91 (11. Black columns show pre-splint values.75 (2.9.80 (1.25 (9.13) 47. and preventing deformities.7. The null hypothesis.05) (Figure 2). in patients with rheumatoid arthritis.18 which showed that the Capener splint could generate a better torque force for optimal correction of flexion contracture at the PIP joint by providing adjustment of core circumferences.032* 0.964 0.779 0. Of the 30 patients selected for this study. After the 6-week splint intervention. TABLE 5. In the biomechanical analysis.24 Other researchers have reported success in the use of corrective splinting in the management of PIP joint flexion contracture.962 0.44) 11. strength. post-splint values.92 (1.10 This study examined the effects of corrective splinting in the management of PIP joint flexion contracture using a pain-controlled model.) 13.032) (Figure 3 and Table 5).32) 12.5 (11. There were no signs of inflammation on the affected PIP joints. but a significant difference in active flexion was noted between patients in the dynamic splint program and those in the static splint program (p = 0.20) Group 2 (n=12) 17.49) 3.80) 3. 6 were found to have active synovitis during the 6-week control period.15–17 Nevertheless. showing that the regular medication and therapy services did not have direct effect on the correction of PIP flexion contracture. The pain and disease aggravation had no direct correlation with the splint intervention program.05). The results were supported by those of previous studies by Wu17 and Li.08) 47.11–13. and they were asked to increase the dosage of medication. and length.

with regard to defining the coil strengths. This may be because of soft tissue contracture at the joint causing PIP joint extension contracture. This might contribute to the lack of significant differences between the two groups in the correction of flexion contracture of the PIP joints. Two types of corrective splints.15–18 Both objective measurements. the dynamic splint was easy to apply and remove. the joint is in good alignment and the tendon excursion is working at its most mechanically advantageous position. the torque generated at the PIP joint causing joint compression. and patients reported some difficulties in adjusting it to the right tension. patients were divided into two groups. CONCLUSION Twenty-four patients with rheumatoid arthritis were investigated to determine the effect of corrective splinting on flexion contracture of the rheumatoid finger. Therapists have to monitor the resistive corrective force very carefully when treating patients with rheumatoid arthritis. the cosmesis.e. or damage at the volar plate in particular. as described previously. The flexor and extensor ten190 JOURNAL OF HAND THERAPY don excursions are changed.25 Once the contracture has developed. compared with function assessed at baseline. were selected for comparison of the effect on hand function. There was no significant difference in the percentage improvement in grip strength between the static splint group and the dynamic splint group.11. a splinting program is effective in correcting flexion contracture of the joint and improving grip strength and hand function. We cannot substantiate any negative effects of the application of the dynamic Capener splint to increase motion in our patients with rheumatoid arthritis. because the clinical observations showed that the patients in group 1 regained more than 20° active extension. All patients showed significant improvement in their hand function after the splinting program. It is possible that the soft tissue contracture is due to shortening of collateral ligaments or other factors. Group variance was greater among patients wearing the dynamic splint. However. This may be explained by the fact that the Capener splint encouraged both active flexion and extension during the splint program. in contrast. with active flexion limited as a result. Although there was no difference in extension correction between the two splints. the strap of hook-and-look tape across the joint had to be adjusted every time the splint was put on.13 Once the soft tissue contracture has been dealt with.. articular surface damage. The position of application of corrective force. and after a baseline period of 6 weeks.The other factor to consider is the duration of splint wear. one static (belly gutter splint) and one dynamic (Capener splint). In this study. in group 2. so the grip strength is stronger. If a PIP joint is limited in active movement. Functionally. The data suggest support for the biomechanical model. Both groups of patients showed a significant improvement in grip strength after the splint intervention program. It remained difficult for the investigator to document exactly the duration of splint wear for individual patients. Patients in both groups also reported improvement in daily functional hand tasks. patients in group 1 showed better improvement than those in group 2. most patients preferred to wear the static splint during night rest (i. The generated forces thus varied with each application of the static splint. Results of the JHFT clearly showed that impairment of even a single joint would affect hand function in a patient with rheumatoid arthritis. around 8 hours of wear). whereas the patients in group 2 showed an improvement of only about 15° extension. A matched-pair controlled group design was adopted for the study. whereas the static belly gutter splint could not perform both functions.16 Hunter et al. Improvement in PIP flexion was significantly greater . Extension contracture may be due to adhesion of the central extensor tendon. and the mechanical advantage is decreased. On the static splint. a post-splint assessment was performed. which inclined patients to put it on more regularly between daily activities. According to feedback from the patients. even though there was strong evidence from the biomechanical analysis that the dynamic splint creates a better corrective force than the static splint does. and subjective impressions of patients should be taken into consideration. the contact pressure. After 6 weeks of splint use. then activities involving handling and maintaining grip on medium to small objects becomes difficult. depending on the tension of the strap. a significant difference existed in the flexion resulting from the splinting. which each used a different splint program. Thus. and the material properties of the splint are the key factors to consider in the management of flexion contracture in patients with rheumatoid arthritis.4. the PIP joint is responsible for 85% of total encompassment in the grasping of an object. although the actual improvement in functional daily activities was not documented. but most patients in group 1 could not recall how long they wore the dynamic splint. Therefore. the finger has a faulty position of grip. the grip strengths are affected. It was interesting to find out that improvement in active flexion of the PIP joint was significantly greater in group 1 than in group 2.21 also emphasize that active mobilization of the joint is useful to correct the contracture.

Louis.35:173–8. 3rd ed. 1990. April–June 2002 191 . Spring wire splinting of the proximal interphalangeal joint. Occupational Therapy in Practice.: Mosby. 4. The prevention of hand deformities with resting splints in rheumatoid arthritis patients: a randomized single blind one-year follow-up study. for their help in collecting data for the project.3(4):227–32. 19.5(4):118–22. Batterman RC. In: Hunter JM. Post-operative metacarpophalangeal arthroplasty dynamic splint for patients with rheumatoid arthritis. An objective and standardized test of hand function.24 Patients did not complain of pain. 8. Trotter M. 24. Dieppe PA. Baltimore. C. In: Pedretti LW (ed).9:378–86. Pa. Sanny Cheng. Louis. Trombly CA. Fasler P. 1995. 22. Rheumatoid arthritis. Rehabilitation of the Hand. Special care should also be taken not to overstretch the delicate tissues around the joints. In: Hunter JM. The methods of splint fabrication need to be taken into special consideration as well. although this finding is not statistically proved. 11. Management of the stiff hand. 6. Force analysis of the belly gutter and Capener splint. St.: Davis.55(3):141–6. AD. or over-stretching after wearing the dynamic splint. Louis. Mr. Kasch MC. Meaki Chan. J Hand Ther. Further studies should examine the effect of splinting and the generation of corrective force in greater depth. 10. Prosser R.: Williams & Wilkins. Dopherty M. Pedretti LW. Callahan AD (eds). 23. Schumacher R Jr. Brandt KD. 3rd ed. Biomechanical analyses of different designs should also be conducted. Simon Wong. Dellhag B. J Hand Ther. 1986. A five-year follow-up of hand function and activities of daily living in rheumatoid arthritis patients. 14. The clinical findings in this study did not confirm deductions made from the biomechanical findings. Trieschmann R. which was not monitored properly in this study. 12. 5.9:371–7. Wong. Palella TD. 1984:862–74. MacFarlane DG. Mo. Edward Chan. Melvin JL. 1994. Hollister A. Colditz JC. Li C.: Mosby.: Mosby. Ms. 16. Mackin EJ. Hittle JM. Evaluation of the Jebsen Hand Function Test for use in patients with rheumatoid arthritis. Curtis RM. such as the total duration of wearing time. Nonsurgical management of the boutonniere deformity. Wilson R. Mr. 2nd ed. 1985. Mackin EJ. Brand P. Howard L.with the dynamic splint than with the static splint. Mo.1:86–90. Am J Occup Ther. S. 2. 1990. Rennie HJ. Orthop Clin North Am. Ms. Hanten DW. Arthritis. J Hand Ther. Callahan AD (eds). Evaluation of the effectiveness of a metacarpophalangeal ulnar deviation orthosis. and Mr. Therapeutic criteria in rheumatoid arthritis. 7. Special Interests Section Newsletter. Although no significant difference was shown between the dynamic splint and the static splint in the regaining of active extension of the PIP joint. St. 1999. This indicated that therapy should focus not only on regaining lost finger extension but also on increasing joint mobility in both flexion and extension. but no differences were found between the other outcome measures. Rheumatological Medicine. Dijkmans BAC. Hunter JM. Philips CA. and Ms. Leung. However. This is a clinical study to investigate the effectiveness of corrective splinting on flexion contracture in the rheumatoid hand. Bjelle A. 13.13(2):108–23. 25. Philadelphia. Rheumatic Diseases in the Adult and Child: Occupational Therapy and Rehabilitation. Clinical Mechanics of the Hand. Rheumatoid arthritis of the hand. Rosanna Kay. Occupational Therapy for Physical Dysfunction. 1996. 20. compared with the static splint. Fess EE. 4th ed. St. A belly gutter splint for proximal interphalangeal joint flexion contracture. 1981. 1988.45:839–43. 1996:639–60. Janssen M. J Hand Ther.11. Hacking S. Rehabilitation of the Hand. Callahan. since it is important to control the amount of corrective force on the joint generated by the coil spring. Jebsen R. 1969. 1999. 1994:815–30. Hand Splinting: Principles and Methods. Steinbrocker O. Mackin EJ. St. Schnedier LH. 1987.18 There may be factors that researchers neglected during the clinical study. W. Acknowledgments The author thanks Professor P. Rehabilitation of the Hand. Force magnitude of commercial spring-coil and spring-wire splints designed to extend the proximal interphalangeal joint. Dynamic splints are effective in the correction of soft tissue contracture of the PIP joint in patients with rheumatoid arthritis. Schulz AJ. Wu SH. This study does not confirm the hypothesized negative effects of dynamic splinting. Edinburgh.50:311–9. 1995. Use of resting splints by patients with rheumatoid arthritis. Md. Mo. 1996. Bochenek C. 1949:140-659. Splinting in the management of proximal interphalangeal joint flexion contracture. 15. 1982. 21. Am J Occup Ther. Arthritis Rheumatol. REFERENCES 1. Practice Skills for Physical Dysfunction. Fairleigh A. Dedrick RF. McLellan AT. Dr. Schneider LH. Estes JP. Feinberg JR. Mo. 9. fatigue. Louis. Arthritis Care Res.7(1):16–9. Gilbert NL. Can J Occup Ther. St. 2nd ed. Mo. Palchik NS. Arch Phys Med Rehabil. 17.33:123–6. In addition. 1989. the dynamic splint was not associated with a negative or adverse effect noted in other reports.12(4):337–43. 18. JAMA.: Mosby. Fess EE. 2nd ed. J Hand Ther.12(1):33–41. Arthritis Care Res. Maddison PJ.17:313–43. The splinting controversy in rheumatoid arthritis. Louis. Osteoarthritis of the fingers. 1990. Sharma S. biomechanical analysis showed that dynamic splinting is more effective than static splinting in correcting flexion contracture of the PIP joint. 4th ed. Arthritis Care Res. Hercy Li for their great support in completing the project. Information gained from this study has helped us develop further research into the biomechanical and clinical aspects of splinting intervention for patients with rheumatoid arthritis. 2000.18 Moreover.: Mosby. 1988. 4th ed. 3. In: Trombly CA (ed). UK: Churchill Livingstone. Taylor N. Feinberg JR.: Mosby. The dynamic splint is reported to be better in the correction of flexion contracture of the PIP joint. active flexion showed significant improvement with the dynamic finger extension splint. Phiferons. Louis. Traeger CG. She also thanks the occupational therapy students. 1990:321–7. the elasticity of the coils should be checked frequently. Mitchell DM. St. Mo.

let alone achieve its therapeutic goal. 2002. with the least possible structure. Published reports rarely address the issue of whether a proposed splint design achieves its goals The author has a financial interest in one or more products mentioned in this article. In a splint as in a work of art. I realized that I was clueless about splint design and construc- 192 JOURNAL OF HAND THERAPY . A decision flowchart is presented and discussed in detail. were not very exciting. MS Rucaplein. Splint making involves the application of science combined with the art of healing and the art of creating objects that can be appreciated for their utility and beauty by patients. the shape of a splint did not match the hand well. but it is applied here specifically to the making of effective splints. like certain paintings or buildings.15:192–201. although it was not yet clear what masterpieces were supposed to look like. It takes into consideration the many different aspects of making splints in the most structurally efficient way. Too often. J HAND THER.be>. OT. a rationale for minimalistic splint design. Rucaplein. and therapists alike. they provided various patterns. The basic principle of minimalistic design is illustrated by the objects shown in Figure 1. BACKGROUND Until the end of the 1960s. prescribing physicians. “Minimalistic art” describes those works of art. during construction. An extra dimension of splint design is emphasized—namely. The purpose of this paper is to present an algorithm of decision steps that will help therapists consider all aspects of splint making proactively. the greater the effectiveness of the splint and the patient’s appreciation of it. described working techniques. 556 B2610 Antwerp. the more clearly an intended effect can prevail. The concept of minimalistic design is also important in the creation of tools used in daily living. Antwerp Belgium ABSTRACT: Theoretic clinical reasoning is becoming increasingly important in splint construction.Minimalistic Splint Design: A Rationale Told in a Personal Style Paul Van Lede.1 Promoting the use of the newly invented low-temperature thermoplastics. but I could read from many patients’ faces a somewhat doubtful appreciation. MS. which ultimately did little to improve the product? The purpose of this paper is to present. and included pictures of the finished products. Instead of correcting design shortcomings on the go. dating from this period. Who does not remember a disastrous splinting experience. Around the same time. Often. including technical and financial possibilities and constraints. The splints they made were rarely masterpieces. What was wrong? On self-evaluation. A minimalisticdesign splint is rarely the fruit of a first attempt. when a splint did not fit the patient’s hand and an endless series of small and ineffective alterations began. The paper concludes that the use of a comprehensive decision algorithm provides the basis for successful working technique and that the ability to create minimal-design splints is more a state of mind than a technical skill. improvements simply add more structures. My first personal attempts at splint making. such as splints. the therapist uses the minimalistic-design splinting algorithm proactively to revise the original design and create a new prototype. in a personal style. frugality in structure. Correspondence and reprint requests to Paul Van Lede. OT. The less structure. Minimalistic splint design is an approach that anticipates and answers many questions that arise in splint making prior to fabrication of a splint. it was common knowledge that splint makers working with patients with spasticity generally wished that the patients would either be under strong relaxation medication or be totally insensitive to pain. It was not that the end results were failing. technique. which could be molded directly to the patient. so that they can take the necessary steps to be successful. and cost. e-mail: <pvanlede@ skynet. whose full meaning is expressed in the least possible structure. such as corkscrews. Belgium. the first hand splinting brochures and manuals addressed to occupational therapists were published. and tools used in patient treatment. it is often true that the less structure there is. in order to achieve optimal effectiveness of the splint with the least amount of structure.

get a decent pair of scissors. What was it. then. THE SPLINTING ALGORITHM What Is an Algorithm? An algorithm is a list of decisions that are made in a predetermined order to find an answer to a question. I was in a position to learn my patients’ functional splinting needs as no one else could. and management are a rational process that can (and must) be clearly and proactively structured. I learned that splint making necessarily begins with physics (read “mechanics”) and must be followed by a thorough study of materials—in other words. the table top. Second. But something was missing. unlike plaster casts. and 15. I had learned in practice what the splinting manual never suggested—namely. inexpensive. Use of the algorithm is helpful for those who make splints only occasionally and for advanced splint makers who face unusual splinting challenges.2 The splinting algorithm (Figure 2). The algorithm takes the form of a flowchart that outlines sequential problem-solving steps to create a perfectly fitting splint that fulfills the therapeutic requirements. and worn by our patients without reservations. 4. our splints are more likely to be fully effective. if followed with care. Minimal-design table. training on a trainee’s hand. to be assembled by clicking the components in place. Splints. heat up some water in a small frying pan.tion and that none of the existing handouts addressed these issues. Details appear in Figures 3. . can be removed. The splinting algorithm is also designed to define the technical and financial feasibility of a splint. Some splints could be fabricated much more easily and were more attractive than others. design starts from scratch. For this reason. the questions no longer troubled me. I was backed and encouraged by a prescribing physician who discovered a new and very interesting therapy modality. Improvisation is not good enough in splinting. that by following an algorithmic sequence we can achieve both simplicity of design and optimal effectiveness. therapists are obligated to design splints that at least look and feel attractive enough to be worn. consisting of three prefabricated parts—the base. that motivated me to make splints? First. not with reference to a “recipe” book. I thought. and get going. I had learned that. So. The design is efficient. After a couple of months (or years?). cosmetically acceptable. and the foot. fabrication. When the algorithm is used. and without any excess. easy. no problem: All that’s needed is to order some more of these expensive thermoplastics. the one thing that I hated most as a student and the other that no manufacturer seemed eager to publish. Bird’s-eye overview of the algorithmic sequences. I could appreciate what kind of splint was likely to meet these needs. From orthotic study books (addressed to orthotists). as an occupational therapist. that splinting design. April–June 2002 193 FIGURE 1. and patients do not accept poor standards. can guarantee good splint function and enable the splint maker to avoid bungling. neat. if we use the algorithm. And third. But it soon became apparent that not all splint patterns found in the literature were the products of genius design minds. grab some more stuff from the OT department. Was it just that I found copying boring? Or could these designs be done better with more creativity? FIGURE 2. and a dissatisfied patient will discard a bad splint and quit the therapy.

for example. Using these data. whereas volar splints have to leave clear the bulk of soft tissues that could impede joint motion. MCP joint flexion removes a barrier against PIP joint extension by relaxing the long flexor muscles. an inflamed metacarpophalangeal (MCP) joint that needs to be immobilized by a 194 JOURNAL OF HAND THERAPY .FIGURE 3. whereas the return is accomplished passively by the splint. the MCP joint. as when a drop hand is positioned in a functional position. It is then the therapist’s responsibility to fill in the first part of the flowchart using the following guidelines. Mobilization stops can be placed either across the motion path or over a motion plane. Immobilization means that no mobility is allowed and usually concerns all planes of motion. In a clinical situation. splint reaching from the proximal extremity of the metacarpal to the distal extremity of the first phalanx. From biomechanics. usually where the pathologic tissues are located or at least where the pathologic action is concentrated—e. the splint maker’s technical expertise. Splints can be used to mobilize. relaxed position. for example. immobilize. or correcting. and the availability of materials. the splint possesses a source of energy— hence the term “dynamic. even more. which require the device to contain two movable parts.. Each goal suggests a particular splint design. The prototype is further refined according to technical considerations based on the patient’s personality. or identification of the pathology. A painful wrist.” Mobilization can further be described as positioning. issued in 1992 and designed to be used as aid to the prescription. The mobilization is dynamic when back and forward motions are allowed. since there is no source of energy. restrict mobilization. At least one item from each level must be found in the medical prescription. is immobilized in a neutral. the MCP joint is thus a secondary focus. As a result. The Splint Prescription Besides the diagnosis. and the interphalangeal (IP) joint. we learn further that dorsal splints are allowed to reach and even partially cover adjacent joints to increase the lever arms. a blocking hinge is used. Mobilization is when a joint is brought into a new position and possibly held in this position. when gradual motion improvement is expected. This first part of the algorithm is based on the original ASHT splint classification system. First part of the flowchart: the splint prescription.g. unless the coverage of the adjacent segments is necessary to improve stability of the splint. A segment may consist of either two articulated bones (basically. The secondary focus is not directly involved in the pathology. It implies that the splint can be made of a single piece of material.2 Anatomic Boundaries The anatomic boundaries are determined by the segments that need to be splinted. Range of motion restriction is when. or shield a target tissue. non-articulation splints. The rigidity of the splint material and. or a muscle contracture of the flexor digitorum superficialis that must be treated by mobilization of the wrist. of the splint design determines the sturdiness of the splint. It is commonly assumed that splints should embrace the whole segment without covering adjacent segments that are not specified in the prescription. compress. rather. The secondary focus is not the target tissue of the splint’s action but is. Therapists often complain that splint prescriptions lack the information they require. The mobilization modality is static when the positioning takes place with the donning of the splint. Such splints should be called mobile instead of dynamic. a segment that facilitates or hinders the completion or achievement of the primary focus.2 The position of the hand in which immobilization is carried out is dictated by the prescription. the algorithm begins with a prescription that clearly and fully specifies the therapeutic aims and goals of the desired splint. For example.3 Therapeutic Goals There is a limitation to what can be achieved by the application of splints. The primary focus is the segment that is the target of the splint’s action. since splints are only simple mechanical tools. There may be more than one secondary focus. the splint maker compiles the theoretic mechanical inputs that are necessary to draft a prototype. the motion in one direction is achieved actively by the patient. the prescription should mention clearly and in detail the anatomic boundaries and therapeutic goals of the splint (Figure 3). when no changes in position are expected over time. a joint) or just a bone—hence the need to consider articulation splints vs. With simple dynamic splints.

it must be decided how the three points of contact (or multiple of three) are to be connected to each other—on the bottom (Figure 6. middle). In designing a splint. Volar splints have a bed-like construction that is very comfortable for resting.. Ideally. and shifting have specific effects on the skin and the underlying tissues. for example. extension. dictate this choice. for immobilization of long bone fractures (functional fracture bracing). This step is crucial in any splint design. a single hinge is used. magnitude of torque. Any splint design will adhere closely to the mechanical rules that govern their operation—no more. Top. it is also the responsibility of the splint maker. top). but since there is no force application. precut patterns. A common mistake in many splints may originate in a missing point of support to complete the lever 4.5 (Figure 5. FIGURE 5. it is also very simple. In my opinion. no less. To identify these areas. flexion vs. Mechanical Considerations We now consider the mechanical issues.g. The drawing of a pathologic starting position. The intensity of action and the wearing regimen do not influence the splint design and so will appear at the end of the algorithm. To complete the prescription. resting April–June 2002 195 . A good example of a minimalistic-design three-point splint is the swan neck splint made by The Silver Ring Company (Charlottesville. Lever-based Splints Levers are defined as rigid bars that pivot on a fixed point and are used to transmit forces called power and load.g. Virginia). and neurologic inhibition (cerebral palsy). deep-wound healing (burns). the intensity of the action (e. The distal anatomic segment is the load to be mobilized. Since pulling. however. such as in an ulnar drift splint designed to allow only flexion and extension of the MCP joints. The single hinge mandates a large contact surface to avoid torsion. Shin pads for football players and breast shields for slalom skiers are examples of such devices. Consequently. and traction). on the top (Figure 6. Minimalistic design avoids the covering of areas where no contact is needed—hence. to work through the next steps of the algorithm. left). the idea to create windows for aeration and lighter construction. To minimize the splint design.Plane restriction is when bilateral hinges are used to guide the joint in a determined path of motion. rather than the prescribing physician. bottom). or on the sides (Figure 6. Mechanical issues should. and the power arm is anchored around the proximal anatomic segment. these devices can no longer be termed (therapeutic) tools. pressure. Ignoring or neglecting these rules will inevitably result in malfunction or non-function of the splint. it suffices to sketch the pathologic starting position and indicate the areas of contact according to the desired mobilization (Figure 5. abduction vs. the direction of mobilization (e. at least one item from each level must be selected according to results of the structural analysis. Possible consequences of a missing point of support. Splints are used as levers either to lift up loads or to increase a movement path (muscle weakness). which are dictated by physical laws (Figure 4). or the need for accessories (such as outriggers) on dynamic splints.. Shielding from external forces and thermal isolation are other possible therapeutic actions. it is easy to determine the areas of pressure that are needed for extension of a whole finger. dorsal-based splints pull it in extension. The decision for a volar-based rather than dorsalbased splint is usually not intentional but dictated by habits. adduction). when the wearing protocol is worked out by the therapist. the mechanics are not equally favorable. Only two tools can be considered—levers and coaptation circuits. Volarbased splints push the joint. FIGURE 4. pushing. and the wearing regimen need to be described. Next. including the final design of the splint and the choice of materials. Bottom. Compression (of soft tissue) has several therapeutic indications and is used. right). the therapist does not need to be able to discern the various lever categories so much as identify the various areas where the splint will be in contact with the anatomic segments. Working from top to bottom. The second part of the flowchart: mechanical considerations. the splint pivot is located at the level of the joint axis.

Pressure can easily be dispersed over large surfaces. The design of circumferential splints results from a three-point analysis when joint motion is allowed in none of the motion planes. left) That is why lateral-connection splints are indicated to mobilize “big” joints. This action is much more efficient. not the splint material. Examples are the swan neck splint mentioned earlier and spiral wrist splints. such as the wrist and the elbow. softened by padding. left). Lateral-connection splints can be designed with or without fixation straps. that holds one or more joints in a flexed position (Figure 11. the splint resembles a crowbar. which is not always easy or fea- sible. A volar splint is comfortable while resting. A lateral-connection splint without straps can be considered a true minimalistic design (Figure 9. These splints are known to be extremely stable and very comfortable since the stability is neither due to the material stiffness nor the thickness. The smaller the circuit. A nice feature of lateral-connection splints is that hinges can be incorporated that perfectly match the joint axis. only pressure. The standard example is the flexion glove. Try to do this with either a volar or a dorsal splint and you will see both a huge motion discrepancy and plenty of excess material to be trimmed of the volar splint to allow full range of motion. benefits the most. right). A dorsal splint is efficient in the application of traction. One girdle surrounds the pivot. With dorsal connections. the patient should have sufficient joint range of motion to sneak into the splint. Could the friction be reduced if padding were avoided and lubricant used instead? Not sufficiently! With dorsal splints. Can padding be used in dorsal splints? Absolutely. 196 JOURNAL OF HAND THERAPY . making tilting very easy (Figure 9. With a strap. and no friction builds up. The more pressure is applied and soft padding is used. The analysis reveals three girdles around the points of contact. Such splints are particularly efficient for increasing joint flexion. Connecting the girdles results in a circumferential design (Figure 10). the higher the friction and the less efficient the splint action becomes.FIGURE 6. FIGURE 8 (right). then. However. Once the FIGURE 7 (left). the proximal segments in a circuit are more compressed and flexed. since such a splint has no opening strap. splints should always be volar (Figure 7). the therapeutic action is directed in a proximal-to-distal direction. The art of the therapist is demonstrated in designing the circuit so that the target joint of a digit. Circuit-based Splints A coaptation system2 is a closed circuit. splints correcting multiple joints do not have to contour each joint precisely. For this reason. as in stiff fingers. the primary focus. because of the relatively high friction that occurs between the skin and the splint surface at both splint extremities. usually of soft elastic material. They are also very practical for mobilizing joints out of awkward positions. Biomechanical possibilities to connect points of support on the bottom (left). For those cases. straps on the extremity pull (rather than push) the joints into extension (Figure 8). as with longstanding hypertonicity that results in strong muscle contractures. since the straps. and two girdles surround both extremities. take up the forces. Doesn’t that make sense? Yet volar splints are not so efficient for extending resisting joints (stiff joints or hypertonic muscles). a volar design should not be used. Because the proximal segments of digits are longer than the distal segments. on the top (middle). as long as it is not used to disguise a faulty design. the more flexion is obtained. or on the sides (right).

A lateral-connection splint with strap provides easy leverage. Right.FIGURE 9. using only part of the coaptation circuit. Circumferential design offers good total immobilization. a shortcut coaptation design will need an outrigger on the volar aspect. which makes the splint voluminous. The joint distal to it now becomes the most proximal joint to benefit from the splint action. Coaptation circuit (far left). a shortcut that follows the radius of the theoretic circle is allowed (Figure 11. April–June 2002 197 . With a stiff extended digit. FIGURE 11. To avoid excessive bulk and favor the minimalistic design of a circuit. These two splints show that a lateral-connection splint without a strap is the minimalistic design. right). proximal joint has reached its end position. FIGURE 10. it is removed from the circuit to allow tightening of the circuit. Only after the digit is semi-flexed can the outrigger be removed and the splint become less cumbersome. is allowed along the radius only (left). A shortcut. however. Left.

What I call a vertical profile (usually termed a high profile. in the sense of splint making. Why can we not keep it simple and remain content with outriggers and rubber bands? Let’s consider the patient. Full range of motion is not an issue yet. It addresses the motion path of the participating bony elements (osteokinematics) and motion within the joint (arthrokinematics) as well as the applied energy (kinetics). dynamic splints should move throughout the entire range of motion. long outrigger) (Figure 12) and by the length of the rubber band (determined by the elasticity modulus) (Figure 13). sometimes not) are less cumbersome to wear but more difficult to make. When simple eyelets replace rotational pulleys (to save money) and fishing line replaces part of the rubber band (to reduce drag). Horizontal-profile splints (sometimes genuinely low profile. high-profile splints. although not minimalistically designed. Here is where true artistry will shine! The fabrication of dynamic splints with hinges. especially when we realize that all sound joint motions have rotational motion paths. Splints that have rigid outriggers and rubber bands that move linearly cannot do this. because pulleys need to be added to redirect the rubber band from horizontal to vertical. although it is not necessarily high) is actually a preferred minimalistic design option. the elastic modulus increases dramatically. splints with outriggers and rubber bands. although it is sometimes less appealing cosmetically because of its bulk. The treatment modality can be either static or dynamic. The angle of pull determines the length of the outrigger (and vice versa). let alone the inclusion of a source of energy to obtain a minimalistic design. Thus. This does not mean that any profile is tolerable. again. FIGURE 13. and patient’s motions are slow. With vertical profile splints. Dynamics. external fixation devices. is not a beginner’s cup of tea. and the situation in which the splint is to be used. In addition. making it necessary to lengthen the rubber band—and lose the original minimalistic design.4 The profile does not show the splint maker’s skill as some like to believe. have to comply with work situations and be discrete. Mode of Force Application All medical requirements except the treatment modality have now been translated into mechanical splint requirements. the accuracy of the splint design and the applied force are of much more importance than aesthetics and discretion. They are also likely to be more expensive.Because postoperative splints sometimes have to be combined with other medical devices. they may end up bulky and not minimalistically designed at all. such as Baxters. The patient is entitled to sleep at night and must be able to move comfortably through doorways. 198 JOURNAL OF HAND THERAPY . on the contrary. without a functional goal. The natural biomechanics of the hand are complex and hard to mimic. Consequently. The splint maker is allowed to opt for an easily adjustable and usable dynamic system even at the expense of a sleek and slim design. the length of the rubber band determines the height of the outrigger. In the postoperative treatment phase. During early postoperative care. this common-sense view is not as obvious as it seems. are acceptable. the therapist needs to consider carefully the amount of force provided by the elastic modulus of FIGURE 12. and plaster of Paris casts. patients usually do not argue about the splint bulk. given that other horrors are probably hounding their subconscious at this time. (Given the constraints imposed by some exaggerated. so minimalistic designs are paramount. is the study of splint motion in harmony with joint motion. It is efficient and easy to make.) The minimalistic profile of a dynamic splint with outrigger is dictated by the angle of pull of the rubber band (short vs. Functional splints.

Third part of the flowchart: technical considerations. median nerve splint. in the near future. the patient is king. such as high-temperature thermoplastics. If it is too weak. the accuracy of the traction force is important. in the event that several therapists. Patients decide for themselves whether splints are worn or not. driving uphill can be tedious and time-consuming. just taking a little more time on the finishing. the car will swerve out of control on the first curve! In the rehabilitation phase. electronic devices. of course. An example of this is a splint fabricated for a burn patient. when they are worn. are involved in the care of the patient. A simple finishing touch. Technical Considerations According to the flowchart (Figure 15). 6 the dynamic splint. Right. is the user-friendliness of the splint. such as polycentric hinges. NOTE: Kinematic parts provide positioning and angular control. colors. is also part of minimalistic design and takes only seconds to do.FIGURE 14. specific functions may require long-lasting splint materials. The time has come that we as therapists not only consider the biomechanics of a splint design. kinetic parts provide forces. fancy decoration for kids (Figure 16)—in short. and special accessories. but it also improves the likelihood that the splint will be included in the total package of care. but these are often beyond the technical scope of therapists. This benefits the patient directly. these splints should allow most activities of daily living. such as realigning a swiveled edge or polishing the splint surface. but if it is too strong. A splint can be called functional only when it provides more benefit than inconvenience. for how long. The glitter of poster splints is often just such a touch. 7 LTTP indicates low-temperature thermoplastic. How the splint is supposed to April–June 2002 199 FIGURE 15. Elastic modulus is like the horsepower in a car. the prototype is now ready to be refined according to the anatomic shape and biomechanics specific to the patient. but even more important. The quest is for a “no-profile” design (Figure 14). but also consider aesthetics. in which the splint maker—as well as nursing and medical personnel—is active in the care of the patient. The algorithm thus far has described decisions made without reference to the personal skill of an individual therapist. Except for functional splints that are designed for a particular function. Now comes the time when we have to make final decisions based on our preferences and skills and the splint’s feasibility. Granger-design splint with a short sling attachment. In functional situations. not the splint maker’s. and how often. It is not a matter of the splint maker being exceptional. and riding a bike. “No-profile” splints. A splint should reflect the patient’s taste. such as grabbing keys out of a narrow pocket. Left. HTTP. driving a car. high-temperature thermoplastic. and exposed rubber bands are frail. Materials and accessories are selected according to the patient’s needs and taste as well as availability. with coil springs or maybe. Outriggers are always too bulky and cumbersome. and ultimately decisive. For patients with long-term or permanent handicaps. writing and typing. styling. everything fun or aesthetically pleasing that helps increase a patient’s compliance in use of the splint. or clinicians from more than one discipline. Good knowledge of the technical side of various splinting materials and accessories surely will help the therapist finalize the splint. .

FIGURE 16. A special design for a special person.

look is known; the question is whether we are the right person to fabricate it. How have we been trained? In what part of the world are we living? What materials are available, and who is going to pay the bill? Sometimes the choice of material is dictated by the prescription (thermoplastic splinting material vs. Neoprene, for example), but it is never dictated by brand name. This would not make sense, since some brands are offered in a limited number of countries and identical materials may be distributed under different names. The better therapists know the properties of splinting materials, the more judicious the choices they will make and the more perfectly their splints will be fabricated, without needing corrections or reinforcements. We want to use thin material for finger or thumb splints and thick material for elbow splints, perforated material for circumferential immobilization splints, but non-perforated for lateral connection splints. This is also minimalistic splint design! These early years of the new millennium are not likely to bring us new splinting materials that are more convenient than low-temperature thermoplastics. Forty years after their introduction, low-temperature thermoplastics are available with a wide variety of properties, marketed by many manufacturers, and distributed all over the world. If the greatest advancements in the near future are not expected to occur because of changes in materials, then the question is what other factors have con200 JOURNAL OF HAND THERAPY

tributed, or will contribute, to advancements in splinting. How much have we improved our skills in shaping thermoplastics, and how much knowledge have we gained from experts other than therapists? Mechanical, chemical, and orthotic engineers are the people we should consult initially. The issue is not limited to the conformability, drape, and resistance to stretch of thermoplastics. Other, fine-tuning features, which are less often specified, are worth considering in the fabrication of a minimalistic-design splint. Elasticity, for example—usually called “memory”—is not only a matter of material re-usability. Elasticity is primarily the ability of the material to stretch evenly and retract excess material, avoiding the need for the therapist to fold the material, as shown in the elbow splint in Figure 17. 3 Many splint makers think some thermoplastics are just pliable, not very stretchable, which is of course incorrect. It is by stretching, not folding, that a twodimensional sheet is magically transformed into a three-dimensional splint. The result is a neat shape, free of fringes and extra reinforcements. Another unusual feature of splinting materials is adhesion. Although many tedious stories circulate about the accidental bonding of untreated plastics, many splint makers have learned to use the exquisite properties of the sticky materials. Neatly bonded straps and hinges, instead of rivets, may also be part of a minimalistic design. As for the fabrication of accessories, such as hinges, outrigger systems, and pulleys, the question is whether we are content with what is available or, instead, have the ability, time, and desire to custommake them. Minimalistic-design splinting often favors custom fabrication. Prefabricated kits are convenient to use but not necessarily the best choice. Because prefabricated designs address as many pathologic conditions and sizes as

FIGURE 17. With a splinting material that lacks elasticity, folds are inevitable. With elastic products, folds are easily avoided, as shown in the lower splint.

possible, the splints have many features that may not be relevant for a particular patient. Pathologic conditions with identical target joints, and identical primary foci for splinting, do not necessarily call for identical splint designs, either. For instance, most therapists choose a dynamic splint design with outrigger to assist MCP extension for treatment of postoperative arthroplasty, but flexible outriggers without rubber bands are the right choice for a patient with a radial nerve palsy, because they are more functional. Prefabricated kits are intended for splint makers who have limited technical skills or time.

minimalistic approach. Does the design directly address all the splinting requirements before the splint is fabricated? Does it address technical and financial possibilities and limitations in the most structurally efficient ways? Minimalistic splint designs are never created overnight. They grow, rather, out of a constant search to improve a basically sound concept. Are we prepared to reconsider the quality of our work and our habits continually? Acknowledgments
The splinting algorithm was created with Griet van Veldhoven, OT, orthopedic engineer, as the basis of the working method elaborated in the second volume of our book Therapeutic Hand Splints: A Rational Approach and Practical Applications (Antwerp, Belgium: Provan, in press). The author thanks Caroline W. Stegink Jansen, PT, PhD, for her endless support and encouragement in designing this paper and making it readable.

Because splint making is a rational activity, it has been possible to draw up a detailed flowchart that includes all the features that need to be considered, ensuring that all the steps necessary for success will be taken. If all the decision steps of the flowchart are followed correctly, no omissions will occur and the splint maker will not have to make corrections, losing precious time and ruining the design. The flowchart presented in this paper is not unique, and many splint makers have developed their own, but most of these do not have minimalistic design as a goal. Minimalistic design is an extra dimension that results not only from a straightforward thinking but also from an emphasis on simplicity and economy. Minimalistic splint design can be learned easily. The desire to refine the splint design and the design process over and over again is a state of mind. A minimalistic design emerges as we continue to question whether our splint fabrication is following a

1. Malick MH. Manual on Static Hand Splinting. Pittsburgh, Pa.: Harmarville Rehabilitation Center, 1968. 2. Bailey JM, Cannon NM, Fess EE, et al. (eds). Splint Classification System. Chicago, Ill.: American Society of Hand Therapists, 1992. 3. Van Lede P, van Veldhoven G. Therapeutic Hand Splints: A Rational Approach. Vol 1: Mechanical and Biomechanical Considerations. Antwerp, Belgium: Provan, 1998. 4. Fess EE, Philips CA; Hand Splinting: Principles and Methods. St. Louis, Mo: Mosby 1987. 5. Brand PW, Hollister A. Clinical Mechanics of the Hand. 2nd ed. St. Louis, Mo.: Mosby, 1993. 6. Crochetière W, Granger CV, Ireland J. The Granger orthosis for radial nerve palsy. Orthot Prosthet. 1975;29(4):27–31. 7. Craik RL, Oatis CA. Gait Analysis: Theory and Practice. St. Louis, Mo.: Mosby, 1995:455,160.

April–June 2002 201


Splinting Materials Old and New
For this special issue on splinting, the Practice Forum presents two splinting ideas. The first article features an ancient material largely unknown in western clinics, and the second utilizes a new material. Our ancient idea comes from Uganda and demonstrates the creativity borne of necessity, beautifully illustrating the spirit that has made splinting such an important contribution to rehabilitation of the hand. Our second article is a new variation on a popular theme, static progressive splinting. For readers interested in the theory of static progressive splinting, two scientific articles in this issue discuss the concept in detail—”A Proposed Decision Hierarchy for Splinting the Stiff Joint, with an Emphasis on Force Application Parameters” (p. 158), by Ken Flowers, and “Static Progressive Splinting” (p. 163), by Karen Schultz-Johnson.—PEGGY FILLION, OTR, CHT

Gail N. Groth, MHS, OTR, CHT
Rehab in Motion Watertown, Wisconsin

Julius Kamwesiga, OT
Program in Occupational Therapy Makerere University Kampala, Uganda

No thermoplastics in the supply cabinet? Just grab a length of bark cloth, and go to it! Therapists in Uganda have been using bark cloth for decades, maybe centuries. In Third World countries, therapists have learned creative solutions to the problems they encounter. Their creativity is fostered by necessity, since western technologies, if available, are rarely affordable. Furthermore, western solutions often infringe on local culture and tradition. While familiar with the properties of low-temperature thermoplastics, the professors at the Makerere University in Kampala, Uganda, recognize the impracticality of training their students in the use of
Gail Groth was the recipient of the 2001 Vargas International Hand Therapist Teaching Fellowship from the American Association of Hand Surgeons. This enabled her to volunteer at the Mulago Hospital in Kampala, Uganda, in May 2001. Correspondence and reprint requests to Gail Groth, MHS, OTR, CHT, 1406 Beacon Drive, Watertown, WI 53098; e-mail: <davegroth@mindspring.com>.

the material. It is cost-prohibitive and can be obtained only through infrequent donations. The creative solution is to teach students to fabricate custommade removable splints out of bark cloth. Bark cloth (Figure 1) is harvested from a species of fig tree, Ficus natalensis, known locally as the mutuba or banyan tree. The tree grows best in low-lying wetlands found throughout Uganda. This species of fig tree is one of few that can withstand the complete removal of its bark and then grow it back again. Local workers use a sharp knife to peel the bark away from the tree trunk. They begin just above ground level and stop debarking just below the level of the first branch. The bark is processed through a series of steps, which take two to five days to complete. The bark is laid on top of a felled tree and beaten with wooden mallets to make it more malleable. A series of wettings and dryings then transforms it into a fibrous, cloth-like material. A dye made from roots is applied, turning the bark cloth a beautiful burnt umber color. Bark cloth is traditionally used for burial shrouds and for women’s clothing. It is also used to honor royals in the Bagandan tribe. Often, it is embroidered with bright colors and made into wall hangings, coasters, and placemats that are sold at the marketplaces. It is produced primarily in Uganda, but it is also made in southern Sudan and western Kenya. Therapists have found that bark cloth splints provide sufficient immobilization, protection, and positioning for a variety of clinical conditions. Ugandan occupational therapy professors at Makerere University, in Kampala, provide the following instructions for making a bark cloth splint.



FIGURE 1. Bark cloth, made from a species of fig trees (ficus natalensis).

FIGURE 2. A small piece of ripped bark cloth.

FIGURE 3. Finger-painting flour paste onto the cloth.

FIGURE 4. Layering the cloth pieces onto the arm.

Fabrication of a Volar Wrist Splint
Preparation 1. Rip the bark cloth into small pieces, approximately 2 square inches each (Figure 2). 2. Make a flour paste by mixing approximately one part warm water with four parts flour. 3. Position the patient so that he or she is seated with the elbow on a table, forearm supinated, wrist in desired position, fingers relaxed. 4. Cut two small holes in a thin plastic bag and place the holes over the patient’s thumb and fingers. 5. Crumble pieces of newspaper into three or four balls.

Construction 1. Finger-paint the back of a piece of bark cloth with the flour paste (Figure 3). Cover the surface entirely, but not so thickly that the paste drips off. 2. Lay the piece of cloth on top of the plastic, just proximal to the distal palmar crease (Figure 4). Using broad and sweeping motions, press and smooth the piece onto the plastic. 3. Repeat this process, working distally to proximally. Place each new piece so that it overlaps approximately one third of the previous piece. CAUTION: If you overlap too much, the splint will take too long to dry. If you don’t overlap enough, the splint will lose strength—and it will lose its shape when removed from the patient’s arm for drying.

April–June 2002 203

and allow the splint to dry overnight. Remove the newspaper and plastic bag when the upper surface of the bark cloth feels dry. and to some patients. Extend the bark cloth pieces down two-thirds the length of the forearm. but a typical piece is approximately 2 x 3 yards. 4. 10. Splinting an injured extremity with a burial shroud may have a negative effect on compliance. Disadvantages of Bark Cloth Splints Bark cloth is traditionally used to shroud the dead. This is enough for six to eight splints and costs 5. and splints designed to remediate hypertonicity. The completed bark cloth splint. 4. Advantages of Bark Cloth Splints Because it is a traditional product of the Ugandan people. 5.FIGURE 5.000 shillings (about $3). 6. Gently insert the newspaper balls into the splint to protect the forearm mold. even in the most remote parts of the country. It is sold in large strips at the marketplaces. It is best used with medium to small (non-weight-bearing) splints. gently pry the bark cloth off the patient. for straps. Thread the strapping material through a slit and sew the shorter end onto the longer strap. 204 JOURNAL OF HAND THERAPY . Finally. Repeat steps 1 to 10 until the desired rigidity is obtained. The strips vary in size. they would not be appropriate for edematous body parts or for parts of the body in which significant muscular atrophy is anticipated. Bark cloth costs very little. When one layer is complete. Typically. it is somehow difficult to fix the straps on a bark cloth splint. it may take from 2 to 6 days to complete a bark cloth splint. Once formed. three layers are sufficient for most splinting purposes. Allow the splint to dry for 1 to 2 days. 7. Gently smooth each new piece as it is added. Repeat steps 3 to 5 for the remaining straps. This protracted time is prohibitive for postoperative patients and for traveling therapists who move from village to village. 5. staying in each for only a day. Therefore. 8. A completed splint is shown in Figure 5. 11. 9. 3. Finally. Sew Velcro hook-and-loop tape onto the strapping material. Varnish all surfaces with a clear polyurethane or similar product. such as long-arm splints. 2. bark cloth splints cannot be adjusted in size. Allowing for drying time. Wrap the bark cloth pieces around three quarters of the forearm diameter. Finishing 1. Thread the same strapping material through the opposite slit. bark cloth splints have proved to be durable and able to withstand heavy use. 6. Bark cloth is not suitable for all splints. the splint may not be appealing cosmetically. fold it back on itself. It is unsuitable for large splints. Trim all edges. and cut three slits (each approximately 1 inch long) on both sides of the splint. Reinsert a smaller amount of newspaper. leaving the plastic bag intact. and lightly mark the area for closure with a pencil. Bark cloth splints in particular can be very light in weight and thin (much like 3/ Orofit) 16 but have high rigidity. bark cloth is easily obtained. The thickness and durability of a bark cloth splint is easily adjusted with variation in the number of layers of cloth applied. Custom-made splints are renowned for their superior fit and comfort.

ClikStrips have measurable. ClikStrips and Reveals materials are available from WFR Corporation. The Strip (Figure 3) is 16 mm long and 0. e-mail: <davegroth@mindspring. Velcro) Solvent Liquid adhesive (like super glue) Heat pan Heat gun Scissors Hole punch Crimp tool FIGURE 3. 50 lb. medium size 25-lb test monofilament for wrist and digits. Its volar surface consists of a April–June 2002 205 . s s s s s s s s s s s s ClikStrips component 1 -inch-thick Reveals (low-temperature / 16 thermoplastic) thermoplastic Reveals Tube. for elbow Line connectors Finger sling Hook-and-loop straps (e. consecutive advancing isometric settings at 1. repeatable. CHT. Correspondence and reprint requests to Nelson Vazquez. the Strip and the Lockclip.4-mm intervals. Suite 301. all other materials and tools are available from WFR or any other national supply company that serves hand therapists. ClikStrips are made of a translucent semi-crystalline thermoplastic material.g. Materials used in fabrication of the splint. Kessler Rehabilitation Centers. heat. which is now under preliminary scientific investigation. Tools. polyamide-nylon 6/6. The material has a high resistance to wear. CHT Kessler Rehabilitation Centers Miami. The ClikStrips Strip has seven isometric advancements per centimeter (18 per inch). advancing isometric settings.. Miami. FIGURE 1. Wyckoff. OTR/L. and chemicals. The author has a financial interest in one or more products mentioned in this article. Florida Clinicians using inelastic traction (also known as static progressive splinting) will be interested in this new technique for applying inelastic mobilization forces with a low-profile component called ClikStrips. reveals.7 mm wide. King1 suggested that an inelastic mobilization mechanism should apply low-load prolonged stress to contracted tissue with consecutive.com). New Jersey (www. FL 33155.com>. including solvents. a part of the Vazquez Inelastic Mobilization System. Keep in mind that there are currently no published data that define a precise force application (in grams or newtons) for the biologically safe and effective use of inelastic traction devices like this one.INTRODUCTION TO A NEW METHOD FOR INELASTIC MOBILIZATION Nelson Vazquez. The purpose of this clinical paper is to present a simple and inexpensive technique for applying inelastic traction forces to essentially any static progressive splint design. Materials and Methods Materials and Tools (Figures 1 and 2) s s FIGURE 2. OTR/L. It has a melting point of 490° F and a locking strength of 50 lb. The ClikStrips component consists of two parts. 401 SW 42nd Avenue.

When the outrigger has cooled. c. Finger sling. The ClikStrips Strip inserted into the Lockclip. Punched hole in the strip. A completed hand-based splint using ClikStrips. Outrigger. While the material is still moldable. the elbow can also be statically mobilized. 3. Splint base. The entrance tunnels toward the smaller opening. test monofilament. The Strip is inserted into the Lockclip to engage the inelastic mobilization (Figure 4). Before it cools. Solvent is brushed on a 1 2 inch of a 2-inch-long contour tube 7 mm in diameter. d. Figure 6 shows a completed hand-based splint design using a ClikStrips component. FIGURE 4. Method The low-profile ClikStrips allow creative liberty in hand and wrist splint designs. The Lockclip (Figure 5) has an entrance with an arch projecting from it. is dipped into the heated water in the splint pan and. Crimped hinge.) / 1. Diagram of the Lockclip. FIGURE 6. once transparent. and the release tab. A line connector is slipped onto a 4-inch length of 25-lb.4166-mm intervals. The softened portion is folded to 90° for bonding to the distal border of the splint base just opposite the involved digit. showing the entrance and exit for the strip as well as the upright. (With the Lockclip properly bonded. then threaded through the line connector. Approximately 1 inch of the monofilament is slipped through one portal of the finger sling of choice. the tip of the outrigger is flattened by a sustained pinch. and a second hole is made through the flattened tip. Strip component. Punched hole for strip attachment. Lockclip. a. The hinged outrigger will move with the proximal phalanx as range of motion increases. the angled clip. The patient had a plated fifth metacarpal fracture with a resultant metacarpophalangeal joint extension contracture. Punched hole for sling attachment.series of ridged stops at 1. The outrigger should fold toward the scaphoid to follow the anatomic flexion of the metacarpophalangeal joint. (The placement site is spot-heated for 1 or 2 seconds after the solvent is applied). a crimp tool is used to form a horizontal hinge (slightly angled toward the scaphoid) at the base of the outrigger (Figure 7). The remainder of the outrigger. is molded into a cobra-like hook. There are approximately seven ridges or advancements per centimeter (approximately 18 per inch). f. the exit. one hole is made with the hole punch at the curve facing the proximal phalanx (for a 90° traction alignment of the sling relative to the proximal phalanx). At the upper rim of the exit is the angled clip. g. distal to the hinge. e. Reveals Tube bonded to base. which is controlled superiorly by the release tab. called the upright. The splint base is 1 16-inch-thick Reveals thermoplastic formed circumferentially to minimize distal migration. / 2. FIGURE 5. and then dry-heated with a heat gun. b. 206 JOURNAL OF HAND THERAPY .

The line connector is firmly compressed at both ends. This is repeated with the second portal of the sling. ensuring a unified bond. ClikStrips Lockclip. The square piece is dry heated with a heatgun until transparent (Figure 9). Cobra-shaped outrigger with hinged base and flattened tip. and is crimped to form a closed loop connecting the sling to the outrigger (Figure 8). With the outrigger positioned parallel to the proximal phalanx. b. Positioning of the outrigger in relation to the finger. The square piece is placed over the marked spot. If more than one drop of adhesive is used. 4. FIGURE 9. and the marked area on the splint base is dry-heated for 1 to 2 seconds. The Lockclip is firmly embedded into the still / transparent 1 16-inch-thick Reveals thermoplastic. The crimped hinge axis of the outrigger will not mimic flexion of the MCP joint axis. A line connector is used to join the monofilaments of both portals. to form a small closed monofilament loop around the portal. Finger sling portal. Finger sling monofilament connection to first punched hole of outrigger. d.FIGURE 7. therefore. A crimp tool is firmly compressed to form a thin hinge. a monofilament from one of the portals is passed through the first punched hole of the outrigger. Immediately. as is the mark on the splint base. FIGURE 10. an additional hole may be punched and the sling monofilament re-attached to it to maintain the optimal 90° angle of pull. c. FIGURE 8. as motion improves. April–June 2002 207 . one drop of liquid adhesive is placed on the bottom of the ClikStrips Lockclip (Figure 10). Reveals thermoplastic is dry-heated on both sides until transparent. with the crimp tool. A 1. the excess will overflow into the tunnel and hinder the ease with which the Strip moves through it. a mark is made at the proximal edge of the splint base in alignment with the scaphoid relative to the affected digit. a. One small drop of liquid adhesive is placed on the bottom of the Lockclip.5-cm square of 1/ 16 inch-thick Reveals thermoplastic is brushed with solvent on both sides. Finger sling. For the placement of the Lockclip.

at least initially. the involved digit is actively extended. b.2 According to Flowers and LaStayo. ClikStrips Strip. to form a loop. and the finger sling is placed over the proximal pha- 208 JOURNAL OF HAND THERAPY .lanx to position the hinged outrigger at its starting point. 5. and firmly pinches. The unridged proximal end of the Strip is firmly pinched and the Strip pulled through the Lockclip one click at a time.2 FIGURE 11. Because of the 100% memory and 2% shrinkage of the Reveals thermoplastic. A 3-inch length of monofilament is cut and woven through the second hole of the outrigger and then through the hole in the Strip. Implementation. Unridged proximal end. For any mobilization technique. Baseline tracking mark on strip indicates start of traction. and a small hole is punched near the cut edge (Figure 12). it is the clinician who determines the appropriate force and duration of force for a particular tissue restriction. c. The inherent feedback from each advancing visible ridge may. The indentation of the ridge immediately proximal to the angled clip is marked with a pen as a baseline and then marked subsequently as progress is made. It is very important that the patient understands the concept of incremental increases to prevent damage to tissues.3 increases in the passive range of motion of a contracted joint are directly proportional to the time the joint is maintained at end range. places the tip (not the pulp) of the thumb against the upright and the tip (not the pulp) of the index finger on the release tab. because of variances in tissue response and in the severity of injuries. at times. Each end of the monofilament is passed into a line connector and crimped. so that the material will not encroach into the Lockclip’s tunnel once the clip has been embedded. it firmly hugs the circumference of the Lockclip base as it cools and hardens. The splint is secured to the patient’s hand with hook-and-loop straps. The Lockclip is compressed into the 1/ -inch-thick 16 Reveals thermoplastic and held for 30 seconds. The tension itself is progressively altered to coincide with and maintain the matrix turnover rate4. While the pinch is maintained. however. Sizing and attachment of the ClikStrips Strip. with the entrance directly facing the outrigger (Figure 11). Sized ClikStrips Strip with punched hole and monofilament attachment to flattened tip of outrigger. The Strip is then cut 1 to 1 1/ 2 inches from the outrigger. FIGURE 12. providing an excellent bond. causing the Strip to slide out of the Lockclip in a distal direction. To disengage the Strip and release the isometric traction. no specific time can be generally established for the duration of splint application to gain motion. 6. a. With the ridges facing upward. tempt an enthusiastic patient to be too aggressive in advancing the Strip before the tissue is able to tolerate the tension. using the uninvolved hand. With the components in place and the splint base properly secured with hookand-loop straps. For this reason it is suggested that the therapist perform the advancements. the Strip is pushed through the Lockclip until the slack of the components is eliminated. the patient. the Strip is sized by slipping the unridged tip through the Lockclip and pushing it through three or four audible clicks. until the appropriate force (which does not exceed safe end range) is established. It is imperative to use 1 16-inch-thick / elastic thermoplastic material.

without need for modification. this component can be fabricated with materials found at some hardware stores. 3. Patient compliance is excellent in that they have visible. Fess EE. J Hand Ther.reveals. Each increment has a distinct.: Mosby. The influence of splinting on healing tissues. Rehabilitation of the Hand: Surgery and Therapy. makes it cosmetically acceptable. measurable feedback of their improvement. J Hand Ther. April–June 2002 209 .Conclusion The ClikStrips inherent measuring device within its ridged traction line allows for precise control in mobilization of stiff tissue. 2. Effect of total end range time o improving passive range of motion. Colditz JC. audible click per advancement to assure limited progression. Static progressive splints. It is versatile. from WFR Corporation (Wyckoff. J Hand Ther. 4. www. cost-effective and relatively simple to apply. 4th ed. It is also available commercially. LaStayo P. Mo. McCollum M. Mackin EJ. direct. New Jersey.com). 1998. Callahan AD (eds).5:36–7. In: Hunter JM. Louis. Its opaque hue blends well with Reveals and.2:157–161. St. Therapists’ management of the stiff hand. References 1. With modification. unmistakable.3:150–7. along with its low profile. 1992. 1994:1141–59. Flowers KR. 1994. King JW.

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