Rebecca: I want to welcome you all back. Hopefully you joined us for Part One, because this will be much more meaningful. Last time we talked about the functional deficits associated at each neurological level for patients with spinal cord injury. We talked about assessment and appropriate functional level and participation domain for patients with spinal cord injury. We discussed interventions designed for compensation. Today we are going to focus on restoration and recovery of function in spinal cord injury.
Upper Limb Orthoses
Algorithm for Prescription of Orthoses
Figure 1 shows an algorithm designed by the Paralyzed Veterans Administration in their upper extremity preservation clinical practice guidelines. It clinicians make decisions about appropriate splinting for patients. Sorry for the small size- you can zoom in via computer controls.
Figure 1. Algorithm for prescription of orthoses.
It breaks it down by level and is a handy tool to guide your decision making. The thing to keep in mind of course is that this is more compensatory in nature, so depending on your approach or frame of reference or your patient's goals, you might find that you deviate some from this algorithm.
Orthoses are better accepted when there is a clearly defined therapeutic program and functional gain. I work in an outpatient setting, and often I have patients show up with a bag full of splints. They do not know what they are for or how to put them on. We need to make sure that the intent is clear with your patient and that you are practicing with them at the time of prescription.
We generate low temperature thermoplastic orthoses all the time. We evaluate the need for orthoses, recommend devices, and train in their use. Then we call in an orthotist when we are ready to recommend, design, fabricate, and fit a longterm orthoses. These are generally constructed out of more durable metal and plastic alloys so they are more durable and tend to smell less over time, which is a big problem for some patients and a big reason why patients abandon their orthoses.
Goals for Therapeutic Use
In terms of therapeutic goals for orthotic use, we can increase independence, increase ease of activity, and increase spontaneity, and by that I mean the patient's ability to use their upper limb or hand as much as often as they want to. It can also improve temporal aspects of performance, so make things go quicker. It can maintain biomechanics of the upper limb and be used for contracture management. Depending on your setting, contracture management becomes really critical in terms of making sure that we maintain the biomechanics of the hand if we are aiming for any sort of restorative interventions down the road.
Classes of Orthotics
There are two classes of orthotics, static and dynamic, and both can be either therapeutic or functional. Therapeutic means that its primary goal is contracture management or maintaining the biomechanics of the hand. Functional is used for a specific task. Static splints are good for general positioning, joint protection and preservation, to maintain length in the muscle. Dynamic splints tend to be more aggressive positioning, used for contracture management, and to add strength to a particular function. Here are some resting hand splint examples in Figure 2.
Figure 2. Examples of resting hand orthoses.
The goal here is to maintain the length tension relationship and joint integrity. This is a thermoplastic, anti-spasticity resting hand splint. You can see there is pressure in the palm, separation of the fingers, and abduction of the thumb. There is both a volar or a dorsal option. This is a prefab resting hand splint on the left. This is made of more durable plastic and foam lining. This is good for somebody in sort of a longterm care setting, somebody who is going to be wearing these overnight or has skin issues.
Figure 3 shows a static functional split, in this case to prevent wrist drop. We can put the hand in a more functional position, and/or serve as a point to attach utensils.
Figure 3. Examples of functional dorsal wrist orthoses (WHO).
It is static, but it has a specific intent. These are both prefab versions. The one on the left has a more durable plastic with foam lining, and the one on the right is made of metal and synthetic leather, so it is easier to clean.
Here is a static progressive splint in Figure 4. This involves the use of inelastic components to apply torque to a joint to statically position it as close to end range as possible.
Figure 4. Example of a static progressive orthosis.
It has the advantage of maximizing total end range time, thus increasing passive range of motion. This is made with a turnbuckle, and you would just increase the distance between the brachium and the antebrachium as the patient tolerates. It is inelastic and does not move.
Next I will show you some dynamic options that have the same goal of maximizing total end range time, but they allow for some movement within that range, unlike this version. The goal of this dynamic splint in Figure 5 is to increase elbow extension.
