Splinting within Neurology

hand thermoplastic splintSplinting the neurologically impaired limb can be a challenge. A splint is defined as an appliance used to support or immobilise a part while healing takes place to correct or prevent deformity’ (Bailliere’s Dictionary, 2000).

Occupational therapists working with individuals who have experienced a neurological event are often required to assess and where appropriate fabricate splints.

Currently there is insufficient evidence to support or refute the fabrication of splints.  Studies have supported splinting, particularly for preventing contractures, reducing spasticity and pain and also improving range of movement (Hill, 1993, Pizza et al 2005). Although randomised controlled trials are few in number the demand for splinting continues to increase both in the acute setting and also during rehabilitation and beyond.


Occupational therapists with a multi-disciplinary team will agree treatment goals which may involve the fabrication and issue of splints supporting a person’s treatment plan and longer term care programme.   Although the majority of splints are mainly fabricated for the upper limb, occupational therapists also make splints for lower limbs.  The range of splints available are extensive and although off the shelf splints do exist, occupational therapists have specialists skills in fabricating splints for individuals which meet their specific needs.

In accordance with professional guidelines (College of Occupational Therapists Code of Conduct 2010) and also national guidelines (National Service Frameworks for Long Term Conditions, 2005) an occupational therapist will always conduct a full assessment prior to proceeding with any treatment. An upper limb assessment will not only entail a physical assessment but will also involve ascertaining from the person their functional needs, current difficulties in managing or using their affected limb, and also any psychological/emotional difficulties. A person is encouraged to be involved in discussions regarding treatment and also agreeing treatment goals, for example, what does the person want to achieve? How would they like to use their arm or hand? How does the arm/hand affect them psychologically or emotionally? These are all important questions to ask in order to ascertain what the person expects from wearing a splint.  Determining this will be important, particularly if the person will be responsible for maintaining a daily regime for wearing a splint.  In the same way, the views of carers is also important and also their agreement to support a regular splinting regime.

Reasons for splinting are varied and may include any number of the following reasons:
•    To align joints (corrective)
•    To reduce oedema
•    To prevent further flexion of joints
•    To promote active movement by fabricating a dynamic splint
•    To maintain a resting position of limb
•    To reduce abnormal muscle tone
•    To maintain range of movement of limbs
•    To prevent shortening of soft tissues

Splinting by no means is the be all and end all of treatment for anyone who presents with any of the above difficulties.  In my experience, splinting works best when supplemented with activity if this is possible.  Many people will receive advice and support in how to use their affected limb in function. This may involve formulating an exercise programme which incorporates functional tasks promoting specific joint movements.   If function is not possible, a person will receive practical support to help them better manage a weak limb so as to prevent problems in the future which many include:  pain, swelling, poor alignment of joints, flexion contractures, learnt non-use of a limb and muscle tone changes.

As an occupational therapist with considerable experience of splinting within neurology, the benefits of splinting have become more apparent, particularly when used in conjunction with other therapies such as physiotherapy and injection therapy.  An occupational therapist may also advise and support individuals with therapeutic activities and other functional tasks as a treatment media to splinting.  It is understandable why an individual may choose not to use a weak arm or hand which also has limited range of movement.  If movement of the limb is precarious an individual may dedicate considerable time and effort learning to use their less dominant arm or hand.  However, if this practice continues they will quickly forget how to use their dominant limb (learnt non- use).  By giving a weak limb attention, whether it is by wearing a splint, carrying out an exercise routine and/or using the limb in function, skills may be relearnt.  Weak limbs may be better managed with a splint resulting in less pain, swelling or deformity.

An occupational therapist will advise on SMART goals and support a person as they work towards achieving treatment goals. Functional goals may involve the use of a weak limb, for example:
•    To open a door independently
•    To make a drink and snack
•    To lift a cup with two hands
•    To hang my coat independently
•    To fasten a shirt requiring no help
•    To play games with my grandchildren
•    To use a knife and fork at meal times
•    To continue with gardening tasks

 

functional use of hands


Treatment goals can be endless, the most important aspect is that goals are meaningful and purposeful to the person.  It is this situation that can motivate people in continuing to work on recovery of a weak limb and which in many cases has proven very successful.  Benefits are seen and people show commitment to their recovery which may continue over months and years.

 

References:
Weller B ed. (2000) Bailliere’s Nurses Dictionary, 23rd Edition, Bailliere Tindall, London
College of Occupational Therapists, Code of Ethics and Professional Conduct (2010), College of Occupational Therapists, London
DH Long –term Conditions NSF Team (2005) The National Service Framework for Long-term Conditions, London
Hill J. (1994) The Effects of Casting on Upper Extremity Motor Disorders After Brain Injury.  The American Journal of Occupational Therapy (48) 3 p219-p224
Pizzi A, Giovanna C, Catuscia F, Verdesca S, Gripo A (2005) Application of a Volar Static Splint in Poststroke Spasticity of the Upper Limb. Archives of Physical Medicine and Rehabilitation 86 1855-9

Declan McNichol

Bill Young

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