VOLUME
II
Practical applications
ISBN 9080868418
The “orthotic philosophy” is further developed in Volume 2. Not
the technical construction of the orthosis is the starting point for splint
design but rather the presented pathology and the personal characteristics
of the patient and the splint maker.
The first step in the systematic approach to the construction of an orthosis
is a clear prescription that is well-specified either by a referring physician
or the splint maker, depending on nationally and locally accepted practice
patterns. It is important that the prescription is precise, complete, and
unambiguous in its interpretation.
The prescription need to answer the following questions:
1. What is (are) the therapeutic clinical goal(s) of the orthosis?
2. How is the treatment applied?
3. What is the target tissue that needs to be treated?
Based on the answers to questions 1-3, the following questions are being answered.
4. What are the mechanical options to the design of the orthosis?
5. What are the personal characteristics of the patient and in which personal
context will the orthosis be used?
6. What splinting and accessory materials are best suited to construct the
orthosis, what kinematic and kinetic components are needed?
7. What are the technical skills and preferences of the splint maker?
8. What is the wearing protocol?
Volume 2 aims to revisit the existing decision tree of questions (algorithm)
from a clinical perspective, and will answer the stated questions integrating
the base knowledge stated in Volume 1 with the clinical applications in mind.
Stated differently, the reader will learn in Volume 2 how to transpose a well-specified
prescription into a systematic set of decisions (algorithm) that guide the
construction plan of the orthosis and, and subsequently how to execute the
construction of the orthosis. Amongst many other considerations, this rationale
will form the key to the support point analysis that forms the basis of each
device, in specific, the intended orthosis. It not until this device is adjusted
to the individual anatomy of the patient, and forces are developed to act
on the hand of the patient, that one can call the constructed device an orthosis.
It is only then that the therapeutic implications can be assessed.
The resulting form and style of the orthosis will eventually further develop
depending on the clinical goal of the splint (pre-operative, post-operative
treatment, conservative treatment, functional assistive usuage). Also, the
orthosis will show the “hand” of the splintmaker with his or her
personal strengths and preferences. And last, but not least, the orthosis
will take the esthetical taste and preferences of the patient in consideration.
How should this book be used?
Readers who want to gain knowledge and insight in a variety of pathologies,
and their appropriate treatment using orthotic devices can use this book as
a basis for the efficient interpretation of an orthotic prescription. Therefore,
chapters in this book are designated by pathology.
Each chapter is subdivided systematically in the same order, so that the reader
can easily find the answer to his or her questions.
First, the “state of the art” of the clinical presentation of
the pathology will be summarized briefly as well as the underlying physiology
of the pathology. A list of references is provided at the end of the chapter
to enable the reader a more in-depth study of the literature addressing the
pathology.
Next follows a description of clinical treatment goals, based of the physiology
of the pathology, from which the objectives/indications for the application
of an orthosis can be derived. From this, it should be clear if the application
of a splint for the given pathology makes sense or not. It will be reasoned
which tissues need to be impacted by the splint, which anatomical boundaries
need to be included in the splint, what the nature of the physics of the interaction
between the splint and the tissues should be (static, dynamic, compression),
which wearing protocol needs to be applied, and lastly what the method of
treatment will be.
Based on these findings, an analysis will be conducted to determine the needed
points of support, and to determine simultaneously the type of device (lever
or circuit). The points-of-support analysis will be transposed to an actual
pattern for the orthosis that serves as a prototype. The presented prototypes
are based not only on the theoretical considerations but also on the extensive
clinical experience of both authors. Quite naturally, the ultimate construction
of the orthotic for an individual patient will depend on the personal traits
of the splintmaker as well as the patient, but that will not restrain the
discussion of the material properties of the splint materials that are ideally
suitable. Choosing splint material with material properties most suitable
to meet the goals of the splint will ease the efficient fabrication of the
splint, and will enhance the comfort to wear the splint for the patient. At
the end of the discussion, alternative prototypes will be shown, and their
advantages and disadvantages will be discussed.
In an effort to maintain focus and clarity of discussions, we limit the discussion
of the pathology to the classical presentation of each pathology, and will
not discuss in detail side-effects, or secondary consequences of the pathologies,
even if they commonly occur.
Occasionally, a case presents his or her self to the splint maker for whom
a readily existing split design is not available. The aim of this textbook
is that the reader can find guidance in a chapter dedicated to the pathology
of the patient that will assist the splint maker to systematically state the
problems and their possible solutions. These solutions can then be adjusted
further to meet the needs of the individual case.
Systematic use of the algorithm will also enable the splint maker to anticipate
possible future problems, such as the onset of edema, and incorporate proactive
solutions in the orthosis targeted to prevent the emergence of these problems.
Example of a wrist splint management for a radial nerve injury:
Splint indications
Wrist and MP joint mobilization
Anatomical boundaries
The paralysis affects the wrist, the MP joints and the thumb. The splint must
extend from the proximal one-third of the forearm down to the PIP joints of
the four digits and the IP joint of the thumb.
Mechanical considerations
All joints (wrist and MP’s) require extension support. In addition the
thumb needs abduction support.
To achieve extension of the joints 3 point lever systems are required.
For the sake of user friendliness, functionality, and mechanical advantage
a lateral design with fixation strap is chosen.
Technical considerations
Because of the long rehabilitation period both LTTP and HTTP materials can
be used. LTTP materials need to be stable, stiff and rigid, 3mm (1/8”)
thickness, non-perforated, maximum resistance to stretch and with strong bonding
properties for ease of application and fixation of hinges.
Kinametic and kinetic elements for the wrist consist of lateral spring coils,
made from 1,5 mm (1/16”) stainless steel spring wire, wound into 2 or
3 coils of 1,5 cm (1/16”) diameter each. For the MP joints semicircular
arches are made out of 1 mm (1/25") stainless steel with at the proximal
end 2 to 3 small coils (minimum diameter 3 mm (1/8")) to create more
flexibility for the curved arch. Finger loops made from Velcro® or leather
are not necessary when the arch fits precisely around the finger and the spring
wire is coated with soft material.
The proximal fixation strap is 5 cm (2”) wide. An additional smaller
strap at the wrist is useful to ensure stability during supination. A soft
lining at the wrist is a necessity.
Wearing protocol and force application
This splint clearly has a functional character en will only be used by the
patient when performing certain tasks. The force of the spring wires is dependent
on each individual and will need careful calculation. The torque force to
balance the weigth of a drop hand in neutral is for a male adult on average
4000 g.cm, for females 1500 g.cm and for children (12 yr) 1000 g.cm. For raising
the digits, on average a force of 1N is needed, measured at the PIP joint
level (=300 g/cm torque).
Alternative designs
In daily practice, many therapists are satisfied using a static mobilization
of the wrist and possibly even for the MP joints.
A combination of a static wrist splint with a dynamic MP splint is a
good alternative because it allows the fingerextension assist to be removable.
To allow for lateral movement at the wrist, which can be important for
certain activities, there is a possibility to place a hinge at the axis for
deviation.
What you should not look for in this book.
- Cook book recipes for othoses. Experience has taught us that the cook book
approach to the fabrication of orthoses leads to misunderstandings and ill-adjusted
splints.
- A technical manual to guide the therapist step by step through the fabrication
of a splint. Fabrication depends too much on the choice of materials, practice
setting, technical skills and preferences of the splint maker.
- In-depth discussion of pathology. Each chapter will include references to
important in-depth literature in the field.
- Scientific evidence to indicate clinical effectiveness of used orthoses.
Scientific evidence is offered when needed to justify the orthotic treatment.
- Treatment protocols.
What you can expect to find in this book.
- A summary of frequently occurring pathologies and their treatment by mechanical
means.
- A systematic proactive approach to orthotic design problems with sensible,
easy to understand solutions.
- Sound guidance to facilitate the choice of used materials.
- Tips to make child-friendly splints.
- Guidance to solve problems that may arise during a treatment plan using
orthotics.
What approach is used in this textbook regarding the choice of materials
and fabrication of an orthotic?
In Volume 1 we at length discussed characteristics of currently used orthotic
materials and accessory materials, independent of commercial considerations.
In this Volume, we suggest a choice of material for each discussed orthotic
design, but without mentioning brand names. Both authors have their personal
brand name preferences, but will not force these preferences onto the reader.
The suggestions are based on the knowledge of material properties of the products
and on the clinical experiences of the authors.
As stated previously, a detailed step-by-step description of the technical
fabrication will not be given, because the used fabrication procedure may
depend on the skill of the splint maker and the availability of materials.
Many companies provide guidance and instructions to use their splint materials
that take the material properties of their products in consideration.
The success of splint fabrication depends more on the material properties
of the products, the planning and fabrication skills of the splint maker than
on the brand names of the used products!
The authors hope that publication of Volume 2 of this textbook will stimulate
the creation of innovative splint designs. We hope that these future splints
will please the splint maker, will help solve clinical problems, and will
please and help patients!
CONTENT
- Nerve injuries, including brachial plexus and peripheral nerves
- Flaccid, as well as spastic central nerveous system lesions
- Tendon pathologies including overuse syndromes and surgical repairs of lacerations
- Arthritis, including rheumatoid- and osteoarthritis as well as Duypytren’s
disease
- The stiff hand, either resulting from complex regional pain syndrome, ischemia
or long standing immobilization
- Burns
- Paedriatic conditions with emphasis on congenital deformities and central
brain injuries