Introduction to Orthotics

A Clinical Reasoning & Problem-

Solving Approach

FIFTH EDITION

Brenda M. Coppard, PhD, OTR/L,

FAOTA
Professor, Associate Dean for Assessment, Department of Occupational
Therapy, Creighton University, Omaha, Nebraska

Helene L. Lohman, OTD, OTR/L,

FAOTA
Professor, Department of Occupational Therapy, Creighton University,
Omaha, Nebraska
Table of Contents

Instructions for online access

Cover image

Title page

Copyright

Dedication

Contributors

Preface

Acknowledgments
Unit One. Orthotic Foundations

1. Foundations of Orthotics

Definition of Splint and Orthosis

Historical Synopsis of Orthotic Intervention

 Professionals WHO Make Orthoses

Occupational Therapy Theories, Models, and Frame-of-

Reference Approaches for Orthotic Intervention

Categorization of Orthotics

Terminology of Orthotic Designs

Evidence-Based Practice and Orthotic Provision

2. Occupation-Centered Orthotic Intervention

Three Lens’ of Occupation

The Influence of Occupational Desires on Orthotic Design and

Selection

Evidence to Support Preservation of Occupational Engagement

and Participation

Utilizing an Occupation-Centered Approach to Orthotic

Intervention

Orthotic Design Options to Promote Occupational Engagement

And Participation

Summary

3. Orthotic Processes, Tools, and Techniques

Thermoplastic Materials

Thermoplastic Material Content and Properties

Process: Making the Orthosis

 Prefabricated Orthoses

Orthotic Workroom or Cart

Documentation and Reassessment

4. Anatomical and Biomechanical Principles Related to Orthotic

Provision

Basic Anatomical Review for Orthotic Intervention

Shoulder Joint

Elbow Joint

Wrist Joint

Finger and Thumb Joints

Extrinsic Muscles of the Hand

Intrinsic Muscles of the Hand and Wrist

Arches of the Hand

Anatomical Landmarks of the Hand

Grasp and Prehensile Patterns

Biomechanical Principles for Orthotic Intervention

Contour

Mechanics of Skin and Soft Tissue

Summary
5. Clinical Examination for Orthotic Intervention

Clinical Examination

Post–Orthotic Provision Evaluation and Follow-Up

Orthotic Precautions

Adherence

Orthotic Care

Summary

Unit Two. Orthosis for Conditions and

Populations

6. Clinical Reasoning for Orthotic Intervention

Clinical Reasoning Models

Clinical Reasoning Throughout the Intervention Process

Orthotic Intervention Approach and Design Considerations

Clinical Reasoning Considerations for Designing and Planning the

Orthosis

Postfabrication Monitoring

Evaluation and Adjustment of Orthoses

Orthotic-Wearing Schedule Factors

Discontinuation of an Orthosis

Cost and Payment Issues

 Orthotic Intervention Error and Client Safety Issues

7. Orthoses for the Wrist

Volar, Dorsal, Ulnar, Circumferential, and Dart Thrower’s Wrist

Orthoses

Features of the Wrist Immobilization Orthosis

Wrist Joint Contracture: Serial Orthotic Intervention with a Wrist

Orthosis

Fabrication of a Wrist Immobilization Orthosis

Prefabricated Orthoses

Impact on Occupations

Summary

8. Thumb Immobilization Orthoses

Functional and Anatomical Considerations for Orthotic

Intervention of the Thumb

Features of the Thumb Immobilization Orthosis

Diagnostic Indications

Fabrication of a Thumb Immobilization Orthosis

Fabrication of a Dorsal Hand-Based Thumb Immobilization

Orthosis

Impact on Occupations

Prefabricated Orthoses
 Summary

9. Hand Immobilization Orthoses

Preformed Hand Orthoses

Precut Orthotic Kits

Customized Orthoses

Purpose of the Resting Hand Orthosis

Components of the Resting Hand Orthosis

Resting Hand Orthosis Positions

Diagnostic Indications

Fabrication of a Resting Hand Orthosis

Precautions for a Resting Hand Orthosis

10. Elbow and Forearm Immobilization Orthoses

Anatomical and Biomechanical Considerations

Clinical Indications and Common Diagnoses

Features of Elbow and Forearm Orthoses

Fabrication of a Posterior Elbow Immobilization Orthosis

Technical Tips for A Proper Fit

Precautions for Elbow Immobilization Orthoses

11. Orthoses for the Shoulder

Anatomical and Biomechanical Considerations

Common Diagnoses

Shoulder Orthoses

Airplane Orthoses

Adduction and Internal Rotation Sling

Abduction and/or External Rotation Sling

Shoulder Support Figure-Eightorthosis

12. Orthotics for the Fingers

Functional and Anatomical Considerations of Orthotics for the

Fingers

Diagnostic Indications

Precautions for Finger Orthotics

Occupation-Based Orthotics

Fabrication of A Dorsal-Volar Mallet Orthosis

Prefabricated Mallet Orthoses

Fabrication of A Proximal Interphalangeal Gutter Orthosis

Fabrication of A Proximal Interphalangeal Hyperextension Block

(Swan Neck Orthosis)

Impact of Swan Neck Deformities on Occupations

 Fabrication of A Three-Point Proximal Interphalangeal Extension
Low-Profile Orthosis

Prefabricated Proximal Interphalangeal Extension Orthoses

Impact of Proximal Interphalangeal Flexion Contractures on

Occupations

Fabrication of A Finger-Based Trigger Finger Orthosis

Prefabricated Trigger Finger Orthosis

Impact of Trigger Finger on Occupations

Fabrication of the Distal Interphalangeal Stabilization Orthosis

Prefabricated Distal Interphalangeal Stabilization Orthosis

Impact of Distal Interphalangeal Osteoarthritis on Occupations

Conclusion

13. Mobilization Orthoses: Serial-Static, Dynamic, and Static-

Progressive Orthoses

Goals of Mobilization Orthoses

Types of Mobilization Orthoses

Biomechanical Principles

Common Features of Mobilization Orthoses

Technical Tips for Dynamic Orthotic Fabrication

Materials and Equipment Needed to Fabricate A Dynamic

Orthosis
 Precautions for A Mobilization (Dynamic) Orthosis

Clinical Considerations for Mobilization Orthoses

14. Orthotic Intervention for Nerve Injuries

Peripheral Nerve Anatomy

Nerve Injury Classification

Surgical Nerve Repair

Purposes of Orthotic Intervention for Nerve Injuries

General Guidelines for Orthotic Provision with Nerve Injuries

Upper Extremity Compression Neuropathies

Locations of Nerve Lesions

Substitutions

Prognosis

Radial Nerve Injuries

Ulnar Nerve Injuries

Median Nerve Lesions

Summary

15. Orthotic Provision to Manage Spasticity

Spasticity

Orthotic Designs for the Neurologically Impaired Hand

 Managing the Neurologically Impaired Hand Using a Problem-
Solving Approach

16. Orthotic Intervention for Older Adults

Treatment Settings and Orthotic Designs

Age-Related Changes and Medical Conditions Impacting Orthotic

Intervention

Medications and Side Effects

Purposes of Orthoses for Older Adults

Orthotic Intervention Process for an Older Adult

Cost and Payment Issues

17. Orthoses for the Pediatric Population

Purpose of Orthoses for Pediatrics

Goals

Development

Common Pediatric Upper Extremity Conditions

General Principles for Orthotic Fabrication

Evidence for Orthotic Intervention for Children

Summary

Unit Three. Topics Related to Orthosis

18. Lower Extremity Orthotics

Role of the Occupational Therapist

Interdisciplinary Approach

Orthotic Design Principles

Foot Orthoses

Ankle-Foot Orthoses

Knee Orthoses

Knee-Ankle-Foot Orthoses

HIP Orthoses

HIP-Knee-Ankle-Foot Orthoses

Summary

19. Casting

Diagnostic Indications for Casting

Contraindications to Casting

Evidence for Casting

Upper Extremity Assessment for Casting

Assessment Between Casts

Client Participation And Other Client Factors

Types of Casts, Rationale for Use, Instruction for Application

 Protocol

Casting Materials

Rigid Circular Elbow Cast

Rigid Circular Wrist Cast

Long Arm Cast

Wrist Cast with the Thumb Included

Metacarpophalangeal Wrist Cast

Metacarpophalangeal Wrist Cast to Increase Flexion of the

Metacarpophalangeal and Proximal Interphalangeal Joints

Functional Cast Therapy

Thumb Spica with Functional Cast Therapy Materials

Functional Cast Therapy Materials (Table 19.13)

Cast Removal

Summary

20. Upper Extremity Prosthetics

Reasons and Causes for Upper Extremity Amputations

General Knowledge of Upper Extremity Amputations and their

Impact On Function

Role of Team Members and the Importance of Collaboration

Prosthetic Options and Components

 The Prosthetic Rehabilitation Process

Phases of Rehabilitation

Secondary Conditions

Psychological and Social Issues of Clients with Amputations

Upper Extremity Prosthetic Intervention for Children

Marketing Strategies and Recommendations

21. Professional Development in Upper Extremity Rehabilitation

Entry-Level Practice in Upper Extremity Rehabilitation

Specialty Areas in Occupational Therapy

Professional Development for Experienced Therapists

Supplement for 13. Mobilization Orthoses: Serial-Static, Dynamic, and

Static-Progressive Orthoses

Dynamic Orthotic Provision for Flexor Tendon Injuries

Static-Progressive Approach for Composite Finger Flexion

Glossary

Appendix A. Answers to Self-Quizzes, Case Studies, and Laboratory

Exercises

Appendix B. Web Resources and Vendors

Index
Copyright

INTRODUCTION TO ORTHOTICS: A CLINICAL REASONING

ISBN: 978-0-323-52361-5 AND PROBLEM-SOLVING APPROACH,

FIFTH EDITION
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Dedication

This work is dedicated to the late Roman Renner, my

beloved father, my family, and the Creighton community.

Brenda M. Coppard

This book is dedicated to my late husband, Michael, who

passed away during the time of our work on this edition. He
was an occupational therapist and an orthotist who inspired
me to enhance my skills with orthotics.

Helene Lohman
Contributors
Debbie Amini, EdD, OTR/L, FAOTA , Director of Professional
Development, Business Operations, AOTA, Bethesda, Maryland

Salvador Bondoc, OTD, OTR/L, FAOTA , Professor and Chair,

Department of Occupational Therapy, Quinnipiac University,
Hamden, Connecticut

Paul Bonzani, BS/OT MHS, CHT , Assistant Clinical Professor,

Occupational Therapy, University of New Hampshire, Durham, New
Hampshire

Brenda M. Coppard, PhD, OTR/L, FAOTA , Professor of

Occupational Therapy;, Associate Dean for Assessment, School of
Pharmacy & Health Professions, Creighton University, Omaha,
Nebraska

Yvette Elias, BS/OT , Clinical Specialist, Certified Hand Therapist,

Department of Occupational Therapy, Nicklaus Children’s Hospital,
Miami, Florida

William Finley, BS Health Science, MS Occupational Therapy

Senior Clinical Instructor, Orthopedic Center, New York University
Langone Medical Center, New York, New York
Lead Instructor, Continuing Education, Gold Standard Seminars, LLC,
Montclair, New Jersey
Faculty, Physical Medicine and Rehabilitation, New York University
Langone Medical Center, New York, New York

John P. Jackson, EdD , Chair and Program Director of MOT

Program, Master of Occupational Therapy, Emory and Henry College,
School of Health Sciences, Marion, Virginia

Elizabeth Kloczko, OTD, OTR/L , Clinical Assistant Professor,

Department of Occupational Therapy, Quinnipiac University,
Hamden, Connecticut

Debra Latour, OTD, MEd, BS

Assistant Professor of Practice, Division of Occupational Therapy,
Western New England University, Springfield, Massachusetts
Owner, Single-Handed Solutions, LLC, Springfield, Massachusetts

Helene L. Lohman, OTD, OTR/L, FAOTA , Professor,

Occupational Therapy, Creighton University, Omaha, Nebraska

Marlene A. Riley, BA, MMS , Clinical Associate Professor,

Department of Occupational Therapy & Occupational Science,
Towson University, Towson, Maryland

Tara Ruppert, OTD , Assistant Professor, Occupational Therapy,

College of Saint Mary, Omaha, Nebraska

Linda Scheirton, PhD

Professor, Occupational Therapy, Creighton University, Omaha,
Nebraska
Faculty Associate, Center for Health Policy and Ethics, Creighton
University, Omaha, Nebraska

Kris Vacek, OTD, OTR/L , Dean, College of Health and Human

Services, Rockhurst University, Kansas City, Missouri

Kristin Valdes, OTD, OT, CHT , Assistant Professor, Occupational

Therapy, Gannon University, Ruskin, Florida

Audrey Yasukawa, BSE, MOT , Chief of Occupational Therapy,

Developmental and Rehab Services, La Rabida Children’s Hospital,
Chicago, Illinois
EVIDENCE-BASED PRACTICE CHART CONTRIBUTORS

Andrea Coppola, OTD, OTR/L , Assistant Professor, Occupational

Therapy, Springfield College, Springfield, Massachusetts

Whitney Henderson, OTD, MOT, OTR/L , Assistant Clinical

Professor, Department of Occupational Therapy, University of
Missouri-Columbia, Columbia, Missouri
Preface
Over two decades ago, as instructors in a professional occupational
therapy program, we were unable to find an introductory orthotic
textbook that addressed the development of orthotic theory and skills.
This quest resulted in writing the first and subsequent editions of
Introduction to Orthotics: A Clinical Reasoning and Problem-Solving
Approach. Entry-level occupational therapy practitioners are expected
to have fundamental skills in orthotic theory, design, and fabrication.
It is unrealistic to assume that students gain these skills through
observation and limited experience in didactic course work or
fieldwork. With the growing emphasis in the health care environment
on accountability, productivity, and efficacy, educators must
determine the skills students need to apply theory to practice. The
book emphasizes clinical reasoning to help students develop skills to
critically and effectively provide orthotics in any area of practice.
Additionally, laboratory activities intentionally guide the students to
fabricate and evaluate a variety of orthoses. We know you have a
choice in textbook selection and are hopeful you will consider this
important textbook as required reading material for orthotic theory
and practical skills.
Several features are improved in this fifth edition. Updated
evidence-based orthotic provision is emphasized throughout the
chapters, both in narrative and table formats. A focus on occupation-
based orthotic intervention is present, and the Occupational Therapy
Practice Framework terminology is incorporated throughout the book.
In alignment with practice trends, new chapters address casting,
orthoses for the shoulder, and professional issues related to upper
extremity rehabilitation. The latest information from experts in the
field, new patterns, and additional photographs enhance the book
tremendously.
The fifth edition of Introduction to Orthotics: A Clinical Reasoning and
Problem-Solving Approach is again designed with a pedagogy to
facilitate the process of applying theory to practice in relationship to
orthotic provision. The pedagogy employed within the book facilitates
learning to meet the unique needs of students’ preferred learning
styles. Resources for students and educators on the Evolve website are
expanded. Students have access to video clips, supplemental material
for Chapter 13, and additional client resources, manufacturer
resources, and tests and measures for Chapter 20. Educators have
access to the image collection and a new test bank. The website
provides visual and auditory instructions on orthotic provision.
Additional case studies stimulate clinical reasoning and problem-
solving skills. Self-quizzes and review questions with answers
provide the reader with excellent tools to test immediate recall of basic
information. Readers are guided through orthotic fabrication in the
laboratory with more illustrations and photographs than in the
previous editions. The forms provided in the book present
opportunities to promote reflection and to assist students’
development of their self-assessment skills. Case studies, orthotic
analyses, and documentation exercises are examples of learning
activities designed to stimulate authentic problem solving. The
learning exercises and laboratory experiences provide opportunities to
test clinical reasoning and the technical skills of orthotic pattern
design and fabrication.
This text is primarily designed for entry-level occupational therapy
students, occupational therapy practitioners, and interdisciplinary
practitioners who need development in orthotic provision, therapists
re-entering the field, and students on fieldwork. Students continue to
report they find the book beneficial because it facilitates the mastery of
basic theory and furthermore the principles and techniques of
orthotics skills that entry-level clinicians need for clinical competence.
Instructors enthusiastically welcome the text because the text is
targeted for entry-level occupational therapy students. Novice
practitioners also report that the book enhances the development of
knowledge and skills related to orthotics.
A cadre of expert contributors revised and expanded chapters that
reflect current practice. This edition of Introduction to Orthotics
contains 21 chapters. The first 5 chapters consist of foundations of
orthotics; occupation-based orthotic provision; orthotic tools,
processes, and techniques; anatomical and biomechanical principles;
and assessment related to orthotic provision. These chapters provide
fundamental information, which is built upon in subsequent chapters.
Chapter 6 addresses thorough clinical reasoning processes used in
making decisions about practice involving orthotic design and
construction. The material presented in this chapter relates to
answering questions of case studies presented in subsequent chapters.
Chapters 7 through 12 present the theory, design, and fabrication
process of common orthoses used in general clinical practice. Orthoses
for the wrist, hand, thumb, elbow, and fingers are addressed. A new
chapter in this edition is dedicated to the shoulder and orthotic
provision.
The remaining chapters in the book are geared toward more
specialized topics and to intermediate-to-advanced orthotic provision.
Topics include mobilization orthoses, orthotic provision for nerve
injuries, spasticity management orthoses, orthotics for elders and
children, orthoses for the lower extremity, and prosthetics. We are
pleased to offer two new chapters in this section. The chapter on
casting offers knowledge and skills related to upper extremity casting.
The last chapter of the book addresses professional issues related to
hand therapy and orthotic provision. Written by a certified hand
therapist, the chapter offers suggestions for professional development
and career planning for the certification examination to those who are
interested in this professional specialty area of practice.
A glossary of terms used throughout the book follows Chapter 21.
This book contains two appendixes. Appendix A provides answers to
quizzes, laboratory exercises, and case studies. Appendix B contains
listings of web resources.
Although many therapists reviewed this book, each experienced
therapist and physician may have a personal view on orthotic
provision and therapeutic approaches and techniques. This book
represents the authors’ perspectives and is not intended to present the
only correct approach. Thus therapists are encouraged to employ their
clinical reasoning skills in practice.
We hope this fifth edition of the book complements your
professional development and continued competence!
Brenda M. Coppard, PhD, OTR/L, FAOTA, and Helene
L. Lohman, OTD, OTR/L, FAOTA
Acknowledgments
The completion of this fifth edition was made possible through the
efforts of many individuals. We are grateful to Mojca Herman, MA,
OTR/L, CHT, for the peer reviewing of drafts and revisions of
chapters. We are grateful to Phil Beagle for his photography work.
Additionally, we appreciate the talent and expertise of the following
contributor authors to the current and previous editions: Debbie
Amini, EdD, OTR/L, CHT; Omar Aragon, OTD, OTR/L; Janet Bailey,
OTR/L, CHT; Serena M. Berger, MA, OTR; Shirley Blanchard, PhD,
OTR/L, ABDA, FAOTA; Salvador Bondoc, OTD, OTR/L, FAOTA; Paul
J. Bonzani, MHS, OTR/L, CHT; Maureen T. Cavanaugh, MS, OTR;
Cynthia Cooper, MFA, MA, OTR/L, CHT; Andrea Coppola, OTD, MS,
OTR/L; Lisa Deshaies, OTR/L, CHT; Beverly Duvall-Riley, MS, BSOT;
Yvette Elias, OTR/L, CHT; Stefania Fatone, PhD; William Finley, MS,
OTR/L, CSCS, CHT; Deanna J. Fish, MS, CPO; Sharon Flynn, PhD,
OTR/L, CHUT; Linda Gabriel, PhD, OTR/L; Whitney Henderson,
OTD, OTR/L; John Jackson, EdD, OTR, CHT; Karyn Kessler, OTR/L;
Elizabeth Kloczko, OTS; Debra Latour, MEd, OTR/L; Dulcey G. Lima,
OTR/L, CO; Michael Lohman, MEd, OTR/L, CO; Peggy Lynn, OTR,
CHT; Ann McKie, OTR/L; Debra A. Monnin, OTR/L; Sally E. Poole,
MA, OT, CHT; Debbie Rider, OTR/L, CHT; Marlene A. Riley, MMS,
OTR, CHT; Christopher Robinson, MBA; Tara Ruppert, OTD, OTR/L,
CHT; Susan Salzberg, MOT, OTR/L; Linda Scheirton, PhD; Deborah
A. Schwartz, OTD, OTR/L, CHT; Lauren Sivula, OTS; Brittany Bennett
Stryker, OTD, OTR/L, CO; Joan L. Sullivan, MA, OTR, CHT; Kris
Vacek, OTD, OTR; Kristin Valdes, OTD, OT, CHT; Jean Wilwerding-
Peck, OTR/L, CHT; Aviva Wolff, OTR/L, CHT; and Audrey
Yasukawa, MOT, OTR/L.
 We thank our families, colleagues, and friends for their continual
support, encouragement, and patience. We also thank our students for
enabling us to learn from them.
UNIT ONE
Orthotic Foundations
OUTLINE

1. Foundations of Orthotics
2. Occupation-Centered Orthotic Intervention
3. Orthotic Processes, Tools, and Techniques
4. Anatomical and Biomechanical Principles Related to Orthotic
Provision
5. Clinical Examination for Orthotic Intervention
Foundations of Orthotics
Brenda M. Coppard

CHAPTER OBJECTIVES
1. Define the terms splint and orthosis.
2. Identify the health professionals who may provide orthotic
services.
3. Appreciate the historical development of orthotics as a
therapeutic intervention.
4. Apply the Occupational Therapy Practice Framework (OTPF) to
optimize evaluation and intervention for a client.
5. Describe how frame-of-reference approaches are applied to
provision of orthoses.
6. Familiarize yourself with orthotic nomenclature of the past and
present.
7. List the purposes of immobilization (static) orthoses.
8. List the purposes of mobilization (dynamic) orthoses.
9. Describe the six orthotic designs.
10. Define evidence-based practice.
11. Describe the steps involved in evidence-based practice.
12. Cite the hierarchy of evidence for critical appraisals of research.

KEY TERMS
dorsal
evidence-based practice
immobilization
mobilization
orthosis
splint
torque transmission
volar

Maria is a student who is enrolled in an orthotics course. She is a bit

anxious but is looking forward to gaining the knowledge and skills to be
competent in orthotic provision. The instructor told Maria and her
classmates that it takes time to build skills, and much practice is
necessary.

Note: This chapter includes content from previous contributions

from Peggy Lynn, OTR, CHT.
The human upper extremity helps people carry out the activities
that make their lives productive and meaningful. Dressing, bathing,
typing, cooking, scrapbooking, and driving are a few of the activities
that rely on the incredible complexity of the upper extremity.
Therefore it is obvious that impairments of and disabilities affecting
the upper extremity are often the domain of therapy intervention—
including orthotic provision.
Determining orthotic design and fabricating hand orthoses are
important aspects to providing optimal care for persons with upper
extremity injuries and functional deficits. Fabrication of orthoses is
both a science and an art. Therapists apply knowledge of occupation,
pathology, physiology, kinesiology, anatomy, psychology, payment
systems, and biomechanics to best design orthoses for persons. In
addition, therapists consider and appreciate the aesthetic value of
orthoses. People who are novices at making orthoses must be aware
that each person is different, requiring a customized approach to
orthoses. The use of occupation-based and evidence-based approaches
to orthotic provision guides a therapist’s consideration of a person’s
valued occupations. As a result, those occupations are used as both a
means (e.g., as a medium for therapy) and an end to outcomes (e.g.,
intervention goals). 13
Therapists develop and use clinical reasoning skills to effectively
evaluate and treat clients with upper extremity conditions who may
need orthotic interventions. This book emphasizes and fosters such
knowledge and skills for those who are learning how to make
orthoses in general practice areas. After therapists are knowledgeable
in the science of orthotic design and fabrication, practical experience is
essential for them to become comfortable and competent.
Definition of Splint and Orthosis
According to the American Society of Hand Therapists (ASHT) 4 , a
splint “refers to casts and strapping applied for reductions of
fractures and dislocations. Splinting is a term that should not be
utilized by therapists [who] are fabricating and issuing…orthoses.
[Splinting] is used by physician offices for applying a cast. There are
Current Procedural Terminology (CPT) codes for splinting that are
used when billing for this purpose.” 3 An orthosis is defined by ASHT
4 as a single device that is rigid or semirigid. Orthoses are applied to

support a weak or deformed body part or to restrict or eliminate

motion of a body part. Orthoses can be custom made or prefabricated.
The terms splint and orthosis are often used synonymously. However,
for payment purposes, therapists must use the proper term.
Historical Synopsis of Orthotic
Intervention
Reports of primitive orthoses date back to ancient Egypt. 10 Decades
ago, blacksmiths and carpenters constructed the first orthoses.
Materials used to make the orthoses were limited to cloth, wood,
leather, and metal. 25 Hand orthoses became an important
intervention in physical rehabilitation during World War II. Survival
rates of injured troops dramatically increased due to medical,
pharmacological (e.g., the use of penicillin), and technological
advances. During this period, occupational and physical therapists
collaborated with orthotic technicians and physicians to provide
orthoses to clients: Sterling Bunnell, MD, organized hand services at
nine army hospitals in the United States. 10 In the mid-1940s under the
guidance of Dr. Bunnell many orthoses were made and sold
commercially. During the 1950s many children and adults needed
orthoses to assist them in carrying out activities of daily living (ADLs)
secondary to poliomyelitis. 21 During this time, orthoses were made of
high-temperature plastics. With the advent of low-temperature
thermoplastic materials in the 1960s, hand orthoses became a common
intervention for clients.
Today some therapists and clinics specialize in hand therapy. Hand
therapy evolved from a group of therapists in the 1970s who were
interested in researching and rehabilitating clients with hand injuries.
6 In 1977 this group of therapy specialists established the ASHT. In

1991 the first certification examination in hand therapy was

administered. Those therapists who pass the certification examination
are credentialed as certified hand therapists (CHTs). The term CHT is
not 100% accurate in that CHTs specialize in therapy for the upper
extremity versus solely the hand.
Specialized organizations (e.g., American Society for Surgery of the
Hand and ASHT) influence practice, research, and education in upper
extremity orthoses. 8 For example, the ASHT Splint Classification
System offered a uniform nomenclature in orthotics. 9
Professionals WHO Make Orthoses
A variety of health care professionals design and fabricate orthoses.
Occupational therapists (OTs) and physical therapists (PTs) constitute
a large group of health care providers whose services include orthotic
design and fabrication. Certified occupational therapy assistants
(COTAs) and physical therapy assistants (PTAs) also assist in the
provision of orthotic services under the supervision or guidance of the
OT and PT, respectively. PTs are frequently involved in providing
orthoses for the lower extremities. Certified orthotists (COs) are
trained and skilled in the design, construction, and fitting of braces
and orthoses prescribed by physicians. Dentists provide orthoses to
address selective dental problems. Some nurses who have had special
training fabricate orthoses, typically for patients in hospital burn
units.
 FIG. 1.1 Hand therapy experience matrix.

Cooper, Zarbock, and Zondlo 7 devised a hand therapy experience

matrix to represent the collaborative roles for therapists and assistants
(Fig. 1.1). Their model represents the therapist (axis x) and assistant
(axis y) and the level of experience (low, high). In any therapist-
assistant pairing, asking questions, seeking input, and sharing
knowledge should be routine for a healthy collaborative relationship.
The context and implications according to the quadrants include the
following:

Quadrant I: Inexperienced therapist and assistant

• Will require obtaining information about diagnoses
• May require input and networking with an
experienced therapist and/or physician
 Quadrant II: Inexperienced therapist and experienced assistant
• Work collaboratively to develop an assessment and
intervention plan similar to Quadrant I
• Therapist continues to supervise the assistant
Quadrant III: Experienced therapist and inexperienced assistant
• Therapist helps develop the assistant’s knowledge and
skills
• Therapist provides close supervision of assistant
Quadrant IV: Experienced therapist and experienced assistant
• Ideal pairing to continue specialization

Diagnoses that may require expertise include the following 7 :

• Complex crush injuries

• Complex regional pain syndrome (CRPS)
• Dupuytren release
• Flexor and extensor tendon injuries
• Joint replacements
• Nerve injury
• Replantations and revascularizations
• Severe burn injuries
• Severe wound infections

Orthotic design is based on scientific principles. A given diagnosis

does not necessarily specify the orthosis required. Orthotic fabrication
often requires creative problem solving. Such factors as a client’s
occupational needs and interests influence orthotic design, even
among clients who have common diagnoses. Health care professionals
who make orthoses must allow themselves to be creative and take
calculated risks. Practice is needed to become proficient with the
design and fabrication process. Students or therapists beginning to
design and fabricate orthoses should be aware of personal
expectations and realize that their skills will likely evolve with
practice. Therapists experienced in orthotic provision tend to be more
efficient with time and materials than novice students and therapists.
Occupational Therapy Theories,
Models, and Frame-of-Reference
Approaches for Orthotic Intervention
The Occupational Therapy Practice Framework (OTPF) outlines the
occupational therapy process of evaluation and intervention and
highlights the emphasis on the use of occupation. 12 Performance
areas of occupation as specified in the framework include the
following: ADLs, instrumental activities of daily living (IADLs),
education, work, play, leisure, and social participation. Performance
areas of occupation place demands on a person’s performance skills
(i.e., motor skills, process skills, and communication/interaction
skills). Therapists must consider the influence of performance patterns
on occupation. Such patterns include habits, routines, and roles.
Contexts affect occupational participation. Contexts include cultural,
physical, social, personal, spiritual, temporal, and virtual dimensions.
The engagement in an occupation involves activity demands placed
on the individual. Activity demands include objects used and their
properties, space demands, social demands, sequencing and timing,
and required actions, body functions, and body structures. Client
factors relate to a person’s body functions and body structures. Table
1.1 provides examples of how the framework assists one in thinking
about orthotic provision to a client.
Occupational therapy practice is guided by conceptual systems. 11,19
One such conceptual system is the Occupational Performance Model,
which consists of performance areas, components, and contexts. A
therapist using the Occupational Performance Model views a client’s
performance area or component while considering the context in
which the person lives, works, and plays. The therapist is guided by
several approaches in providing assessment and intervention. The
therapist may apply the biomechanical, sensorimotor, and
rehabilitative approaches. The biomechanical approach uses
biomechanical principles of kinetics and forces acting on the body.
Sensorimotor approaches are used to inhibit or facilitate normal motor
responses in persons whose central nervous systems have been
damaged. The rehabilitation approach focuses on abilities rather than
disabilities and facilitates returning persons to maximal function
using their capabilities. 11 (See Self-Quiz 1.1.)

TABLE 1.1

Examples a of the Occupational Therapy Practice Framework and Orthotic

Provision
a Examples are inclusive, not exclusive.
 a
Self-Quiz 1.1
Match the approach used in each of the following scenarios.

a. Biomechanical approach
b. Sensorimotor approach
c. Rehabilitation approach
1. _________ This approach is used on a child who has cerebral
palsy. The goal of the orthosis is to decrease the amount of tone
present.
2. _________ This approach allows a person who had a stroke to
grasp the walker by using orthoses that are adapted to assist
with grasp.
3. _________ This approach helps a person who had a tendon
repair that resulted in flexor contractures of the
metacarpophalangeal (MCP) joint regain full range of motion.

a
See Appendix A for the answer key.

Each approach can incorporate orthoses as an intervention,

depending on the rationale for orthotic provision. If the therapist is
using the biomechanical approach, a dynamic (mobilization) hand
orthosis may be chosen to apply kinetic forces to the person’s body to
increase range of motion (ROM). When the therapist chooses a
sensorimotor approach, an orthosis may be used to manage spasticity.
If a person wears a tenodesis orthosis to recreate grasp and release to
maximize function in ADLs, the therapist is using the rehabilitation
approach. 10

BOX 1.1 Contextual and Subjective Dimensions

of Occupation

Pierce’s notions 20 of contextual and subjective dimensions of

occupation are powerful concepts for therapists to use for appropriate
inclusion of orthotics into a client’s care plan. Understanding how an
orthosis affects a client’s occupational engagement and participation is
salient in meeting the client’s needs and goals, which may result in
increased adherence to the wearing schedule. Contextual dimensions
include spatial, temporal, and sociocultural contexts. 13 Subjective
dimensions include restoration, pleasure, and productivity. Box 1.1
explicates both contextual and subjective dimensions of occupation.
Pierce’s framework is used to structure questions for a client
interview.
Categorization of Orthotics
The Splint Classification System (SCS) of the ASHT was published in
1992. 14 The SCS uses the terms splint and orthosis interchangeably.
The classification system defines splints or orthoses in relationship to
the function the orthosis is performing on the body part, rather than
the diagnosis or purpose of the orthosis. In 2004 the system was
augmented with the inclusion of two device groups: splint-prostheses
and prostheses. 12 Thus there are generally two types of terminology
lexicons in practice: (1) terminology that preceded the SCS and (2) the
SCS, which began in the 1990s. Not all clinics use the SCS orthotic
terminology. Therapists must be familiar with the SCS and older,
commonly used nomenclature.
According to the ASHT, 3 there are six orthotic classification
divisions (Fig. 1.2):

• Identification of articular or nonarticular

• Location
• Direction
• Purpose
• Type
• Total number of joints

Identification of Articular or Nonarticular

The first element of the ASHT classification indicates whether or not
an orthosis affects articular structures. Articular orthoses use three-
point pressure systems “to affect a joint or joints by immobilizing,
mobilizing, restricting, or transmitting torque.” 3 Most orthoses are
articular, and the term articular is often not specified in the technical
name of the orthosis.
 FIG. 1.2 Expanded orthotic classification system division.
From Fess, E. E., Gettle, K. S., Philips, C. A., et al. [2005]. Hand and
upper extremity splinting: Principles and methods [3rd ed.]. St. Louis,
MO: Elsevier Mosby.

Nonarticular orthoses use a two-point pressure force to stabilize or

immobilize a body segment. 3 Thus the term nonarticular should
always be included in the name of the orthosis. Examples of
nonarticular orthoses include those that affect the long bones of the
body (e.g., humerus).

Location
Orthoses, whether articular or nonarticular, are further classified
according to the location of primary anatomical parts included in the
orthosis. For example, articular orthoses will include a joint name in
the orthosis (e.g., elbow, thumb metacarpal [MP], index finger
proximal interphalangeal [PIP]). Nonarticular orthoses are associated
with one of the long bones (e.g., ulna, humerus, radius).

Direction
Direction classifications are applicable to articular orthoses only.
Because all nonarticular orthoses work in the same manner, the
direction is not specified. Direction is the primary kinematic function
of orthoses. Such terms as flexion, extension, and opposition are used to
classify orthoses according to direction. For example, an orthosis
designed to flex the PIP joints of index, middle, ring, and small fingers
would be named an index–small-finger PIP flexion orthosis.

Purpose
The fourth element in the ASHT classification system is purpose. The
four purposes of orthoses are (1) mobilization, (2) immobilization, (3)
restriction, and (4) torque transmission. The purpose of the orthosis
indicates how the orthosis works. Examples include the following:

• Mobilization: Wrist/finger-MP extension mobilization orthosis

• Immobilization: Elbow immobilization orthosis
• Restriction: Elbow extension restriction orthosis
• Torque transmission: Finger PIP extension torque transmission
orthosis, type 1 (2). (The number in parentheses indicates the
total number of joints incorporated into the orthosis.)
 Mobilization orthoses are designed to move or mobilize primary
and secondary joints. Immobilization orthoses are designed to
immobilize primary and secondary joints. Restrictive orthoses “limit a
specific aspect of joint range of motion for the primary joints.” 3 The
purpose of torque transmission orthoses is to “(1) create motion of
primary joints situated beyond the boundaries of the orthosis itself or
(2) harness secondary ‘driver’ joint(s) to create motion of primary
joints that may be situated longitudinally or transversely to the
‘driver’ joint(s).” 8 Torque transmission orthoses, illustrated in Fig. 1.3,
are also referred to as exercise orthoses.

Type
The type classification specifies the secondary joints included in the
orthosis. Secondary joints are often incorporated into the orthotic
design to affect joints that are proximal, distal, or adjacent to the
primary joint. There are 10 joint levels that constitute the upper
extremity: shoulder, elbow, forearm, wrist, finger MP, finger PIP,
finger distal interphalangeal (DIP), thumb carpometacarpal (CMC),
thumb metacarpophalangeal (MCP), and thumb interphalangeal (IP)
levels. Only joint levels are counted, not the number of individual
joints. For example, if the wrist joint and multiple finger PIP joints are
included as secondary joints in an orthosis, the type is defined as 2.
(PIP joints account for one level, and the wrist joint accounts for
another level, thus totaling two secondary joint levels.) The technical
name for an orthosis that flexes the MCP joints of the index, middle,
ring, and small fingers and incorporates the wrist and PIP joints is an
index–small-finger MCP flexion mobilization orthosis, type 2. If no
secondary joints are included in the orthotic design, the joint level is
type 0.
 FIG. 1.3 Torque transmission orthoses may create motion of primary
joints situated longitudinally (A) or transversely (B) according to
secondary joints.
From Fess, E. E., Gettle, K. S., Philips, C. A., et al. [2005]. Hand and
upper extremity splinting: principles and methods [3rd ed.]. St. Louis,
MO: Elsevier Mosby.

Total Number of Joints

The final ASHT classification level is the total number of individual
joints incorporated into the orthotic design. The number of total joints
incorporated in the orthosis follows the type indication. For example,
if an elbow orthosis includes the wrist and MCPs as secondary joints,
the orthosis would be called an elbow flexion immobilization orthosis,
type 2 (3). (The number in parentheses indicates the total number of
individual joints incorporated into the orthosis.)
Terminology of Orthotic Designs
The purpose for an orthosis as a therapeutic intervention assists the
therapist in determining its design. Several orthotic designs exist.
Orthotic design classifications include the following 3,5 :

• Static
• Serial static
• Dropout
• Dynamic
• Static-progressive

Static orthoses have no movable parts. 3,5 In addition, static orthoses

place tissues in a stress-free position to enhance healing and to
minimize friction. 3,5 A static or immobilization orthosis (Fig. 1.4) can
maintain a position to hold anatomical structures at the end of
available ROM, thus exerting a mobilizing effect on a joint. 3,5 For
example, a therapist fabricates an orthosis to position the wrist in
maximum tolerated extension to increase extension of a stiff wrist.
Because the orthosis positions the shortened wrist flexors at maximum
length and holds them there, the tissue remodels in a lengthened
form. 15
Serial static orthoses (Fig. 1.5) require the remolding of a static
orthosis. The serial static orthosis holds the joint or series of joints at
the limit of tolerable range, thus promoting tissue remodeling. As the
tissue remodels, the joint gains range, and the practitioner remolds the
orthosis to once again place the joint at end range comfortably.
A dropout orthosis (Fig. 1.6) allows motion in one direction while
blocking motion in another. 3 This type of orthosis may help a person
regain lost ROM while preventing poor posture. For example, an
orthosis may be designed to enhance wrist extension while blocking
wrist flexion. 3,5
Dynamic (mobilization) orthoses have one or more movable parts.
16,23 Elastictension dynamic (mobilization) orthoses (Fig. 1.7) have
self-adjusting or elastic components, which may include wire, rubber
bands, or springs. 16 An orthosis that applies an elastic tension force to
straighten an index finger PIP flexion contracture exemplifies an
elastic tension/traction dynamic (mobilization) orthosis.
Static-progressive orthoses (Fig. 1.8) are types of dynamic
(mobilization) orthoses. They incorporate the use of inelastic
components, such as hook-and-loop tapes, outrigger line, progressive
hinges, turnbuckles, and screws. The orthotic design incorporates the
use of inelastic components to allow the client to adjust the amount of
tension to prevent overstressing of tissue. 16 Chapter 13 more
thoroughly addresses mobilization and torque transmission
(dynamic) orthoses.
Many possibilities exist for orthotic design and fabrication. A
therapist’s creativity and skills are necessary for determining the best
orthotic design. Therapists must stay updated on orthotic techniques
and materials, which change rapidly. Reading professional literature
and manufacturers’ technical information helps therapists maintain
knowledge about materials and techniques. A personal collection of
reference books is also beneficial, and continuing-education courses
and professional conferences provide ongoing updates on the latest
theories and techniques.
Evidence-Based Practice and Orthotic
Provision
Calls for evidence-based practice have stemmed from medicine but
have affected all health care delivery, including orthoses. 2,15,17,18,22
Sackett and colleagues 22 and Law 17 defined evidence-based practice
as “the conscientious, explicit, and judicious use of current best
evidence in making decisions about the care of individual clients. The
practice of evidence-based medicine means integrating individual
clinical expertise with the best available external clinical evidence
from systematic research.”

FIG. 1.4 Static immobilization orthosis. This static orthosis

immobilizes the thumb, fingers, and wrist.
FIG. 1.5 Serial static orthoses (A and B). The therapist intermittently
remolds the orthosis as the client gains wrist extension motion.
 FIG. 1.6 Dropout orthosis. A dorsal–forearm-based dynamic
extension orthosis immobilizes the wrist and rests all fingers in a
neutral position. A volar block permits only the predetermined
metacarpophalangeal joint flexion.
From Evans, R. B., & Burkhalter, W. E. [1986]. A study of the dynamic
anatomy of extensor tendons and implications for treatment. Journal of
Hand Surgery, 11A, 774.
 FIG. 1.7 Elastic tension orthosis This orthosis for radial nerve palsy
has elastic rubber bands and inelastic filament traction.
Courtesy Dominique Thomas, RPT, MCMK, Saint Martin Duriage,
France; from Fess, E. E., Gettle, K. S., Philips, C. A., et al. [2005].
Hand and upper extremity splinting: principles and methods [3rd ed.].
St. Louis, MO: Elsevier Mosby.

The aim of applying evidence-based practice is to “ensure that the

interventions used are the most effective and the safest options.” 22
Additionally, the American health care system increasingly
emphasizes effectiveness and cost-efficiency and less credibility of
provider preferences. 22 Essentially therapists apply the research
process for practice. This process includes (1) formulating a clear
question based on a client’s problem, (2) searching the literature for
pertinent research articles, (3) critically appraising the evidence for its
validity and usefulness, and (4) implementing useful findings to the
client case. Evidence-based practice is not about finding articles to
support what a therapist does. Rather, it is reviewing a body of
literature to guide the therapist in selecting the most appropriate
assessment or intervention for an individual client.
 Sackett and colleagues 22 and Law 17 outlined several myths of
evidence-based practice and described the reality of each myth (Table
1.2). A misconception exists that evidence-based practice is impossible
to implement or that it already exists. Although keeping current on all
health care literature is impossible, practitioners should consistently
review research findings related to their specific practice and even
consider collecting their own data for evidence. Unfortunately, some
practitioners rely primarily on their training or clinical experience to
guide decision making. Novel clinical situations present a need for
evidence-based practice.
Some argue that evidence-based practice leads to a “cookie-cutter”
approach to clinical care. Evidence-based practice involves a critical
appraisal of relevant research findings. It is not a top-down approach.
Rather, it adopts a bottom-up approach that integrates external
evidence with one’s clinical experience and client choice. After
reviewing the findings, practitioners must use clinical judgment to
determine if, why, and how they will apply findings to an individual
client case. Thus evidence-based practice is not a one-size-fits-all
approach because all client cases are different.

FIG. 1.8 Static progressive orthosis. An orthosis to increase proximal

interphalangeal extension uses hook-and-loop mechanisms for
adjustable tension.
 Evidence-based practice is not intended to be a mechanism whereby
all clinical decisions must be backed by a randomized controlled trial
(RCT). Rather, the intent is to address efficacy and safety using the
best current evidence to guide intervention for a client in the safest
way possible. It is important to realize that efficacy and safety do not
always result in a cost decrease.
Important to evidence-based practice is the ability of practitioners to
appraise the quality of the evidence available. A hierarchy of evidence
is based on the certainty of causation and the need to control bias (Fig.
1.9). 22,24 The highest quality (gold standard) of evidence is the meta-
analysis of randomized controlled studies. Next in the hierarchy are
randomized controlled trials (RCT). A well-designed cohort study is
next in the hierarchy, followed by case-controlled studies and case
reports. Last in the hierarchy is expert opinion or editorials. Box 1.2
presents a list of appraisal questions used to evaluate quantitative and
qualitative research results.

TABLE 1.2

Evidence-Based Practice Myths and Realities

Myth Reality
Evidence-based practice exists. Practitioners spend too little time examining current
research findings.
Evidence-based practice is difficult to Evidence-based practice can be implemented by busy
integrate into practice. practitioners.

Evidence-based practice is a “cookie- Evidence-based practice requires extensive clinical

cutter” approach. experience.

Evidence-based practice is focused on Evidence-based practice emphasizes the best clinical

decreasing costs. evidence for individual clients.

Throughout this book the authors made an explicit effort to present

the research relevant to each chapter topic. Note that the evidence is
limited to the timing of this publication. Students and practitioners
should review literature to determine applicability of contemporary
publications. The Cochrane Library, Cumulative Index to Nursing and
Allied Health Literature (CINAHL), EBSCOhost, EMB Reviews,
MEDLINE, Embase (comprehensive pharmacological and biomedical
database), OT SEARCH, OT CATs, OTseeker, Google Scholar, Health
and Psychosocial Instruments (HaPI), Applied Social Sciences Index &
Abstracts (ASSIA), and HealthSTAR are useful databases to access
during searches for research.

FIG. 1.9 Evidence-based levels of evidence.

Modified from http://ebp.lib.uic.edu/nursing/node/2?q=node/12 and
Feree, N., & Kreider, C. M. [April 2011]. Defining and applying
strategies to find and critically assess the evidence. Presentation at
AOTA conference.

BOX 1.2 Appraisal Questions Used to Evaluate

Quantitative and Qualitative Research
Data from Gray, J. A. M. (1997). Evidence-based healthcare. Edinburgh,
Scotland: Churchill Livingstone; Krefting, L. (1990). Rigour in
qualitative research: the assessment of trustworthiness. American
Journal of Occupational Therapy, 45, 214–222; Rosenberg, W., & Donald,
A. (1995). Evidence-based medicine: an approach to clinical problem-
solving. BMJ, 310, 1122–1126.

Review Questions
1. What health care professionals provide orthotic services to
persons?
2. What are the three therapeutic approaches used in physical
dysfunction? Give an example of how orthoses could be
used as an intervention for each of the three approaches.
3. How might the OTPF 1 assist a therapist in orthotic
provision?
4. What are the six divisions of the ASHT orthosis
classification system?
5. For what purposes might an orthosis be used as part of an
intervention plan?
6. What is evidence-based practice? How can it be applied to
orthotic intervention?
7. In evidence-based practice, what is the hierarchy of
evidence?
References
1. American Occupational Therapy
Association. Occupational therapy practice
framework: doman and process, ed 3. Am J Occup
Ther . 2014;68(Suppl):S1–S48.
2. American Occupational Therapy
Association. AOTA’s evidence-based practice
resources, using evidence to inform occupational
therapy practice. April
2010. http://www.aota.org/Educate/Research/2011-
EBP-Resources.aspx?FT=.pdf.
3. American Society of Hand Therapists. splint
classification system . Garner, NC: American Society of
Hand Therapists; 1992.
4. American Society of Hand Therapists.
http://www.-asht.org/practicemgmt/codingreimb.cfm
5. Bailey J, Cannon N, Colditz J, et al. Splint
classification system . Chicago: American Society of
Hand Therapists; 1992.
6. Cailliet R. Hand pain and impairment . ed
4. Philadelphia: FA Davis; 1994.
7. Cooper C, Zarbock P, Zondlo J.W. OTR and OTA
collaboration in hand therapy. AOTA Phy Dis Spec
Int Sec Quart . 2000;23:2–4.
8. Daus C. Helping hands: a look at the progression of
hand therapy over the past 20 years. Rehab Manag
. 1998:64–68.
9. Fess E.E, Philips C.A. Hand splinting principles and
methods . ed 2. St. Louis: Mosby; 1987.
10. Fess E.E. A history of splinting: to understand the
present, view the past. J Hand Ther . 2002;15(2):97–
132.
11. Fess E.E, Gettle K, Philips C, et al. Hand and upper
extremity splinting: principles and methods . ed 3. St.
Louis: Elsevier; 2004.
12. Fess E.E, Gettle K.S, Philips C.A, et al. A history of
splinting. In: Fess E.E, Gettle K.S, Philips C.A, et
al., eds. Hand and upper extremity splinting: principles
and methods . St. Louis: Elsevier Mosby; 2005:3–43.
13. Gray J.M. Putting occupation into practice:
occupation as ends, occupation as means. Am J
Occup Ther . 1998;52(5):354–364.
14. Hill J, Presperin J. Deformity
control. In: Intagliata S, ed. Spinal cord injury: a guide
to functional outcomes in occupational therapy
. Rockville, MD: Aspen Publishers; 1986:49–81.
15. Jansen C.W. Outcomes, treatment effectiveness,
efficacy, and evidence-based practice: examples from
the world of splinting. J Hand Ther . 2002;15(2):136–
143.
16. Malick M.H. Manual on dynamic hand splinting with
thermoplastic material . ed 2. Pittsburgh: Harmarville
Rehabilitation Center; 1982.
17. Law M. Introduction to evidence based
practice. In: Law M, ed. Evidence-based rehabilitation
. Thorofare, NJ: Slack; 2002:3–12.
18. Lloyd-Smith W. Evidence-based practice and
occupational therapy. Br J Occup Ther . 1997;60:474–
478.
19. Pedretti L.W. Occupational performance: a model for
 practice in physical
dysfunction. In: Pedretti L.W, ed. Occupational
therapy: practice skills for physical dysfunction . ed 4. St.
Louis: Mosby; 1996:3–12.
20. Pierce D.E. Occupation by design: building therapeutic
power . Philadelphia: FA Davis; 2003.
21. Rossi J. Concepts and current trends in hand
splinting. Occup Ther Health Care . 1988;4(3–4):53–68.
22. Sackett D.L, Rosenberg W.M, Gray J.A, et
al. Evidence-based medicine: what it is and what it
isn’t. BMJ . 1996;312(7023):71–72.
23. Schultz-Johnson K. Splinting the wrist: mobilization
and protection. J Hand Ther . 1996;9(2):165–177.
24. Taylor M.C. What is evidenced-based practice? Br J
Occup Ther . 1997;60:470–474.
25. War Department. Bandaging and splinting
. Washington, DC: United States Government
Printing Office; 1944.
Appendix 1.1 Case Study
Case Study 1.1 a

Read the following scenario, and answer the questions based on

information in this chapter.
Fred is a new therapist working in an outpatient care setting. He
has an order to make a wrist immobilization orthosis for a person with
a diagnosis of carpal tunnel syndrome who needs an orthosis to
provide rest and protection.

1. According to the American Society of Hand Therapists (ASHT)

orthotic terminology, which name appropriately indicates the
orthosis indicated in the following figure?
a. Forearm neutral mobilization, type 1 (2)
b. Wrist neutral immobilization, type 1 (1)
c. Wrist neutral immobilization, type 0 (1)
 2. If Simon focuses on the person’s ability to perform activities of
daily living with the orthosis, what is the guiding approach?
a. Rehabilitation
b. Biomechanical
c. Sensorimotor
3. Listed below are several types of evidence. Rank the studies in
descending order (1 = highest level, 3 = lowest level).
___ a. Talking to a certified hand therapist about the
protocol she believes is best for a particular client
___ b. A randomized control trial with one group of
clients serving as the control group and another
group of clients receiving a new type of treatment
___ c. A case study describing the treatment of an
individual client

a See Appendix A for answers.

Occupation-Centered Orthotic
Intervention
Debbie Amini

CHAPTER OBJECTIVES
1. Define occupation-centered treatment as it relates to orthotic
design and fabrication.
2. Describe the influence of a client’s occupational needs on orthotic
design and selection.
3. Review evidence to support preservation of occupational
engagement through orthotic intervention.
4. Describe how to use an occupation-centered approach to orthotic
intervention.
5. Identify specific hand pathologies that can disrupt occupational
performance and participation.
6. Describe orthotic design options to promote occupational
engagement while ensuring safety of body structures and
functions.
7. Apply knowledge of application of occupation-based practice to a
case study.

KEY TERMS
client-centered intervention
context
occupation-based approach
occupation-centered orthotic intervention
occupation-focused approach
occupational deprivation
occupational disruption
occupational profile
treatment protocol

Samuel is a 37-year-old self-employed builder who fell through an aging

second-story floor approximately 5 months ago. His injuries included a
fractured femur of his right leg, fractured metatarsals of his left foot, a
compression fracture of his distal right dominant radius, and a volarly
angulated fracture of his left nondominant radius. Because of these
injuries, Samuel was immobilized in bilateral lower extremity casts, a
cast on his left wrist, and an external fixator on his right wrist and
unable to engage in his work activities.

One month following injury, Samuel began outpatient occupational

therapy. He expressed a desire to return to his job as soon as possible due
to the financial difficulty that he was experiencing from being
unemployed and having no disability insurance. Using an occupation-
centered lens, his occupational therapist helped him implement
strategies to revive his company while addressing his client factor
difficulties surrounding bilateral hand function. Samuel returned to
work when his fractures were fully consolidated.

Unfortunately, through constant use of his left upper extremity, Samuel

began to experience chronic wrist pain and painful snapping of his
forearm with rotational movements. He was diagnosed with ulnocarpal
impingement syndrome due to positive ulnar variance in addition to a
triangular fibrocartilage complex tear. Surgery was suggested, but it
was expected to take him out of work for an additional 2 to 3 months.
 This was not acceptable to Samuel, who consulted with his occupational
therapist in hopes of finding an alternate strategy that would allow him
to work without pain until surgery became a feasible option. The
occupational therapist and Samuel targeted his occupational goals and
designed a custom forearm-based wrist orthosis that immobilized his
wrist and allowed him to work without pain. Samuel plans to undergo a
corrective surgery in approximately 1 year.

As stated eloquently by Mary Reilly, “Man, through the use of his

hands as they are energized by mind and will, can influence the state
of his own health.” 26 This phrase reminds us that the hand, as
directed by the mind and spirit, is integral to function. Occupation-
centered orthotic intervention is an overarching paradigm for
conducting occupational therapy assessment and intervention that
promotes the ability of the individual with hand dysfunction to
engage in desired life tasks and occupations. 14 An occupation-
focused approach to orthotic intervention is attention to the
occupational desires and needs of the individual, paired with the
knowledge of the effects (or potential effect) of pathological conditions
of the hand, and managed through client-centered orthotic design and
provision. 2 In addition to an occupation-focused perspective, an
occupational therapist or occupational therapy assistant (practitioner)
may also approach the provision of issuing orthotic devices from an
occupation-based lens or approach. According to Fisher, 14 an
occupation-based approach is one where the long-term goals of the
client and practitioners are occupations, but the immediate needs of
the client may involve attention to body functions and structures. In
this case, interventions that may not be occupations per se must be
appropriately integrated into the intervention plan.
 FIG. 2.1 Occupation-Centered Orthotic Approach (Occupation-
Focused Orthotic Approach and Occupation-Based Orthotic Approach)

In order to be occupation centered or occupation focused, a

practitioner must first adopt a personal philosophy that supports
occupation-centered practice. Please refer to Fig. 2.1 that explains
these terms. Occupation-centered practice, which is also closely
aligned with client-centered practice, is the acceptance of occupation
as the central guiding paradigm of the profession, where practitioners
assess, intervene, reason, and problem solve understanding the
importance and power of occupation as the means and the end to
what we do. 1,14 Multiple models of practice exist within this
paradigm, including the Canadian Model of Occupational
Performance and Engagement (CMOP-E) 30 ; Person, Environment,
Occupation Model; and the Model of Human Occupation and
Occupational Adaptation. In addition, the practitioner should
understand the tenets of the Occupational Therapy Practice
Framework (OTPF), which provides a foundation for occupational
therapy practice, and its relationship to the International Classification
of Functioning, Disability and Health (ICF) within the United States.
The use of orthoses, an ancient technique of immobilization and
mobilization, became associated with occupational therapy in the mid
part of the twentieth century. 12 According to Fess, the most
frequently recorded reasons for orthotic intervention include
increasing function, preventing deformity, correcting deformity,
protecting healing structures, restricting movement, and allowing
tissue growth or remodeling. 13 From this description, it can be
surmised that historically, orthotic intervention has been most closely
aligned with the neuromusculoskeletal and movement-related body
functions and body structures, described in the client factors category
of the OTPF-3. Understanding orthotics exclusively from this
perspective relegates their use to a preparatory method that is
protocol and practitioner centric. But because body functions and
body structures constitute only a part of the ability of the client to be
an occupational being, the occupation-centered practitioner
understands the importance of assisting the healing or mobility of the
hand, with immediate and concurrent focus on the occupational needs
of the client—those that transcend movement and strength of the
body.
Three Lens’ of Occupation
This chapter provides definitions of client-centered/occupation-
centered and occupation-based and occupation-focused practice and
illustrates the process of combining these ways of thinking for orthotic
intervention. In addition, outcome measures, assessment tools,
intervention models, and orthotic options that promote occupational
participation are described.

Client- and Occupation-Centered Practice With

Orthotic Intervention
Client- and occupation-centered practice are compatible, but a
distinction is made between them. 24 Client-centered practice is
defined as “an approach to service that embraces a philosophy of
respect for, and partnership with, people receiving services.” 20 Law 18
outlined concepts and actions of client-centered practice that articulate
the assumptions for shaping assessment and intervention with the
client (Box 2.1). A client-centered perspective should inform
occupation-centered practice.

BOX 2.1 Concepts and Actions of Client-Centered

Practice

• Respect for clients and their families and choices they make
• Clients’ and families’ right to make decisions about daily
occupations and therapy services
• A communication style that is focused on the person and includes
provision of information, physical comfort, and emotional
support
• Encourage client participation in all aspects of therapy service
 • Individualized occupational therapy service delivery
• Enabling clients to solve occupational performance issues
• Attention to the person-environment-occupation relationship

Occupation-Based Approach
Many definitions of occupation-based practice exist within the
literature. One definition states that it is “the degree to which
occupation is used with reflective insight into how it is experienced by
the individual, how it is used in natural contexts for that individual,
and how much the resulting changes in occupational patterns are
valued by the client.” 15 Methods of employing empathy, reflection,
interview, observation, and rigorous qualitative inquiry assist in
understanding the occupations of others. 24 Christiansen and
Townsend 7 described occupation-based occupational therapy as an
approach to treatment that serves to facilitate engagement or
participation in recognizable life endeavors. Pierce 24 described
occupation-based treatment as including two conditions: (1) the
occupation as viewed from the client’s perspective and (2) the
occupation occurring within a relevant context. This perspective
supports the thinking of practitioners who are occupation based but
address occupations from a bottom-up approach, where orthotics
address the immediate needs of the pathology with focus on the
eventuality of occupational participation.

Occupation-Focused Orthotic Approach

Occupation-focused orthotic intervention has a focus that supports the
goals of the intervention plan and enables clients to engage in
meaningful and relevant life endeavors as soon as possible. Unlike a
more traditional medical and biomechanical model of orthotic
intervention that may initially focus on body structures and functions
or an occupation-based focus that seeks to address participation by
affecting factors and skills, occupation-focused orthotic fabrication
incorporates the client’s occupational needs and desires, cognitive
abilities, psychosocial status, and motivation as the priority of
intervention. When approaching the client from this perspective, the
therapist incorporates client-centered thinking, appreciating that the
client is an active participant in the treatment and decision-making
process. Orthoses as occupation-focused and client-centered
intervention focus on meeting client goals as opposed to therapist-
designed or protocol-driven goals. Body structure healing is not the
main priority; it is a priority equal to that of preservation of
occupational engagement.
Occupation-focused orthotic intervention is part of a top-down
versus bottom-up approach to occupational therapy intervention.
According to Weinstock-Zlotnick and Hinojosa, 32 the therapist who
engages in a top-down approach always begins treatment by
examining a client’s occupational performance and grounds treatment
in a client-centered frame of reference. A therapist who uses a bottom-
up approach first evaluates the pathology and then attempts to
connect the body deficiencies to performance difficulties. The top-
down approach is also consistent with both the OTPF and the Current
Procedural Terminology (CPT) evaluation coding processes, which
describe the creation of the occupational profile, a documented
account of the client’s occupational history and current occupational
goals. The occupational profile is the first part in the occupational
therapy evaluation process 3 (Box 2.2).
To achieve a needed balance between immediate attention to
occupational participation and the needs of healing body structures,
the occupation-centered practitioner can use multiple models or
frames of reference to guide interventions. According to Ikiugu, 17 a
practitioner may choose one primary model to guide selection of
outcome measures, assessments, and interventions and then choose
one or more additional secondary models that further inform
assessment and intervention choices. It is recommended that the
primary model chosen is an occupation-centered model with
secondary models such as biomechanical or rehabilitation being used
to inform the occupation-centered model and vice versa. This
multifaceted yet occupation-centered perspective will ensure that
chosen interventions are safe and effective in addressing desired
occupational needs, which is the first and foremost priority.

Contexts and Environments

According to the OTPF, context and environment relate “to a variety
of interrelated conditions within and surrounding the client that
influence performance.” 1 Occupational therapy is an approach that
facilitates the individual’s ability to participate in meaningful
engagements within specific areas of occupation and varied contexts
of living. 1 Context and environments, in addition to occupations,
client factors, performance skills, and performance patterns, are a part
of the domain of occupational therapy. Contexts include cultural,
personal, temporal, and virtual aspects; environments include
physical and social. 1 Thus therapists should consider both input from
the client (views and perspective) and external conditions. Box 2.3
describes the contexts and environments as set forth in the OTPF-3.

1
BOX 2.2 Occupational Profile

Occupational Profile Marta

Reason the client is Marta is a 58-year-old single woman with a diagnosis of right medial
seeking service and epicondylitis who lives alone in an apartment. She was referred to
concerns related to occupational therapy by her orthopedic surgeon to address pain,
engagement in weakness, and activities of daily living difficulties. At this time she
occupations reports that she is unable to engage in desired work, leisure, and
housework tasks and is not comfortable caring for her new infant
grandson.
Occupations in which Marta reports that she is fully independent in all self-care and hygiene
the client is activities and very light household chores such as microwaving meals
successful and driving to the grocery store or her daughter’s home. She states that
she has pain during these activities but will complete them regardless.
Personal interests and Marta enjoys craft activities and playing games on her iPad when not
values working. Before the onset of medial epicondylitis, she had taken up
adult coloring using gel pens and reports completing several books in
less than a month.
Occupational history Marta works full time at a small local pet store where she waits on
customers, stocks shelves, and cleans animal cages. She enjoys her job
 and is seeking a promotion to a managerial position. She has worked at
this shop for nearly 5 years but now reports difficulty with efficiency
and managing heavy items.
Performance patterns Marta reports that her daily routine involves rising at 7 a.m., showering
(routines, roles, and dressing, and then making herself lunch for work. At 8 a.m. after
habits, and rituals) eating a light breakfast she drives herself the 5 miles to her job. She
works until 12 noon, takes a break for lunch, and completes her day at 5
p.m. She does not drink or smoke and reports no difficulties with
participation in her religion.
What aspects of the Marta has a daughter and son who are supportive even though they do
client’s not live with her. Both will immediately go to her home to help her
environments or manage her apartment whenever she calls them. Marta has concerns for
contexts does he or her job due to her increasing difficulty and slowed pace. She worries
she see as supports that she will be passed over for a promotion when the current store
to occupational manager retires next month. This has caused her a moderate level of
engagement, emotional stress.
barriers to
occupational
engagement
Client’s priorities and Marta states that she would like to be pain-free so that she can
desired targeted participate fully in both work and household activities and get back to
outcomes her crafts and caring for her grandson. She also does not want to miss
her opportunity for promotion at work.

BOX 2.3 Description of Contexts

Context
• Cultural: The ethnicity, family values, attitudes, and beliefs of the
individual
• Personal: Features of the person specific to them (age, gender,
socioeconomic status, and so on)
• Temporal: Stages of life, time of day, time of year
• Virtual: Realistic simulation of an environment and the ability to
communicate in cyberspace

Environments
• Physical: The physical environment in all respects
 • Social: Relationships the individual has with other individuals,
groups, organizations, or systems

From American Occupational Therapy Association. (2008).

Occupational therapy practice framework: Domain and process.
American Journal of Occupational Therapy, 62, 625–683.

Cultural Context
An often overlooked issue surrounding orthotic intervention is
attention to the client’s cultural needs. Unfortunately, to ignore
culture is to potentially limit the involvement of clients in their
orthotic programs. For example, there are cultures in which the need
to rely on an orthosis is viewed as an admission of vulnerability or as
a weakness in character. Such feelings can exist due to large group
beliefs or within smaller family dynamic units. Orthotic intervention
within this context must involve a great deal of client education and
possibly education of family members. Issuing small, unobtrusive
orthoses that allow as much function as possible may diminish
embarrassment and a sense of personal weakness.

Personal Context
Personal context involves attention to issues such as age, gender, and
educational and socioeconomic status. When clinicians who employ
occupation-based orthotic intervention fabricate orthoses for older
adults or children, they consider specific guidelines (see Chapters 16
and 17).
The choices in material selection and color may be different based
on age and gender. For example, a child may prefer a bright-colored
orthosis, whereas an adult executive may prefer a neutral-colored
orthosis. Concerns may arise about the role educational level plays in
orthotic design and provision. For clients who have difficulty
understanding new and unfamiliar concepts, it is important to have
an orthosis that is simple in design and can be donned and doffed
easily. Precautions and instructions should be given in a clear manner.
Temporal Context
Temporal concerns are addressed through attention to issues such as
comfort of the orthosis during hot summer months or the use of
devices during holidays or special events such as proms or weddings.
An example is the case of a bride-to-be who was 2 weeks
postoperative for a flexor tendon repair of the index finger. The young
woman asked repeatedly if she could take off her orthosis for 1 hour
during her wedding. A compromise reached between the therapist
and the client ensured that her hand would be safe during the
ceremony. A shiny new orthosis was made specifically for her
wedding day to immobilize the injured finger and wrist (modified
Duran protocol). The therapist discarded the rubber-band/finger-hook
component (modified Kleinert protocol). This change made the
orthosis smaller and less obvious. The client was a happy bride, and
her finger was well protected. Virtual context addresses the ability to
access and use electronic devices. The ability to access devices (e.g.,
computers, iPads, radios, PDAs, MP3 players, cell phones) plays an
important role in the lives of many people in the 21st century. Fine
motor control is paramount when using these devices and should be
preserved as much as possible to maximize electronic contact with the
outside world for social participation, education, and work-related
occupations. Attention to orthosis size and immobilizing only those
joints required can facilitate the ability to manipulate small buttons
and dials required to use such devices. For an orthosis to be accepted
as a legitimate holistic device, it must work for clients within their
context(s) and environments. Since contextual concerns are not always
apparent to the practitioner, all clients should be asked if their
orthoses are in any way inhibiting their ability to engage in any life
experience. Most orthoses affect a person’s ability to perform
activities.

Social Environment
The social environment pertains to the ability of clients to meet the
demands of their specific group or family. Social environments are an
integral consideration for orthotic provision. For example, a new
mother was given a wrist/thumb orthosis after being diagnosed with
de Quervain tenosynovitis. The mother began to feel inadequate in
her new role because she could not cuddle and feed the infant without
contacting him with a rigid orthosis. In this case, it was suggested that
a softer prefabricated orthosis or alternative wearing schedule be
provided to maximize compliance with the orthotic program (Fig. 2.2).

Physical Environment
Knowledge of physical environments may contribute to an
understanding of the need for orthotic provision, but the physical
environment may also hamper consistent use if clients are unable to
engage in required or desired activities. For example, if a client needs
to drive to work and is unable to drive while wearing an orthosis, he
might remove it despite the potential for reinjury. Fig. 2.3A depicts a
young woman wearing an orthosis because she sustained a flexor
digitorum profundus injury. She found that typing at her workplace
while wearing the orthosis was creating shoulder discomfort. She
asked the therapist if she could remove her orthosis for work, and
with physician approval the therapist created a modified protective
orthosis (see Fig. 2.3B). The newly modified orthosis allowed
improved function and protected the healing tendon.
FIG. 2.2 Prefabricated thumb immobilization orthosis. It improves
comfort while holding the infant.
FIG. 2.3 A, Excessive pronation required to accurately press keys
while using standard dorsal blocking orthosis. B, Improved ability to
work on computer using modified volar-based protective orthosis.
 Depending on its intended purpose, an orthosis might perpetuate
dysfunction and may prolong the return to meaningful life
engagement. Thus it is important to pay attention to the specifics of
the client’s personal environment and multiple contexts. The impact is
a matter of degree, and consideration needs to be given to the trade-
off between how an orthosis enables clients (if only in the future) and
how the orthosis presently disables them. Practitioners must be aware
of the balance between enablement and disablement and must do
their best to appropriately modify the orthosis or the wearing
schedule to facilitate clients’ occupational engagement. To ignore the
interconnection of function is to practice a reductionist form of
intervention, because it emphasizes only isolated skills and body
structures without regard to engagement in selected activities.

Occupation-Centered Orthotics and Types of

Intervention
The OTPF-3 1 describes several types of activities and occupations
used as occupational therapy interventions: preparatory methods and
tasks, activities, occupations, education and training, group
intervention, and advocacy/self-advocacy. Preparatory methods and
tasks prepare clients for the ability to engage in activities and
occupations. They do not meet the definition of activities or
occupations themselves and are either therapist-administered
interventions or contrived engagements that address underlying client
factors and performance skills only. Examples include exercise,
inhibition or facilitation techniques, and positioning devices that are
used in preparation for occupational participation. Examples of
preparatory tasks include simulated activities (e.g., driving
simulators) that begin to prepare the client for participation in actually
driving a vehicle or cone stacking, which is often used to simulate
reaching skills needed for placing items on kitchen shelves. Activities
are goal directed and have an inherent purpose to the client; others
readily understand them in the pragmatic sense. In the case of
driving, the activity is under way when a client gets into a vehicle and
drives. Occupation is the ultimate type of intervention. Clients
participate in occupations within their natural environment and affix
personal meaning to the experience. The ability to complete one’s
morning routine that includes driving to his or her place of
employment is an occupation.
According to the OTPF-3, orthotics fabrication/provision is
fundamentally a preparatory method. It is not an activity; it is
initiated before occupational engagement and discontinued when
hand function resumes. However, from an occupation-focused
orthotic perspective, an orthotic intervention is not only a technique
used in preparation for occupation. For appropriate clients, orthoses
are an integral part of ongoing intervention to support occupational
engagement through all types of intervention. For example, some
clients may receive an orthosis to use as desired in a prophylactic
manner to prevent the onset of pain while engaging in work and
leisure pursuits that could otherwise lead to occupational dysfunction.

Orthotic Intervention as a Therapeutic Approach

In the OTPF-3 1 intervention approaches are defined as “specific
strategies selected to direct the process of evaluation and intervention
planning, selection and implementation on the basis of the client’s
desired outcome, evaluation data, and evidence; approaches inform
the selection of models and frames of reference.” 1 These intervention
approaches include:

• Create or promote health

• Establish or restore a skill or ability
• Maintain performance capabilities
• Modify context or activity demands through compensation
and adaptation
• Prevent disability

From an occupation-based perspective, when orthoses enable

occupation, they become an integral part of that occupation versus
being a preparatory method only. Custom-fitted orthoses within the
context of clients’ occupational experience can promote health,
remediate dysfunction, substitute for lost function, and prevent
disability. When teamed with a full occupational profile, analysis of
occupation, and knowledge of the appropriate use of orthoses for
specific pathologies (supported by evidence of effectiveness), devices
are selected to produce the outcomes that reach the goals
collaboratively set by the client and the practitioner.

Orthotic Intervention as a Facilitator of Therapeutic

Outcomes
As part of occupation-centered practice, orthotic intervention is a
therapeutic approach interwoven through all levels of intervention.
The OTPF 1 describes specific therapeutic outcomes expected from
intervention. Outcomes are occupational performance (improvement
and enhancement), participation, role competence, adaptation, health
and wellness, prevention, quality of life, well-being, and occupational
justice. 1
Positive outcomes in occupational performance are the effect of
successful intervention. Such outcomes are demonstrated either by
improved performance within the presence of continued deficits
resulting from injury or disease, or the enhancement of function when
disease is not currently present. Orthotic intervention addresses both
types of occupational performance outcomes (improvement and
enhancement). Orthoses that improve function in a person with
pathology result in an “increased independence and function in an
ADL, IADL, education, work, play, leisure, or social participation.” 1
For example, a wrist immobilization orthosis is prescribed for a
person who has carpal tunnel syndrome. The orthosis positions the
wrist to rest the inflamed anatomical structures and maximize the
carpal tunnel space, thus decreasing pain and paresthesias and
improving work performance. Orthoses that enhance function
without specific pathology result in improved occupational
performance from one’s current status or prevention of potential
problems. For example, some orthoses position the hands to prevent
overuse syndromes resulting from hand-intensive repetitive or
resistive tasks.
Role competence is the ability to satisfactorily complete desired
roles (e.g., worker, parent, spouse, friend, and team member). Roles
are maintained through orthotic intervention by minimizing the
effects of pathology and facilitating upper extremity performance for
role-specific activities. For example, a mother who wears an orthosis
for carpal tunnel syndrome should be able to hold her child’s hand
without extreme pain. Holding the child’s hand makes her feel as
though she is fulfilling her role as a mother.
Orthoses created to enhance adaptation to overcome occupational
dysfunction address the dynamics of the challenges and the client’s
expected ability to overcome it. An example of orthotic intervention to
improve adaptation might involve a client who experiences carpal
ligament sprain but must continue working or risk losing
employment. In this case a wrist immobilization orthosis that allows
for digital movements may enable continued hand functions while
resting the involved ligament.
Health and wellness are collectively described as the absence of
infirmity and a “state of physical, mental, and social well-being.” 1
Orthoses promote health and wellness of clients by minimizing the
effects of physical disruption through protection and substitution.
Enabling a healthy lifestyle that allows clients to experience a sense of
wellness facilitates motivation and engagement in all desired
occupations.
Prevention in the context of the OTPF involves the promotion of a
healthy lifestyle at a policy creation, population, group, or person
level. 1 When an external circumstance (e.g., environment, job
requirement, and so on) exists with the potential for interference in
occupational engagement, an orthotic program may be a solution to
prevent the ill effects of the situation. If it is not feasible to modify the
job demands, clients may benefit from the use of orthoses in a
preventative role. For example, a wrist immobilization orthosis and an
elbow strap are fitted to prevent lateral epicondylitis of the elbow for
a client who works in a job that involves repetitive and resistive lifting
of the wrist with a clenched fist. In addition, the worker is educated
on modifying motions and posture that contribute to the condition.
One of the most difficult concepts to define is the concept of quality
of life. Despite this, most individuals from Western cultures have a
tacit understanding of its meaning and typically know it to be a
condition that includes general health, physical, emotional, cognitive,
role, and social function with an absence of signs and symptoms of
pathology. Quality of life entails one’s appraisal of abilities to engage
in specific tasks that beneficially affect life and allows self-expressions
that are socially valued. 11 One’s state of being is determined by the
ability of the client to be satisfied, engage in occupations, adapt to
novel situations, and maintain health and wellness. Ultimately,
orthotic intervention focused on therapeutic outcomes improves the
quality of life through facilitating engagement in meaningful life
occupations.
Well-being is a subjective state experienced by individuals when
they are content with their own health, self-esteem, sense of
belonging, security, and opportunities for self-determination. 1 An
orthosis that reduces pain and allows engagement in needed and
desired occupations will afford the individual control over his or her
own health and make way for job and personal security, as well as
ensuring opportunities for maintaining or creating self-determination.
An example is the case of a hand-based thumb orthosis that allows the
client to continue working as a data entry specialist at a place of
employment that offers steady income and health benefits.
Occupational justice refers to the rights of people to be included in
desired life pursuits, including education and movement within the
community. When provided with orthoses that enable function,
individuals who are at a disadvantage and cannot participate fully
within society without a device may become empowered and able to
take full advantage of all that society has to offer. For example, an
individual who is not able to access a computer in the public library
due to significant hand contractures may be able to search the Internet
in this publically funded facility if an orthosis is provided that isolates
the index finger of the dominant hand for one-finger typing.
The Influence of Occupational Desires
on Orthotic Design and Selection
The occupational profile phase of the evaluation process described in
the OTPF-3 involves learning about clients from a contextual and
performance viewpoint. 1 For example, what are the interests and
motivations of clients? Where do they work, live, and recreate? Tools
(i.e., Canadian Occupational Performance Measure (COPM);
Disabilities of the Arm, Shoulder, and Hand [DASH]; Patient-Rated
Wrist Hand Evaluation [PRWHE]; and the Manual Ability Measure-20
[MAM-20]) that offer clients the opportunity to discuss their injuries
in the context of their daily lives lend insight into the needs that must
be addressed. Table 2.1 lists such tools. When used in conjunction
with traditional methods of hand and upper extremity assessment
(e.g., goniometers, dynamometers, and volumeters), they help
therapists learn about the specific clients they treat and assist in
orthotic selection and design.
The outcome measures listed in Table 2.1 emphasize client
occupations and functions as the focus of intervention. Information
obtained from such assessments supports the goal of occupation-
based orthotic intervention, which is to improve the client’s quality of
life through the client’s continued engagement in desired occupations.
An orthosis that focuses on client factors alone does not always treat
the functional deficit. For example, a static orthosis to support the
weak elbow of a client who has lost innervation of the biceps muscle
protects the muscle yet allows only one angle of function of that joint.
A dynamic flexion orthosis protects the muscle from end-range stretch
yet allows the client the ability to change the arm angle through active
extension and passive flexion. Assessment tools that measure physical
client factors exclusively (e.g., goniometry, grip strength, volumeter,
and so on) must remain as adjuncts to determine orthotic design,
because physical functioning is an adjunct to occupational
engagement.
Canadian Occupational Performance Measure
The COPM is an interview-based assessment tool for use in a client-
centered approach. 19 The COPM assists the therapist in identifying
problems in performance areas, such as those described by the OTPF-
3. In addition, clients’ perceptions of their ability to perform the
identified problem area and their satisfaction with their abilities are
determined when using the COPM. 19 Therapists can use the COPM
with clients from all age groups and with any type of disability.
Parents or family members can serve as proxies if the client is unable
to take part in the interview process (e.g., if the client has dementia).
When the COPM is readministered, objective documentation of the
functional effects of orthotic intervention through comparison of
preintervention and postintervention scores is made.

TABLE 2.1

Client-Centered Outcome Measures

Tool General Description Contact Information
Manual Ability A 20-item self-report questionnaire. Tool Chen, C.C., & Bode, R. K.
Measure-20 consists of two parts: (1) a client demographic (2010). Psychometric
(MAM-20) 29 sheet and (2) a self-report task list consisting of validation of the Manual
items that clients rate on a 4-point scale based Ability Measure-36 (MAM-36)
on their perceived ability to complete tasks. It in patients with neurologic
also includes a visual analog pain scale and and musculoskeletal
column for indicating if skill can be completed disorders. Archives of Physical
with the noninvolved hand. Medicine and Rehabilitation,
91(3), 414–420.
Canadian The COPM is a client-centered approach to The COPM can be purchased
Occupational assessment of perceived functional abilities, through the Canadian
Performance interest, and satisfaction with occupations. This Association of Occupational
Measure interview-based valid and reliable tool is scored Therapists (CAOT) at
(COPM) 19 and can be used to measure outcomes of http://www.caot.ca.
treatment.
Disabilities of DASH is a condition-specific tool. The DASH Visit the DASH/QuickDASH
the Arm, consists of 30 predetermined questions website at
Shoulder, addressing function within performance areas. http://www.dash.iwh.on.ca.
and Hand Clients are asked to rate their recent ability to
(DASH) complete skills on a scale of 1 (no difficulty) to 5
assessment 16 (unable). The DASH assists with the
development of the occupational profile
through its valid and reliable measure of
clients’ functional abilities.
The PRWHE is a condition-specific tool MacDermid, J.C., &
Patient-Rated through which the client rates pain and Tottenham, V. (2004).
Wrist Hand function in 15 preselected items. Responsiveness of the
Evaluation disability of the arm, shoulder,
(PRWHE) 21 and hand (DASH) and
patient-rated wrist/hand
evaluation (PRWHE) in
evaluating change after hand
therapy. Journal of Hand
Therapy, 17, 18–23.

When the COPM is used, contextual issues arise during the client
interview about satisfaction with function. Clients may indicate why
certain activities create personal dissatisfaction despite their ability to
perform them. An example is the case of a woman who resides in an
assisted living setting. During administration of the COPM, she
identifies that she is able to don her orthosis by using her teeth to
tighten and loosen the straps. She needs to remove the orthosis to use
utensils during meals. However, she is embarrassed to do this in front
of other residents while at the dining table. The use of the COPM
uncovers issues that are pertinent to individual clients and must be
considered by the therapist.

Disabilities of the Arm, Shoulder, and Hand

The DASH is a condition-specific tool that measures a client’s
perception of how current upper extremity disability has affected
function. 10 The DASH consists of 30 predetermined questions that
explore function within performance areas. The client is asked to rate
on a scale of 1 (no difficulty) to 5 (unable) his or her current ability to
complete particular skills, such as opening a jar or turning a key. The
DASH assists the therapist in gathering data for an occupational
profile of functional abilities. The focus of the assessment is not on
body structures or on the signs and symptoms of a particular
diagnostic condition. Rather, the merit of the DASH is the information
obtained is about the client’s functional abilities.
An interview, although not mandated by the DASH, should become
part of the process to enhance the therapist’s understanding of the
identified problems. The therapist must also determine why a
functional problem exists and how it may be affecting quality of life.
The DASH is an objective means of measuring client outcomes when
readministered following orthosis provision or other treatment
interventions.
When selecting the DASH as a measure of occupational
performance, the therapist may consider several additional facts. For
example, the performance areas measured are predetermined in the
questionnaire and may limit the client’s responses. In addition, the
DASH does not specifically address contextual issues or client
satisfaction or provide insight into the emotional state of the client.
Additional information can be obtained through interview to gain
insight needed for proper orthotic design and selection.

Patient-Rated Wrist Hand Evaluation

The PRWHE is a condition-specific tool through which clients rate
their pain and functional abilities in 15 preselected areas. 21 PRWHE
assists with the development of the occupational profile through
obtaining information about clients’ functional abilities. The
functional areas identified in the PRWHE are generally much broader
than those in the DASH. Similar to the DASH, the PRWHE’s questions
to elicit such information are not open-ended questions as in the
COPM. Information about pain levels during activity and client
satisfaction of the aesthetics of the upper limb are gathered during the
PRWHE assessment.
The PRWHE does not specifically require an inquiry into the details
of function, but such information would certainly assist the therapist
and make the assessment process more occupation based. The
PRWHE does not include questions related to context. Therefore the
therapist should include such questions in treatment planning
discussions.

The Manual Ability Measure-20

The MAM-20 was developed by occupational therapists 3 and can be
used with both musculoskeletally and neurologically based hand
function deficits. The tool was originally described in 2005 in the
Journal of Hand Surgery (British and European volume) as the Manual
Ability Measure-16. The tool consists of two parts: (1) a client
demographic sheet and (2) a self-report task list consisting of items
that clients rate on a 4-point scale based on their perceived ability to
complete the task. The rating scale ranges from 1, “cannot do,” to 4,
“easy.” The 0 (zero) option indicates “almost never do (even prior to
condition).” The tool also includes a visual analog pain scale and a
column to indicate if a task is being completed with the opposite
hand. The MAM-20 takes a positive wellness stance and addresses
function versus dysfunction. The client scores higher when higher
levels of function are present. Research has supported the validity and
reliability of the MAM-20. 4

Analysis Phase
Following the data collection part of the evaluation process, the
analysis of occupational performance occurs. If a therapist uses one of
the aforementioned tools, analysis of the performance process has
been initiated. Further questions will be asked based on the answers
of previous questions. The therapist continues to gain specific insight
into how orthotic intervention can be used to remediate the reported
dysfunction.
During the analysis phase the therapist may actually want to see the
client perform several functions to gain additional insight into how
activity affects, or is impacted by, the diagnosis or pathology. For
example, a client states that he cannot write because of thumb
carpometacarpal (CMC) joint pain. Therefore the therapist asks the
client to show how he is able to hold the pen while describing the type
of discomfort experienced with writing. The therapist begins orthotic
design analysis by holding the client’s thumb in a supported position
to simulate the effect of a hand-based orthosis. The client actively
participates in the process by giving feedback to the therapist during
orthotic design and fabrication.
After a client-centered occupation-based profile and analysis is
completed, an occupation-based orthotic intervention plan is
developed. Measuring only physical factors to create a client profile
results in a therapist seeing only the upper extremity and not the
client. The upper extremity does not dictate the quality of life. Rather,
the mind, spirit, and body do so collectively! (See Self-Quiz 2.1.)
Evidence to Support Preservation of
Occupational Engagement and
Participation
Fundamental to occupational therapy treatment is the belief that
individuals must retain their ability to engage in meaningful
occupations or risk further detriment to their subjective experience of
quality of life. If humans behaved as automatons (completing
activities without drive, interest, or attention), correcting deficits
would become reductionist and mechanical. A reductionistic
approach could guarantee that an adaptive device or exercise could
correct any problem and immediately lead to the continuation of the
required task (much like replacing a spark plug to allow a car to start).
Fortunately, humans are not automatons, and occupational therapy
exists to support the ability of the individual to engage in and
maintain participation in desired occupations.
The literature supports the premise that any temporary or
permanent disruption in the ability to engage in meaningful
occupations can be detrimental. For example, with a flexor tendon
repair therapists must follow protocols to facilitate appropriate tissue
healing. Such protocols typically restrict the hand from performing
functional pursuits for a minimum of 6 to 8 weeks. However,
occupational dysfunction must be effectively minimized as soon as
possible to maintain quality of life. 22

a
Self-Quiz 2.1
Answer the following questions.

1. Consider an orthotic intervention plan with a client of a

different culture than yours. What factors of orthotic design
 and provision may need special attention to ensure acceptance,
compliance, and understanding?
____________________________________________________
2. When designing orthoses to match the occupational needs of a
young child, what performance areas and personal contextual
factors will you be interested in addressing?
____________________________________________________

a
See Appendix A for answers.

Evidence to Support Occupational

Engagement
Supported by research, in addition to anecdotal experiences and
reports of therapists, is the importance of multidimensional
engagement in meaningful occupations. Described by Wilcock and
Hocking, 34 the term occupational deprivation is a state wherein
clients are unable to engage in chosen meaningful life occupations due
to factors outside their control. Disability, incarceration, and
geographical isolation are but a few circumstances that create
occupational deprivation. Depression, isolation, difficulty with social
interaction, inactivity, and boredom leading to a diminished sense of
self can result from occupational deprivation. 7 Occupational
disruption is a temporary and less severe condition that is also caused
by an unexpected change in the ability to engage in meaningful
activities. 7 Additional studies conducted by behavioral scientists
interested in how individual differences, personality, and lifestyle
factors influence well-being have shown that engagement in
occupations can influence happiness and life satisfaction. 6
Ecological models of adaptation suggest that people thrive when
their personalities and needs are matched with environments or
situations that enable them to remain engaged, interested, and
challenged. 5 Walters and Moore 31 found that among the
unemployed, involvement in meaningful leisure activities (not simply
busywork activities) decreased the sense of occupational deprivation.
Palmadottir 23 completed a qualitative study that explored clients’
perspectives on their occupational therapy experience. Positive
outcomes of therapy were experienced by clients when treatment was
client centered and held purpose and meaning for them. Thus, when a
client who has an upper extremity functional deficit receives an
orthosis, the orthosis should meet the immediate needs of the injury
while meeting the client’s desire for occupational engagement.
According to Clark and colleagues, 8 older adults from federally
subsidized housing complexes realized positive outcomes in life
satisfaction, role functioning, and physical and emotional health after
receiving lifestyle interventions. These interventions include
education for safety, time use, and cultural awareness, goal setting,
and activities for social participation. The ability to engage in this
program and the occupations targeted can be facilitated through
orthoses that prevent or correct occupational dysfunction resulting
from upper extremity changes associated with aging (e.g., joint
changes, pain, weakness) or pathological conditions (e.g., arthritis,
fractures, carpal tunnel syndrome).
Research offers evidence that orthoses of all types and for all
purposes are indeed effective in reaching the goals of improved
function. 9,25,27,28,33 Refer to the chapters throughout this book for
current evidence related to specific orthoses. Three examples are
presented to demonstrate such evidence of client-centered and
occupation-based orthotic intervention. One study was conducted on
the effects of orthotic intervention of the CMC joint of individuals
with basal joint osteoarthritis. Two orthoses were provided to
determine client preference and effects of custom versus prefabricated
orthoses. Both orthoses demonstrated modest improvements in hand
function. The prefabricated orthosis was the preferred orthosis,
although the custom-made orthosis decreased pain slightly more.
According to the authors, this reinforces the client-centered approach
to orthotic intervention in that clients can be given a choice in orthotic
design knowing that both types are effective in enhancing
occupational engagement. 27
Thiele and colleagues 28 found that individuals using wrist
immobilization orthoses for pain control during functional activities
did have positive results in pain reduction, occupational performance,
and strength. In addition, it was found that customized leather
orthoses were preferred to commercially available fabric orthoses.
A nocturnal wrist extension orthosis was found to be effective in
reducing the symptoms of carpal tunnel syndrome experienced by
midwestern auto assembly plant workers. 33 This evidence leads us to
conclude that orthotic intervention with attention to occupational
needs can and should be used to preserve quality of life.
Utilizing an Occupation-Centered
Approach to Orthotic Intervention
With guiding philosophies in place, the therapist using an occupation-
based approach to orthotic intervention begins the following problem-
solving process of orthotic design and fabrication.

Step 1: Referral
The clinical decision-making process begins with the referral. Some
orthotic referrals come from physicians who specialize in hand
conditions. A referral may contain details about the diagnosis or
requested orthosis. However, some orders may be from physicians
who do not specialize in the treatment of the hand. If this is the case,
the physician may depend on the expertise of the therapist and may
simply order an orthosis without detailing specifics. An orthotic
intervention order for a client with a condition may also rely on the
knowledge and creativity of the therapist. At this step the therapist
must begin to consider the diagnosis, the contextual issues of the
client, and the type of orthosis that must be fabricated.

Step 2: Client-Centered and Occupation-Based

Evaluation
Therapists use outcome measures (such as, the COPM, DASH, MAM-
20, or PRWHE) to learn which occupations clients desire to complete
during orthotic wear, which occupations orthoses can support, and
which occupations the orthoses will eventually help accomplish. The
therapist and the client use this information for goal prioritization and
orthotic design in Step 4.

Step 3: Understand/Assess the Condition and

Consider Intervention Options
Review biology, cause, course, and traditional interventions of the
person’s condition, including protocols and healing time frames.
Assess the client’s physical status. Research orthotic options, and
determine possible modifications to result in increased occupational
engagement without sacrificing orthotic effectiveness. When an
orthosis is ordered to prevent an injury, the therapist must analyze
any activities that may be impacted by wearing the orthosis and
determining how it may affect occupational performance.

Step 4: Analyze Assessment Findings for

Orthotic Design
Analyze information about pathology and treatment protocols to
reconcile needs of tissue healing and function (occupational
engagement). Consider whether the condition is acute or chronic.
Acute injuries are those that have occurred recently and are expected
to heal within a relatively brief time period. Acute conditions may
require orthoses to preserve and protect healing structures. Examples
include tendon or nerve repair, fractures, carpal tunnel release, de
Quervain release, Dupuytren release, or other immediate postsurgical
conditions requiring mobilization or immobilization through orthotic
intervention.
If the condition is acute, orthotic intervention adheres to protocols
and knowledge of client occupational status and desires. Determine if
the client is able to engage in desired occupations within the orthosis.
If the client can engage in occupations while wearing the orthosis,
continue with a custom occupation-based treatment plan in addition
to orthotic intervention.

Step 5: Determining Orthotic Design

If the client is unable to complete desired activities and functions
within the orthosis, the therapist must determine modifications or
alternative orthotic designs to facilitate function. Environmental
modifications or adaptations may be needed to accommodate lack of
function if no further changes can be made to the orthosis.
Fig. 2.4A is an example of a finger-based trigger finger orthosis that
allows unrestricted ability of the client to engage in a craft activity.
Compare the orthosis shown in Fig. 2.4B with the orthosis shown in
Fig. 2.4C. The orthosis in Fig. 2.4B was previously issued and limited
mobility of the ulnar side of the hand and diminished comfort and
activity satisfaction.
To ensure that an occupation-based approach to orthotic
intervention has been undertaken, the occupation-based orthotic
intervention checklist can be used (Form 2.1). This checklist focuses
the therapist’s attention on client-centered occupation-based practice.
Using the checklist helps ensure that the client does not experience
occupational deprivation or disruption.
Orthotic Design Options to Promote
Occupational Engagement And
Participation
The characteristics of an orthosis have an influence on a client’s ability
to function. The therapist faces the challenge of trying to help restore
or protect the client’s involved anatomical structure while preserving
the client’s performance. To achieve optimal occupational outcomes,
specific designs and materials must be used to fabricate orthoses that
are user friendly. The therapist must employ clinical reasoning that
considers the impact on the injured tissue and the desires of the client.
Such consideration results in an orthosis that best protects the
anatomical structure at the same time it preserves the contextual and
functional needs of the client.
FIG. 2.4 A, Functional ability while using finger-based trigger finger
orthosis. B, Confining hand-based trigger finger orthosis. C, Finger
based metacarpophalangeal blocking trigger finger orthosis.
Summary
Engagement in relevant life activities to enhance and maintain quality
of life is a concept to be considered with orthotic provision. The
premise that orthotic intervention of the hand and upper extremity
can improve the overall function of the hand is supported in the
literature. Hence orthotic intervention that includes attention to the
functional desires of the client is a valid occupation-centered
treatment approach that enhances life satisfaction and facilitates
therapeutic outcomes.

Patient Safety
Based on sound clinical reasoning (refer to Chapters 5 and 6),
therapists may create orthoses to enhance occupational participation
that may deviate from common orthotic designs that follow standard
hand therapy protocols. The therapist should evaluate this creative
design to judge whether the orthosis is appropriate for the client.
When in doubt, therapists must seek and gain approval from the
treating physician to ensure that the orthosis modification will not
cause harm or create the potential for injury during activity. It is the
therapist’s responsibility to give the rationale for the design to the
physician and any compelling literature to support the proposed
intervention.

Review Questions
1. According to this chapter, what is the definition of
occupation-centered orthotic intervention?
2. What is occupational deprivation, and how is it impacted
by occupation-centered orthotic intervention?
3. What are the reasons therapists provide orthoses to clients
who have upper extremity pathology?
4. Why is it important for the client to be an active participant
in the orthotic process?
5. Why is attention to the context of the client integral to
occupation-centered orthotic intervention?
6. What could occur if concern for patient safety is not
present when selecting orthoses used for individuals with
acute conditions of the hand or upper extremity?
7. Why should a therapist be knowledgeable about tissue
healing and treatment protocols despite the fact that such
factors do not imply occupation-focused treatment?
References
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contact sport athlete. Sports Health
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measure (website). Retrieved from
www.dash.iwh.on.ca
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. ed 2. West Sussex: John Wiley & Sons Ltd; 2007.
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Occup Ther . 2014;21:96–107.
15. Goldstein-Lohman H, Kratz A, Pierce D. A study of
occupation-based practice. In: Pierce D, ed.
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. Philadelphia: FA Davis; 2003:239–261.
16. Hudak P.L, Amadio P.C, Bombardier C. Development
of an upper extremity outcome measure: the DASH
(disabilities of the arm, shoulder and hand). The
Upper Extremity Collaborative Group (UECG)
. 1996;29:602–608.
17. Ikiugu M.N, Smallfield S, Condit C. A framework for
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. 2009;76(3):162–170.
18. Law M, ed. Client-centered occupational therapy
. Thorofare, NJ: Slack; 1998.
19. Law M, Baptiste S, Carswell A, et al. Canadian
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ON: CAOT; 2014.
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and patient-rated wrist/hand evaluation (PRWHE) in
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. 2004;17(1):18–23.
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therapy in rehabilitation services. Scand J Occup Ther
. 2003;10:157–166.
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. Thorofare, New Jersey: Slack, Inc; 2013.
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Appendix 2.1 Case Studies
Case Study 2.1 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Natasha is a 68-year-old woman who is legally blind. Natasha
underwent a metacarpophalangeal (MCP) joint silicone arthroplasty
procedure for long, ring, and small fingers of her left hand due to
severe rheumatoid arthritis 3 days ago. You received an order to
fabricate “forearm-based dynamic extension orthosis to hold the
fingers in neutral alignment but allow flexion and extension of the
MCPs throughout the day.” Natasha attends her first therapy
appointment accompanied by her husband, who is now her primary
caregiver.

1. During the initial session, you attempt to conduct an interview

using the Canadian Occupational Performance Measure
(COPM) with Natasha. Her answers seem unrealistic, and you
suspect that she is not providing accurate information. What
steps can you take to verify that the information you obtained
is reflective of her current level of function?
_______________________________________________
_______________________________________________
2. How will you be certain that Natasha is able to read and
comprehend the printed orthosis care sheet?
_______________________________________________
_______________________________________________
3. How will you be certain that Natasha is able to follow the
home exercise program pamphlet?
_______________________________________________
_______________________________________________
4. You design a creative way to allow safe range of motion
exercises while maintaining neutral alignment of the digits.
 How will you ensure that the orthosis modification is
appropriate and will not cause harm?
_______________________________________________
_______________________________________________

Case Study 2.2 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Graysen is a 29-year-old man with a 2-year status post multiple
trauma, which was secondary to an improvised explosive device blast
in Kabul, Afghanistan. Graysen was referred to occupational therapy
by his current orthopedic physician for treatment of residual hand
and upper extremity dysfunction and difficulty participating in
desired occupations. An occupational therapist evaluated him using
goniometry, dynamometry, the Nine Hole Peg Test, and the Canadian
Occupational Performance Measure (COPM). The results of the range-
of-motion measurements indicate full passive motion in flexion and
extension with 75% impairment of active flexion of all digits and full
active extension of all digits of both hands. Thumbs are functional yet
lack 10% of passive and active motion. Grip strength testing indicated
15 pounds of force bilaterally with 5 pounds of lateral pinch strength.
The Nine Hole Peg Test indicated impaired fine motor coordination
with a score of 60 seconds on the left nondominant hand and 72
seconds on the right hand using lateral pinch only.
Graysen indicated three areas of functional concern while
completing the COPM. These include the inability to (1) complete
independent bill paying, (2) use the computer to communicate with
friends and family on social network sites, and (3) prepare his plate
for independent eating. Graysen has scored his ability and satisfaction
with these skills as follows (10 = high; 1 = low).

• Bill paying:
1. Performance: 2
2. Satisfaction: 3
 • Computer use and social communication:
1. Performance: 2
2. Satisfaction: 1
• Eating/plate preparation:
1. Performance: 3
2. Satisfaction: 4
• Average scores:
1. Performance: 8/3, 2.6 average
2. Satisfaction: 7/3, 2.3average
1. According to the information presented previously, what areas
should be addressed first to assist Graysen with occupational
satisfaction? Why?
_______________________________________________
_______________________________________________
2. What approach to treatment facilitates the most expedient
return to function? Why?
_______________________________________________
_______________________________________________
3. What components of this assessment indicate a concern for the
occupational participation and context of the client?
_______________________________________________
_______________________________________________
4. What occupational areas would you need to consider for
Graysen’s orthotic design?
_______________________________________________
_______________________________________________

Case Study 2.3 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Irene is a 63-year-old married female. She does not work outside of
the home but is very involved in civic organizations such as
volunteering for Boys and Girls Club. She and her husband, who
recently retired as the vice president of a local bank, purchased a
historic home in the downtown area of their city. They installed a
swimming pool as swimming is another important leisure and health
pursuit of Irene. Approximately 3 weeks ago, while walking her dog
on an uneven sidewalk, Irene sustained a fracture to her dominant
right elbow and underwent an open reduction and internal fixation
procedure with Kirschner wire to secure the bone fragments for
healing.
At this time Irene is keeping occupied by having multiple friends
visit throughout the day. They spend many hours at poolside
discussing politics and national events. Her husband currently
transports Irene to all of her doctor appointments and assists her with
some activities such as grocery shopping.
Irene is being seen for the first time in occupational therapy today
to begin active mobilization of the elbow joint and to address
occupational concerns.
The half-cast orthosis provided by the physician was effective in
immobilizing and protecting the joint, yet Irene reported to the
therapist the following difficulties:

• General dependency for all self-care and transportation

• Unable to attend volunteer and church activities
• Unable to engage in desired swimming activities due
to water-soluble orthosis/cast
• Dependency in application of orthosis (elastic wrap required)
• Limited wrist mobility due to length of orthosis/cast
• Bulkiness of orthosis/cast creating difficulty with dressing into
long-sleeve shirts and jackets
• Heaviness of orthosis/cast, leading to shoulder soreness
1. What additional information should the therapist acquire to
create an occupation-centered treatment plan for Irene?
2. Identify an appropriate outcome measure that could be used in
the case of Irene.
3. Using an occupation-focused approach, what would be the first
change that you would make to the orthosis that Irene is
currently using? Why?
4. How would your answer to question 3 change if you decided
to use an occupation-based approach to her care due to the
severity of the elbow fracture?
Appendix 2.2 Form
Form 2.1 Occupation-Based Orthotic
Intervention Checklist
Matching Activity of Occupation-
Centered Orthotic Intervention a
Matching: Match the terms from the chapter text in column A to the
best description in column B.

a See Appendix A for answers.

a See Appendix A for answers.
a See Appendix A for answers.
a See Appendix A for answers.
Orthotic Processes, Tools, and
Techniques
Brenda M. Coppard

CHAPTER OBJECTIVES
1. Categorize orthotic materials according to their properties.
2. Recognize tools commonly used to make orthoses.
3. Identify various methods to optimally prepare a client for orthotic
intervention.
4. Explain the process of cutting and molding an orthosis.
5. List common items that should be available to a therapist for
making orthoses.
6. List the advantages and disadvantages of using prefabricated
orthoses.
7. Explain the reasons for selecting a soft orthosis over a
prefabricated orthosis.
8. Explain three ways to adjust a static progressive force on
prefabricated orthoses.
9. Relate an example of how a person’s occupational performance
might influence prefabricated orthosis selection.

KEY TERMS
handling characteristics
hard end feel
heat gun
memory
performance characteristics
physical agent modality (PAM)
soft end feel
thermoplastic material

Lola is a new therapist beginning her first week of practice in an

outpatient clinic. She receives her first referral for a client who needs
evaluation and intervention, including the provision of an orthosis.
Lola’s heart beats quickly, and for a few seconds she panics! Then she
calms down and remembers her education whereby she gained
foundational knowledge and skills required for orthotic intervention.
With a clear head, she rises to the challenge.

Britt became employed a week ago at an outpatient therapy clinic. He

received an order to fabricate a wrist immobilization orthosis for a male
construction worker recently diagnosed with carpal tunnel syndrome.
Britt felt confident making the pattern and molding the orthosis on the
client. However, when Britt initiated removal of the orthosis from the
client, he realized the thermoplastic material stuck to the client’s arm
hair! Britt was embarrassed and began thinking about how to remove
the orthosis without causing the client discomfort.

Therapists who offer orthotic intervention must have competency in

a variety of processes, tools, and techniques to avoid situations like
the one that Britt encountered. This chapter presents commonly used
processes, tools, and techniques related to making orthoses. Orthotic
intervention is used for variety of clients who require custom-made or
prefabricated orthoses.
Thermoplastic Materials
Low-temperature thermoplastic (LTT) materials are most commonly
used to fabricate orthoses. The materials are considered “low
temperature” because they soften in water heated between 135°F and
180°F. 19 The therapist can usually safely place the softened material
directly against a person’s skin while the plastic is still moldable. LTT
materials compare to high-temperature thermoplastics that become
soft when warmed to greater than 250°F 27 and cannot touch a
person’s skin while moldable without causing a thermal injury. When
LTT material is heated, it becomes pliable and then hardens to its
original rigidity after cooling. The first commonly available LTT
material was Orthoplast. Currently many types of thermoplastic
materials are available from several companies. Clinics stock various
types of materials based on patient population, common diagnoses,
therapists’ preferences, and availability.
In addition to orthotic fabrication, LTT material is commonly used
to adapt devices for improving function. For example, thermoplastic
material may be heated and wrapped around pens, handles, utensils,
and other tools to build up the circumference and decrease the
required motion needed to use such items.
Therapists select the best type of thermoplastic material for orthotic
fabrication. Decisions are based on such factors as cost, properties of
the thermoplastic material, familiarity with orthotic materials, and
therapeutic goals. One type of thermoplastic material is not the best
choice for every type or size of orthosis. If a therapist has not had
experience with a particular thermoplastic material, it is beneficial to
read the manufacturer’s technical literature describing the material’s
content and properties. Practice using new materials before
fabricating orthoses on clients can avoid disastrous effects. 11
Thermoplastic Material Content and
Properties
Thermoplastic materials are elastic, plastic, a combination of plastic
and rubberlike, and rubberlike. 16 Thermoplastic materials that are
elastic based have some amount of memory. (Memory is addressed
later in this section.) Typically, elastic thermoplastic material has a
coating to prevent the material from adhering to itself. (Most
thermoplastic materials have a nonstick coating, but there are a few
that specify that they do not.) Elastic materials have a longer working
time than other types of materials and tend to shrink during the
cooling phase.
Thermoplastic materials with a high plastic content are drapable
and have a low resistance to stretch. Plastic-based materials are often
used because they result in a highly conforming orthosis. Applying
LLT with a high plastic content requires great skill in handling the
material (e.g., avoiding fingerprints and stretch) during heating,
cutting, moving, positioning, draping, and molding. Thus for novice
practitioners positioning the client in a gravity-assisted position is best
to prevent overstretching of the material.
Thermoplastic materials that are described as rubbery or rubberlike
tend to be more resistant to stretching and fingerprinting. These
materials are less conforming than their more drapable plastic
counterparts. Therapists should not confuse resistance to stretch
during the molding process with the rigidity of the orthosis upon
completion. Materials that are quite drapable become extremely rigid
when cooled and set. In addition, the more contours that an orthosis
has, the more rigid it will be.
Some LTT materials are engineered to include an antimicrobial
protection. Orthoses can create a moist surface on the skin where
mold and mildew can form. When skin cells and perspiration remain
in a relatively oxygen-free environment for hours at a time, it is
conducive to microbe growth and results in odor. Daily cleansing with
isopropyl alcohol on the inside surface of the orthosis effectively
combats this problem. Thermoplastic materials containing the
antimicrobial protection offer a defense against microorganisms. The
antimicrobial protection does not wash or peel off.
Each type of thermoplastic material has unique properties, 9 which
are categorized by handling and performance characteristics.
Handling characteristics refer to the thermoplastic material properties
when heated and softened, and performance characteristics refer to
the thermoplastic material properties after the material has cooled and
hardened.

Handling Characteristics
Memory
Memory is a property that describes a material’s ability to return to its
preheated (original) shape, size, and thickness when reheated. The
property ranges from 100% to little or no memory capabilities. 16
Materials with 100% memory return to their original size and
thickness when reheated. Materials with little to no memory do not
recover their original thickness and size when reheated or stretched.
Most materials with memory turn translucent (clear) during
heating. Using the translucent quality as an indicator, the therapist
easily determines that the material is adequately heated; thus it
prevents overheating or underheating. The ability to see through the
material also assists the therapist with properly positioning and
contouring the material on the client.
Memory allows therapists to reheat and reshape orthoses several
times without the material stretching excessively. Materials with
memory must be constantly molded throughout the cooling process to
sustain maximal conformability to the underlying body part. Novice
or inexperienced therapists who wish to correct errors in a poorly
molded orthosis frequently use materials with memory. Materials
with memory accommodate the need to redo or revise an orthosis
multiple times while using the same piece of material over and over.
LTT material with memory is often used to make orthoses for clients
who have high tone or stiff joints because the memory allows
therapists to serially adjust a joint(s) into a different position.
Clinicians use a serial adjustment approach when they intermittently
remold to a person’s limb to accommodate changes in range of
motion.
Materials with memory may pose problems when a therapist is
attempting to make fine adjustments. For example, spot heating a
small portion may inadvertently change the entire orthosis because of
shrinkage. Therapists must carefully control duration of heat
exposure. It may be best in these situations to either reimmerse the
entire orthosis in water and repeat the molding process, or prevent the
problem and select a different type of LTT material.

Drape and Contour

Drape and contour is the degree of ease with which a material
conforms to the underlying shape without manual assistance. The
degree of drape or contour varies among different types of material.
The duration of heating is important. The longer the material heats,
the softer it becomes, and the more vulnerable it becomes to gravity
and stretch. When a material with high drape is placed on a surface,
gravity assists the material in draping and contouring to the
underlying surface. Material exhibiting high drape must be handled
with care after heating. Therapists avoid holding the plastic in a
position whereby gravity affects the plastic and results in a stretched,
thin piece of plastic. Thus, therapists carefully take the thermoplastic
material out of the pan in a horizontal rather than vertical position.
When cutting an orthotic pattern from the softened plastic, it is
positioned on a clean countertop to cut the pattern from the material.
This cutting placement also avoids stretching the material. Material
with high drape is difficult to use for large orthoses and is most
successful on a cooperative person who can place the body part in a
gravity-assisted position.
Thermoplastic materials with high drape may be more difficult for
beginning practitioners because the materials must be handled gently,
and often the material is handled too aggressively. Successful molding
requires therapists to refrain from pushing the material during
shaping. Instead, the material should be lightly stroked into place.
Light touch and constant movement of therapists’ hands result in
orthoses that are cosmetically appealing. Materials with low drape
require firm pressure during the molding process. Therefore, persons
with painful joints or soft-tissue damage have better tolerance for
materials with high drape.

Elasticity
Elasticity is a material’s resistance to stretch and its tendency to return
to its original shape after stretch. Materials with elasticity have a slight
tendency to rebound to their original shapes during molding.
Materials with a high resistance to stretch can be worked more
aggressively than materials that stretch easily. As a result, resistance
to stretch is a helpful property when one is working with
uncooperative persons, those with high tone, or when an orthosis
includes multiple joints and placement covers larger surface areas
(i.e., forearm, wrist, ulnar border of hand, and thumb in one orthosis).
Low elastic (high plastic) materials stretch easily and become thin.
Therefore, light touch must be used.

Bonding
Self-bonding or self-adherence is the degree to which material sticks
to itself when properly heated. Some materials are coated; others are
not. Coated materials always require surface preparation with a
bonding agent or solvent to remove the coating. Self-bonding
(uncoated) materials may not require surface preparation.
Coated materials tack at the edges, because the coating covers only
the surface and not the edges. Often the tacked edges can be pried
apart after the material is completely cool. If a coated material is
stretched, it becomes tackier and is more likely to bond. When heating
self-bonding material, the therapist is cautious that the material does
not overlap on itself during the heating or draping process. If the
material overlaps, it sticks to itself. Noncoated materials may adhere
to paper towels, towels, bandages, and even the hair on a client’s
extremity! Thus, it may be necessary to apply an oil-based lotion to
the client’s extremity before the application of the material. To
facilitate handling of the material, therapists often wet their hands and
scissors with water or lotion to prevent sticking.
All thermoplastic material, whether coated or uncoated, forms
stronger bonds when surfaces are prepared with a solvent or bonding
agent (which removes the coating from the material). A bonding agent
or solvent is a chemical that is brushed onto surfaces of both softened
plastic areas that require a bond. In some cases, therapists roughen the
two surfaces that will have contact with each other. This procedure,
called scoring, is carefully done with the end of a scissors, an awl, or a
utility knife. After surfaces are scored, they are softened and then
brushed with a bonding agent and adhered together. The sequence is
important to follow. If bonding agent is applied to the scored material
and then placed in water, fumes develop and the bonding agent is
diluted. Self-adherence is an important characteristic for mobilization
orthoses to secure outriggers to bases of the orthoses (see Chapter 13)
and when the plastic must attach to itself to provide support—for
example, when wrapping around the thumb as in a thumb spica
orthosis (see Chapter 8).

Self-Finishing Edges
A self-finishing edge is a handling characteristic that allows any cut
edge to seal and leave a smooth rounded surface if the material is cut
when warm. This handling characteristic saves time for therapists
because they do not have to manually flare or smooth the edges.

Other Considerations
Other handling characteristics include heating time, working time,
and shrinkage. The time required to heat thermoplastic materials to a
working temperature must be monitored closely, because material left
too long in hot water often becomes excessively soft and stretchy. To
prevent burns and discomfort, therapists must be cognizant of the
material’s temperature before applying it to a person’s skin. After
material that is ⅛-inch thick is sufficiently heated, it is usually pliable
for approximately 3 to 5 minutes. Some materials allow up to 4 to 6
minutes of working time. Materials thinner than ⅛ inch and those that
are perforated heat and cool more quickly. 17 Properties are described
in the manufacturer's product documents.
Shrinkage is an important consideration when therapists are
properly fitting any orthosis, but particularly with a circumferential
design. Plastics shrink slightly as they cool. During the molding and
cooling time, precautions must be taken to avoid a shrinkage-induced
problem, such as difficulty removing a thumb or finger from a
circumferential component of an orthosis.

Performance Characteristics
Conformability
Conformability is a performance characteristic that refers to the ability
of thermoplastic material to fit intimately onto contoured areas.
Material that drapes easily and conforms to a high degree is
impressionable and picks up the client’s fingerprints and crease marks
(as well as therapists’ fingerprints). Orthoses that intimately conform
to persons are more comfortable because they distribute pressure best
and reduce the likelihood of the orthosis migrating on the extremity.

Flexibility
A thermoplastic material with a high degree of flexibility can take
stresses repeatedly. Flexibility is an important characteristic for
circumferential orthoses because these orthoses must be pulled open
for each application and removal.

Durability
Durability is the length of time thermoplastic material will last—or its
shelf life. Rubber-based materials are more likely to become brittle
with age than are plastic-based materials.

Rigidity
Materials having a high degree of rigidity are strong and resistant to
repeated stress. Rigidity is especially important for medium- to large-
size orthoses (such as orthoses for elbows or forearms). Large orthoses
require rigid material to support the weight of larger joints. In smaller
orthoses, rigidity is important if the plastic must stabilize a joint.
Rigidity can be enhanced by contouring an orthosis intimately to the
underlying body shape. 35 Most LTT materials cannot tolerate the
repeated forces involved in weight bearing on an orthosis, such as for
foot orthoses. Most foot orthoses will have fatigue cracks within a few
weeks. 10 Rather the person should be provided with an ankle-foot
orthosis made from high-temperature material.

Perforations
Theoretically, perforations in material allow for air exchange to the
underlying skin. Various perforation patterns are available (e.g., mini-
, maxi-, and micro-perforated). Perforated materials are also designed
to reduce the weight of orthoses. Several precautions must be taken if
one is working with perforated materials. 35 Perforated material
should not be stretched, because stretching enlarges the holes in the
plastic and thereby decreases its strength and pressure distribution.
When cutting a pattern out of perforated material, therapists cut
between the perforations to prevent uneven or sharp edges that occur
when cutting through a perforation. If this cannot be avoided, the
edges of the orthosis should be smoothed, lined with a thin padding
material such as moleskin, or with purchased edging material.

Finish, Color, and Thickness

Finish refers to the texture of the endproduct. Some thermoplastics
have a smooth finish, whereas others have a grainy texture. Generally,
coated materials are easier to keep clean because the coating resists
soiling. 16
The color of the thermoplastic material may affect a person’s
acceptance and satisfaction with the orthosis and compliance with the
wearing schedule. Dark-colored orthoses tend to show less soiling and
appear cleaner than white orthoses. Brightly colored orthoses tend to
be popular with children and youth. Colored materials may be used to
facilitate attention to one side of the body as with unilateral neglect. 8
In addition, colored orthoses are easily seen and therefore useful in
preventing loss (e.g., laundry) in institutional settings. For example, it
is easier to see a blue orthosis in white bed linen than to see a white
orthosis in white bed linen.
A common thickness for thermoplastic material is ⅛ inch. However,
if the weight of the entire orthosis is a concern, a thinner plastic may
be used—reducing the bulkiness of the orthosis and possibly
increasing the person’s comfort and improving adherence to the
wearing schedule. Some thermoplastic materials are available in
thicknesses of 1⁄16, 3⁄32, and 3⁄16 inch. Thinner thermoplastic materials
are commonly used for small orthoses, arthritic joints, and pediatric
orthoses. The 3⁄16-inch thickness is commonly used for lower
extremity orthoses and fracture braces. 12 Keep in mind that plastics
thinner than ⅛ inch soften and harden more quickly than thicker
materials. Therefore, therapists who are novices in orthotic
intervention may find it easier to use ⅛-inch-thick materials than
thinner materials. 10 Table 3.1 lists property guidelines for
thermoplastic materials. (See Laboratory Exercise 3.1.)
Process: Making the Orthosis
Orthotic Patterns
Making an accurate pattern for an orthosis is necessary for success. It
is important initially to spend the appropriate amount of time and
attention when making a well-fitting pattern. In the long run, it saves
the practitioner’s time and the materials involved in adjustments or
fabricating an entirely new orthosis. A pattern is made for each person
who needs an orthosis. Generic patterns rarely fit persons correctly
without adjustments. Having several sizes of generic patterns cut out
of aluminum foil for trial fittings may speed up the pattern process. A
standard adult pattern can be reduced on a copy machine for
pediatric-size patterns.
To make a custom pattern, the therapist traces the outline of the
person’s hand (or corresponding body part) on a paper towel, foil, or
parchment paper, making certain that the hand is flat and in a neutral
position. If the person’s hand is unable to flatten on the paper, or if it
is too painful to make the pattern on the involved hand, the
contralateral hand may be used to draw the pattern and fit the pattern
and orthosis. If the contralateral hand cannot be used, the therapist
may hold the paper in a manner to contour to the hand position. The
therapist marks on the paper any anatomical landmarks needed for
the pattern before the hand is removed. The therapist then draws the
pattern over the outline of the hand, cuts out the pattern with scissors,
and completes final sizing. The therapist must hold the pencil or
drawing utensil at a 90 degree angle to the paper and maintain that
angle when tracing the hand to ensure the best pattern result.

Fitting the Pattern to the Client

As shown in Fig. 3.1, moistening the paper pattern and applying it to
the person’s hand helps the therapist determine which adjustments
are required. Patterns made from aluminum foil work well to contour
the pattern to the extremity. If the pattern is too large in areas, the
therapist can adjust by marking the pattern with a pencil and cutting
or folding the paper. Sometimes it is necessary to make a new pattern
or to retrace a pattern that is too small or requires major adjustments.
Always ensure that the pattern fits the person before tracing it onto
and cutting it out of the thermoplastic material. It is well worth the
time to make an accurate pattern because any ill-fitting pattern
directly affects the finished product.

TABLE 3.1

Thermoplastic Property Guidelines a

a Not all-inclusive.

Resources: https://www.ncmedical.com/; https://www.orfit.com/;

https://www.performancehealth.com; https://www.medwest.ca;
http://remingtonmedical.com
 FIG. 3.1 To make pattern adjustments, moisten the paper, and apply
it to the extremity during fitting.

Throughout this book, detailed instructions are provided for

making a variety of orthotic patterns. Remember that therapists with
experience and competency may find it unnecessary to identify all
landmarks as indicated by the detailed instructions. Form 3.1 lists
suggestions helpful to a beginning practitioner when drawing and
fitting patterns.

Fabricating the Orthosis From the Pattern

After making and fitting the pattern to the client, the therapist places
it on the sheet of thermoplastic material in a way to conserve material
and then traces the pattern on the thermoplastic material with a
pencil. (Conserving materials ultimately saves expenses for the clinic
or hospital.) Pencil lines do not show up on all plastics. Using an awl
to “scratch” the pattern outline on the plastic works well. Another
option is to use a grease pencil or china pencil. However, if using a
grease pencil, the therapist should cut just inside the drawn line as it
is difficult to remove the grease pencil markings. Caution should also
be taken when an ink pen is used because the ink may smear onto the
plastic. With much effort and on some occasions, the ink might be
removed with chlorine. Another option with thermoplastic materials
that have memory and are difficult to draw on, such as Aquaplast, is
to first cut the pattern out of paper towel or aluminum foil. Then after
the thermoplastic material has softened in water and dried off, place
the pattern piece on top of the material, and cut around it.
Once the pattern is outlined on a sheet of material, a rectangle
slightly larger than the pattern is cut with a utility knife (Fig. 3.2).
After the cut is made, the material is folded over the edge of a
countertop. If unbroken, the material is turned over to the other side
and folded over the countertop’s edge. Any unbroken line is then cut
with a utility knife or scissors.
FIG. 3.2 A, A utility knife is used to cut the sheet of material with the
pattern outline on it in such a way that the thermoplastic material fits in
 the hydrocollator or fry pan. B, The score from the utility knife is
pressed against a countertop.

Heating the Thermoplastic Material

Thermoplastic material is softened in an electric fry pan, commercially
available orthotic pan, or hydrocollator filled with water heated to
approximately 135°F to 180°F (Fig. 3.3). (Some materials can be heated
in a microwave oven or in a fry pan without water.) To ensure
temperature consistency, the temperature dial should be marked to
indicate the correct setting of 160°F by using a hook-and-loop (Velcro)
dot or piece of tape. When softening materials vertically in a
hydrocollator, the therapist must realize the potential for problems
associated with material stretching due to gravity’s effects. If a fry pan
is used, the water height in the pan should be a minimum of three-
fourths full (approximately 2 inches deep).
Adequate water height allows a therapist to submerge portions of
the orthosis later when making adjustments. If the thermoplastic
material is larger than the fry pan, a portion of the material should be
heated. When soft, place the material on a wet paper towel or dry
cloth towel. The remaining hard material is placed in the fry pan for
softening. A nonstick mesh may be placed in the bottom of a fry pan
to prevent the plastic from sticking to any materials or particles.
However, it can create a mesh imprint on some plastics. When the
thermoplastic piece is large (and especially when it is a high-stretch
material), it is a great advantage to lift the thermoplastic material out
of the pan on the mesh or a hefty paper towel, or with two spatulas.
This keeps the plastic flat and minimizes stretch.
 FIG. 3.3 Soften thermoplastic material in (A) an electric fry pan or (B)
a hydrocollator.

Cutting the Thermoplastic Material

After removing the thermoplastic material from the water with a
spatula or on the mesh, the therapist places the material on a flat
surface and cuts the material with either curved- or flat-edged orthotic
scissors (Fig. 3.4). The therapist uses sharp scissors and cuts with long
blade strokes (as opposed to using only the tips of the scissors). When
cutting, the therapist must not completely close or collapse the blades
of the scissors. Novice orthotic fabricators should practice their cutting
skills before attempting to fabricate an orthosis for a client. When
cutting the thermoplastic material, the therapist should be careful to
push away excess thermoplastic material pieces to prevent them from
adhering to the thermoplastic portion needed for the actual orthosis.
Scissors must be sharpened annually and possibly more often,
depending on use. Dedicating scissors for specific materials prolongs
the edge of the blade. For example, one pair of scissors is used to cut
plastic, another for paper, another for adhesive-backed products, and
so on. Nonstick scissors that cut through adhesive-backed hook and
loop are commercially available. 11,18 These scissors are designed to
protect the blades and are easily cleaned with water. Adhesive
remover or solvent will remove adhesive that builds up on traditional
scissor blades. Sharp scissors in a variety of sizes (e.g., fingernail
scissors) are helpful for intricate contoured cutting and trimming.
 FIG. 3.4 Sharp round- or flat-edged scissors work well for cutting
thermoplastic.

Reheating the Thermoplastic Material and Positioning

the Client
After the pattern is cut from the material, it is reheated. During
reheating the therapist positions the person to the desired joint
position(s). To expedite the process, it is beneficial to practice
positioning with the client. Visualize the desired joint position(s), and
practice “eyeballing” or estimating the position so that it can be done
quickly without using a goniometer. If the therapist anticipates
positioning challenges and needs to spend time solving problems,
positioning should occur before the material is reheated to prevent the
material from overheating. 24 The therapist completes any prepadding
of bony prominences and covers dressings and padding before the
molding process. (The LTT sticks to the dressings and padding if not
covered with stockinette.)
Several client positioning options exist. The client is placed in a
position that is comfortable, especially for the shoulder and elbow. A
therapist may use a gravity-assisted position for volar-based
hand/wrist orthoses by having the person rest the dorsal wrist area on
a towel roll while the forearm is in supination to maintain proper
wrist positioning. Alternatively, a therapist may ask the person to rest
the elbow on a table and work with the hand while it is in a vertical
position. The vertical position allows for easier visual inspection or
when taking joint measurements, but the material may stretch with
the effects from gravity.
For persons with joint stiffness, a warm water soak or whirlpool,
ultrasound, paraffin dip, or hot pack can be used before positioning
for the orthotic-making process. For persons experiencing significant
pain and who are taking pain medications, orthotic fabrication is
easiest when pain medications are taken 30 to 60 minutes before the
session. This timing helps control the client’s pain during orthotic
fabrication. (Clients taking pain medications should avoid driving
themselves to and from therapy.) For persons with hypertonicity, it
may be effective to apply a hot pack on the joint that needs to be
positioned in the orthosis. Then the joint is positioned, and the
orthosis is applied in a submaximal range. When the orthotic
fabrication is completed after warming or after a physical agent
modality (PAM) session, the joints are usually more mobile.
However, the orthosis may not be tolerated after the preconditioning
effect wears off. Thus, the therapist must find a balance to complete a
gentle warm-up and avoid aggressive preconditioning treatments. 24
Goniometers are used, when possible, to measure joint angles for
optimal therapeutic positioning. As discussed, with experience joint
angles can be “eyeballed,” and a goniometer may not be needed.

Molding the Orthosis to the Client

Once positioning is accomplished, the therapist retrieves the softened
thermoplastic material . Any hot water is wiped off on a paper towel,
a fabric towel, or a pillow that has a dark-colored pillowcase on it.
(The dark-colored pillowcase helps identify any small scraps or snips
of material from previous orthotic intervention activities that may
adhere to the thermoplastic material.) The therapist checks the
temperature of the softened plastic and finally applies the
thermoplastic material to the person’s extremity. The thermoplastic
material may be extremely warm, and thus the therapist uses caution
to prevent skin burn or discomfort. For persons with fragile skin who
are at risk of burns, the extremity may be covered with stockinette
before the thermoplastic material is applied. Another option is to
apply a double layer of wet paper towel pieces over the skin. The
therapist always immediately asks the client if the material is too
warm—regardless of what technique is used and even when
precautions are taken. Some thermoplastic materials stick to hair on
the person’s skin, but this situation can be avoided by using a
stockinette or applying an oil-based lotion on the skin before
application of the thermoplastic material. Note that lotions must not
be used on open wounds.

Patient Safety
Use caution when placing the warm thermoplastic material on the
client. Use caution to prevent skin burn or discomfort. For persons
with fragile skin who are at risk of burns, cover the extremity with a
stockinette or a double layer of wet paper towels before applying the
thermoplastic material. Regardless, any person can benefit from the
double layer of wet paper towels for protection with orthotic
fabrication. Some thermoplastic materials stick to hair on the person’s
skin, but this situation can be avoided by using a stockinette or
applying lotion to the skin before the application of the splinting
material.
 FIG. 3.5 A heat gun is used for spot heating.

Therapists may choose to hasten the cooling process to maintain

joint position and the orthotic shape. Several options exist. First, a
therapist can use an environmentally friendly cold spray. Cold spray
is an agent that serves as a surface coolant. Cold spray should not be
used near persons who have severe allergies or who have respiratory
problems. Because the spray is flammable, it should be properly
stored.
A second option is to dip the person’s extremity with the orthosis
into a tub of cold water. This must be done cautiously with persons
who have hypertonicity because the cold temperature may cause a
rapid increase in the amount of tone, thus altering joint position.
Similar to using a tub of cold water, the therapist may carefully walk
the person wearing the orthosis to a sink and run cold water over the
orthosis.
Third, a therapist may use frozen Theraband and wrap it around
the orthosis to hasten cooling. An Ace bandage immersed in ice water
and then wrapped around the orthosis may also speed cooling. 35
However, the bandages often leave imprints on the thermoplastic
material.

Making Adjustments
Adjustments are made to an orthosis by using a variety of techniques
and equipment. While the thermoplastic material is still warm, a
therapist adjusts the orthosis—such as marking a trim line with one’s
fingernail or a pencil. Before complete cooling, stretching small areas
of the orthosis is possible. The amount of allowable stretch depends
on the property of the material and the cooling time that has elapsed.
If the plastic is too cool to cut with scissors, the therapist quickly dips
the area in hot water to resoften. A professional-grade metal turkey
baster or ladle assists in directly applying hot water to modify a small
or difficult-to-immerse area of the orthosis.
A heat gun (Fig. 3.5) is also used to make adjustments. A heat gun
has a switch for off, cool, and hot. After using a heat gun, before
turning it to the off position, the therapist sets the switch to the cool
setting. The cool setting allows the motor to cool down and protects
the motor from overheating. When a heat gun is on the hot setting,
caution must be used to avoid burning of materials surrounding it
and to avoid skin burns from reaching over the flow of the hot air.
Heat guns must be used with care. Because heat guns warm
unevenly, therapists should not use them for major heating and
trimming. Use of heat guns to soften a large area on an orthosis may
result in a buckle or a hot-cold line. A hot-cold line develops when a
portion of plastic is heated and its adjacent line or area is cool. A
buckle can form where the hot area stretched, and the cooled material
did not. Heat guns are helpful for softening small focused areas for
finishing touches. When using a heat gun, it is best to continually
move the heat gun’s air projection in a circular pattern on the area of
the orthosis to be softened; otherwise it can burn the material. In
addition, the area to be softened should be heated on both sides of the
plastic. Attachments for the heat gun’s nozzle are available to focus
the direction of hot air flow. Small heat guns are available and may
assist in spot heating thinner plastics and areas of the orthosis that
have attachments that cannot be exposed to heat (i.e., orthotic
outrigger line). 24,25

Strapping
After achieving a correct fit, the therapist uses strapping materials to
secure the orthosis onto the person’s extremity. Many strapping
materials are available commercially. Velcro hook and loop, with or
without an adhesive backing, is commonly used for portions of the
strapping mechanism. Velcro is available in a variety of colors and
widths. Therapists trim Velcro to a desired width or shape. For cutting
self-adhesive Velcro, employ sharp scissors other than those used to
cut thermoplastic material. The adhesive backing from strapping
materials often accumulates on the scissor blades and makes the
scissors a poor cutting tool. The adhesive can be removed with
solvent, or the therapist can use nonstick scissors. With self-adhesive
Velcro hook the corners are rounded. Rounded corners decrease the
chance of corners peeling off the orthosis. Precut self-adhesive Velcro
hook dots are commercially available and save therapists’ time in
cutting and rounding corners, and they keep adhesive off scissors.
Clinic aides or volunteers may cut self-adhesive Velcro hook pieces
that have rounded corners to save therapists’ time. Briefly heating the
adhesive backing and the site of attachment on the orthosis with a
heat gun increases the bond of the hook or loop to the thermoplastic
material.
 FIG. 3.6 A, Strap is threaded through a slit in forearm trough. The
strap is overlapped upon itself and securely sewn. B, D-ring strapping
mechanism.

Alternative pressure-sensitive straps, which attach to the Velcro

hook, are available. Soft padded strapping materials add comfort;
however, they tend to be less durable than Velcro loop. Some padded
strapping materials, when cut, are self-sealing for a more finished
look. Soft straps without self-sealing edges tend to tear apart with use
over time. The therapist may cut extra straps and give them to the
client to take home if necessary. Commercially sold orthotic strapping
kits provide all the straps needed for a forearm-based orthosis in one
convenient package.
Another consideration is the patient’s skin integrity with choosing
the amount of softness with strapping material. Spiral or continuous
strapping is used to evenly distribute pressure along the orthosis. A
spiral or continuous strap is a piece of soft strapping that spirals
around the forearm portion of an orthosis. Rather than several
individual pieces of Velcro hook being cut to attach to selected places
on the orthosis, a long strip of Velcro hook can be used on both sides
of the forearm trough. The spiral or continuous strap attaches to the
Velcro hook. Spiral or continuous straps can be used in conjunction
with compression gloves for persons who have edema. The spiral
strapping and glove prevent the trapping of distal edema.
To prevent the person wearing the orthosis from losing straps, the
therapist may attach one end of the strap to the orthosis with a rivet or
strong adhesive glue. Another helpful technique is to heat the end of a
metal butter knife with a heat gun and push it through the
thermoplastic material to make a slit the width of the strapping
material. The area is cooled, and the knife is removed. The therapist
threads the strap through the slit, folds the strap end over itself, and
sews the strap together (Fig. 3.6A). D-ring straps are available
commercially. D-ring straps afford the greatest control over strap
tension and distal migration of the orthosis (see Fig. 3.6B).
Strap placement is critical to a proper fit. Many therapists fail to
place the straps strategically for joint control and render the orthosis
useless. 24 Schultz-Johnson particularly stresses strap placement at the
wrist, rather than proximal to the wrist.

Padding and Avoiding Pressure Areas

Therapists modify portions of orthoses that may potentially cause
pressure areas or irritations. The therapist can use a heat gun to push
out areas of the thermoplastic material that may irritate bony
prominences. If padding is used, any bony prominences must be
padded before the orthosis is formed. Padding must not be added as
an afterthought. Padding over an area(s) or lining of an entire orthosis
may prevent irritation. Sufficient space must be made available for the
thickness of the padding. Otherwise, the pressure may increase over
the area.
Use of a self-adhesive gel disk (other paddings work as well) is
helpful to cushion bony prominences, such as the ulnar head. To use
gel disks, the therapist adheres the disk to the person’s skin and then
forms the orthosis over the gel disk. Upon cooling of the orthosis, the
gel disk is removed from the person and adhered to the
corresponding area in the interior of the orthosis. To bubble out or
dome areas over bony prominences, a therapist can place elastomer
putty over the prominence before applying the warm thermoplastic
material to the client.

FIG. 3.7 Moleskin overlaps the edges of the orthosis.

TABLE 3.2

Padding Categorization Guidelines

From North Coast Medical (https://www.ncmedical.com/);
Performance Health (https://performancehealth.com).

If an entire orthosis is lined with padding, the therapist uses the

orthotic pattern to cut out the padding needed. Tracing the pattern ¼
to ½ inch larger on the padding is completed if the intention is to
overlap the self-adhesive padding over the edges of the orthosis, as
shown in Fig. 3.7.
Gel lining is often used within the interior of the orthosis to assist in
managing scars. Two types of gel lining are available: silicone gel and
polymer gel. Silicone gel sheets, which are flexible and washable, can
be cut with scissors into any shape. The silicone gel sheets are often
positioned in conjunction with pressure garments or orthoses, or they
are positioned with self-adherent wrap (e.g., Coban). Persons using
silicone gel sheets are monitored for the development of rashes, skin
irritations, and maceration. Polymer gel sheets are filled with mineral
oil, which is released into the skin to soften “normal,” hypertrophic, or
keloid scars. Polymer gel sheets adhere to the skin and can be used
with pressure garments or orthoses.
Various padding systems are commercially available in a variety of
densities, durability, cell structures, and surface textures. 15 Padding
with self-adhesive backing is available and saves the therapist’s time
and use of materials because glue does not have to be used to adhere
the padding to an orthosis. While some cushioning and padding
materials have an adhesive backing for easy application, other types
of padding are applied to any flat sheet of thermoplastic material and
put in a heavyweight sealable plastic bag before immersion in hot
water. The padding is adhered to the thermoplastic material before
molding the orthosis on the client. Putting the plastic with the
padding adhered to it in a plastic bag prevents the padding from
getting wet and can save the therapist time. Table 3.2 outlines padding
products.
Padding has either closed or open cells. Closed-cell padding resists
absorption of odors and perspiration, and it can easily be wiped clean.
Open-cell padding allows for absorption. Because of low durability
and soiling, padding used in an orthosis may require periodic
replacement. Some types of padding are virtually impossible to
remove from an orthosis. Thus when padding needs replacement, so
does the orthosis.

Edge Finishing
Edges of an orthosis should be smooth and rolled or flared to prevent
pressure areas on the person’s extremity. The therapist may use a heat
gun or heated water in a fry pan or hydrocollator to heat, soften, and
smooth edges. Therapists can moisten their fingertips with water or
lotion help avoid finger imprints on the plastic. Most of the newer
thermoplastic materials have self-finishing edges. When the warm
plastic is cut, it does not require detailed finishing other than that
necessary to flare the edges slightly.

Reinforcement
Strength of an orthosis increases when the plastic is curved. Thus, a
plastic that has curves is stronger than a flat piece of thermoplastic
material. When the thermoplastic material is stretched too thin or is
too flexible to adequately support an area such as the wrist,
reinforcement is needed. If an area of an orthosis requires
reinforcement, an additional piece of material bonded to the outside
of the orthosis increases the strength. A ridge molded in the
reinforcement piece provides additional strength (Fig. 3.8).
Prefabricated Orthoses
In addition to making custom-made orthoses, options exist for use of
prefabricated orthoses. The manufacturing of commercially available
prefabricated orthoses is market driven. Therefore, changes in style or
materials may appear from year to year. Styles and materials are also
affected by the manufacturing processes. Manufacturers are slow to
change materials and design even when the market requests it. When
a material, cut, or style of a prefabricated orthosis does not sell well, it
may be discontinued or replaced with a different design. Vendors
often attempt to manufacture prefabricated orthoses for broad
populations. Based on research evidence, custom-made orthoses are
preferred for some diagnostic conditions.
Manufacturing for a specific population is often costly and not
financially rewarding unless that “specific population” has a large
market. Improvements in the quality of prefabricated orthoses are
affected by market economics, which stimulate companies to
manufacture better products in terms of comfort, durability, and
therapeutics. Current catalogs serve as the ultimate reference to what
is available. Vendors offering prefabricated orthoses are listed at the
end of this chapter.
In addition to market economics, the proliferation of various styles
of prefabricated orthoses is attributed to two factors. First, the
proliferation of prefabricated orthoses can be influenced by the third-
party payers’ willingness to reimburse for orthoses. Pediatric orthoses
marketed for orthopedic needs tend to be smaller versions of adult-
size orthoses.
 FIG. 3.8 Orthosis reinforcement. This ridge on the reinforcement
piece adds strength.

Another reason for the proliferation of prefabricated orthoses

involves the conceptual advances in design, technology, and the
recognition that a need for these types of orthoses exists. For example,
the refinement of wrist and thumb prefabricated orthoses has been
influenced by the advancement of ergonomic knowledge and the
public’s awareness of the incidence and effects of cumulative trauma
disorders. The development of 3-D printing is an example of a
technological advancement that is beginning to influence orthotic and
prosthetic provision, particularly in pediatrics. 5 The use of 3-D
printing is intended to provide a lower-cost option for serial
applications of pediatric prostheses and orthoses due to the child’s
growth.
Prefabricated orthoses are available from numerous vendors in a
variety of styles, materials, and sizes. Prefabricated orthoses are
available for the head, neck, joints of the upper and lower extremities,
and trunk. Typically, prefabricated orthoses are ordered by size—and
in some cases for right or left extremities. The therapist is responsible
for using the manufacturer’s measurement instructions to provide the
correct size. Some orthoses have a universal size, meaning that one
orthosis fits the right or left hand. Before deciding to provide a
prefabricated orthosis for a client, the therapist must be aware of the
advantages and disadvantages of prefabricated orthoses.

Advantages and Disadvantages of

Prefabricated Orthoses
The advantages and disadvantages of using prefabricated orthoses are
listed in Box 3.1.

BOX 3.1 Advantages and Disadvantages of Using

Soft and Prefabricated Orthoses

Advantages
An obvious advantage of using a prefabricated orthosis is saving of
the therapist’s time and effort. The time required to design a pattern,
trace and cut the pattern from plastic, and mold the orthosis to the
person is saved when a prefabricated orthosis is used. However, keep
in mind the time and expense involved in ordering and paying for the
prefabricated orthoses. The costs and wage hours involved in
processing an order through a large facility are considerable. Many
clinics stock commonly used prefabricated orthoses in their inventory.
Maintaining the inventory requires time, storage space, and overhead
cost.
If a prefabricated orthosis is in a clinic’s inventory, the ability to
immediately assess the orthosis in terms of therapeutic timeliness and
customer satisfaction is an advantage. After orthotic application, the
client is readily able to see and feel the orthosis. When fabricating a
custom orthosis, the therapist may find that it does not meet the
client’s expectations or needs. When this occurs, a considerable
amount of time and effort is expended in modifying the current
orthosis or in designing and fabricating an entirely new orthosis. With
prefabricated orthoses, an educated trial-and-error process can be
used to find the best orthosis to meet the client’s goals and therapeutic
needs.
A third advantage is the variety of materials used to make
prefabricated orthoses. Many prefabricated orthotic materials offer
sophisticated technology that cannot be duplicated in the clinic. For
example, a prefabricated orthosis made from high-temperature
thermoplastic material is often more durable than a counterpart made
of LTT material. Softer materials (combinations of fabric and foam)
may be more acceptable to persons, especially those with rheumatoid
arthritis.
Research about custom-made versus prefabricated orthoses is
mixed. Soft orthoses can be more comfortable or as comfortable as
LTT custom-made orthoses. In a study comparing soft versus hard
resting hand orthoses in 39 persons with rheumatoid arthritis,
Callinan and Mathiowetz 3 found that compliance with wearing the
orthosis was significantly better with the soft orthosis (82%) than with
the hard orthosis (67%). In a systematic review that specifically
addressed interventions for trapeziometacarpal osteoarthritis,
prefabricated polychloroprene (Neoprene) orthoses and custom-made
thermoplastic orthoses were found to equally reduce pain. 1 Some
research outcomes showed no differences among prefabricated and
custom orthoses, and the lowest-cost orthosis was recommended. 6
Therapists must realize that a person who needs rigid immobilization
for comfort will not prefer a soft orthosis, because soft orthoses allow
for some mobility to occur. Some clients may think that the sports-
brace appearance of a prefabricated orthosis is more aesthetically
pleasing than the medical appearance of a custom-fabricated orthosis.
For these clients, adherence to the wearing schedule may increase.

Disadvantages
Several disadvantages of prefabricated orthoses exist. A major
disadvantage of using a prefabricated orthosis is that a custom,
unique fit is often compromised. Soft prefabricated orthoses vary in
how much they can be adjusted. If a high degree of conformity or a
specialized design or position is needed, a prefabricated orthosis will
usually not meet the person’s needs. LTT prefabricated orthoses can
be spot heated and adjusted somewhat (Fig. 3.9), but they will never
conform like a custom-made orthosis of the same material. Some
prefabricated orthoses require adjustments. For example, thumb
orthoses may require adjustment of the palmar bar to prevent chafing
in the thumb web space. Other preformed orthoses must be adjusted
by trimming the forearm troughs for proper strap application.
The second disadvantage of prefabricated orthoses is related to the
therapist’s lack of control over customization. Because most
prefabricated orthoses are made for the public, therapeutic positions
for conditions may not be included in the designs. For example, some
thumb prefabricated orthoses position the thumb in radial abduction,
and the condition may warrant palmar abduction. Thus, when using
prefabricated orthoses, therapists often have little or no control over
joint angle positioning. Often a therapeutic protocol or specific client
need prescribes a specific joint angle for positioning. In such instances
the therapist must select a prefabricated orthosis that is designed with
the appropriate joint angle(s) or choose one that can be adjusted to the
correct angle. If unavailable, a custom orthosis is warranted. For
example, therapists must use prefabricated orthoses cautiously with
persons who have fluctuating edema. The orthosis and its strapping
system must accommodate the extremity’s changing size. In addition,
when conditions require therapists to create unique orthotic designs,
the desired prefabricated orthoses may not always be commercially
available.
A third disadvantage of using a prefabricated orthosis is that the
orthosis may not be in a clinic’s stock, and it may have to be ordered.
Many clinics cannot afford to stock an extensive array of prefabricated
orthoses because of cost and storage restrictions. When an orthosis
must be applied immediately and the prefabricated orthosis is not in
the clinic’s stock, a time delay for ordering it is unacceptable. A
custom-made orthosis should be fabricated instead of waiting for the
prefabricated orthosis to arrive.
 FIG. 3.9 Adjustments can be made to commercial low-temperature
thermoplastic orthoses with the use of a heat gun.
Courtesy Medical Media Service, Veterans Administration Medical
Center, Durham, North Carolina.

Once the advantages and disadvantages are weighed, a decision is

made regarding whether to use a prefabricated or a custom-made
orthosis. The therapist engages in a clinical reasoning process to select
the most appropriate orthosis.

Selecting an Orthosis
Therapists rarely use custom or prefabricated orthoses for 100% of
their clientele. The therapist uses clinical reasoning based on a frame
of reference to select the most appropriate orthosis. Outcome research
continues to address custom versus prefabricated orthosis usage. To
determine whether to use a prefabricated or a custom-made orthosis,
the therapist must know the specific orthotic needs of the person and
determine how best to accomplish them. Some questions to ask are:

• Would a soft material or an LTT best meet the person’s needs?

• How would the function and fit of a prefabricated orthosis
compare with that of a custom-made orthosis?

To properly evaluate whether a prefabricated orthosis or a custom-

made orthosis would best meet a person’s needs, the factors and
questions discussed in the following sections must be considered and
answered.

Diagnosis
Therapists provide orthoses to people, not diagnoses. However, one
must be well versed in clinical conditions that often require orthotic
intervention. Questions about orthotic intervention and diagnoses
include:

• Is a prefabricated orthosis available for the diagnosis?

• Which orthotic design meets the therapeutic goals?
• Is there a match between the therapeutic goals and the design
of a prefabricated or soft orthosis?
• What evidence exists to indicate a particular orthotic design
for a particular diagnostic category?

For example, if a therapist must provide an orthosis to immobilize a

wrist joint in neutral position, a prefabricated orthosis must have the
ability to position and immobilize the wrist in the required neutral
position rather than extension.
Age of the Person
Think about age-related issues that impact orthotic intervention.
Consider questions such as:

• Is the client at an age where he or she may have an opinion

about the orthotic cosmesis?
• What special considerations are there for an older adult or a
young child? (See Chapters 16 and 17.)
• What are the person’s age-related activities and roles?
• How might orthotic provision affect the activities and roles?

For example, an adolescent who is self-conscious may be unwilling

to wear a custom-made elastic tension radial nerve orthosis at school
because of its appearance. However, the adolescent might agree to
wear a prefabricated wrist orthosis because of its less conspicuous
sports-brace appearance.

Medical Complications
Medical complications often impact orthotic design. Considerations
include:

• Does the person have compromised skin integrity, vascular

supply, or sensation?
• Is the person experiencing pain, edema, contractures, or
cognitive impairments?
• Are there incision sites to avoid?

Medical conditions are considered because they may influence

orthotic design. For example, the therapist may choose an orthosis
with wide elastic straps to accommodate the change in the extremity’s
circumference for a person who has fluctuating edema.

Goals
Clients have goals—things they wish to do and symptoms they want
to eliminate. Therapists should consider the following questions:

• What are the client’s goals?

• What are the therapeutic goals?
• What activities and roles are important to the client?

The therapist determines the client’s priorities and goals from an

interview with the client and/or caregivers and guardians. The
therapist facilitates clients’ adherence to an orthotic wear schedule by
understanding each person’s capabilities and expectations.

Orthotic Design
Choosing an orthotic design is individualized for each client.
Questions to consider include:

• Which joints must be immobilized or mobilized?

• What are the therapeutic goals?
• How will the orthosis achieve the desired therapeutic goals?

It is important to avoid immobilizing unnecessary joints. Any

orthosis that limits active range of motion may result in joint stiffness
and muscle weakness. For example, if the hand is solely involved, use
a hand-based orthosis to avoid limiting wrist motion.

Occupational Performance
Clients lead lives that are filled with participation in meaningful
activities and occupations. Participation in such activities is important.
The therapist should reflect on the following questions:

• Does the orthosis affect the client’s occupational performance?

• Does the orthosis maintain, improve, or eliminate occupational
performance?
• Does wearing the orthosis interfere with participation in
valued activities?
 Occupational performance is considered, regardless of the age of
the client. Stern and colleagues 32 studied 42 persons with rheumatoid
arthritis and reported that the “major use of wrist orthoses occurs
during instrumental activities of daily living where greater stresses
are placed on the wrist.” 32 In another study of people with thumb
carpometacarpal osteoarthritis, researchers concluded that client-
centered treatment strategies are useful to control pain during
meaningful activities. 26 Therapists ask the client about his or her
occupational participation and provide opportunities for the client to
engage in such activities while wearing the orthosis. Functional
problems that occur while wearing the orthosis require clinical
reasoning. Resolution of functional problems may lead to a
modification of performance technique, an adjustment in the wearing
schedule, or a change in the orthotic design.

Client’s or Caregiver’s Ability to Adhere to Orthotic

Instructions
Clients and caregivers must be educated on issues related to orthotic
intervention. One should consider the following questions:

• What is the client’s health literacy level and insight into his or
her condition? (See Chapter 5 for health literacy assessments.)
• Is the person or caregiver capable of following written and
verbal instruction?
• Is the person motivated to adhere to the wearing schedule?
Are there any factors that may influence adherence?

The five determinants of adherence include health system factors,

socioeconomic factors, therapy-related factors, patient-related factors,
and condition-related factors. 36 Forgetfulness, fear, cultural beliefs,
desire to be normal, trust of therapist, values, therapeutic priorities,
and confusion about the orthotic purpose and schedule may influence
adherence to a therapeutic plan. 29 A therapist should consider a
person’s motivation, cognitive functioning, and physical ability when
determining an orthotic design and schedule.
Maximizing adherence to therapy-related interventions includes
ensuring orthoses are comfortable and esthetically pleasing;
incorporating occupationally meaningful activities into therapy; and
preparing clients that some aspects of therapy may cause discomfort
or pain early on, but these feelings do not signify further damage or
injury. Furthermore, maximizing adherence involves communicating
with medical staff to ensure appropriate and effective pain
medications are prescribed (especially in the early stages of
rehabilitation) and sharing stories and examples of previous clients
who successfully adapted activities during orthotic wear. 16
Adherence tends to increase with proper education. 2, , 16 For example,
persons receiving education often have a better outcome if
instructions are presented in verbal and written formats. 22 Therapists
often explain to clients that long-term gains are usually worth short-
term inconveniences. When adherence is a problem, the orthotic
intervention may require modification.

Independence With Orthotic Regimen

A client’s follow-through with a therapeutic intervention is important
to achieving optimal outcomes. If there is no caregiver, can the client
independently apply and remove the orthosis? Can the person
monitor for precautions, such as the development of numbness,
reddened areas, pressure sores, rash, and so on? For example, Fred (an
80-year-old man) needs a bilateral resting hand orthosis to reduce
pain from an exacerbation of rheumatoid arthritis. His 79-year-old
wife is forgetful. Fred’s therapist designs a wearing schedule so that
Fred can elicit assistance from his wife. The therapist recommends
putting the orthosis on the bed so that Fred can remind his wife to
assist him in donning the orthosis before bedtime.

Comfort
If an orthosis is uncomfortable to the client, chances are it will not be
worn. Therapists should ask questions related to comfort, including:
 • Does the person report that the orthosis is comfortable?
• Does the person have any condition, such as rheumatoid
arthritis, that may warrant special attention to comfort?
• Are there insensate areas that may be at risk when wearing the
orthosis, and what adjustments need to be made to address
this?

Therapists monitor the comfort of an orthosis on each client. If the

orthosis is not comfortable, a person is not likely to wear it. In
studying three prefabricated wrist supports for persons with
rheumatoid arthritis, Stern and colleagues 33 concluded that
“satisfaction appears to be based not only on therapeutic effect, but
also the comfort and ease of its use.”

Environment
Where people live, work, and recreate has an impact on orthotic
intervention. Therapists must consider the following:

• In what type of environment will the person be wearing the

orthosis?
• How might the environment affect orthotic wear and care?

Industrial settings
Industrial settings may warrant orthoses made of more durable
materials, such as leather, high-temperature thermoplastics, or metal.
For example, orthoses may need extra cushioning to buffer vibration
from machinery or tools that often aggravate cumulative trauma
disorders.

Long-term care settings

Therapists providing prefabricated orthoses to residents in long-term
care settings must consider the influence of multiple caretakers and
the fragile skin of many older adults. The following suggestions may
assist in dealing with multiple caretakers and older adults’ fragile
skin. Orthoses should be labeled with the person’s name. To avoid
strap loss, consider attaching them to the orthosis, or choose a
prefabricated orthosis with attached straps. Select orthotic materials
that are durable and easy to keep clean. Orthoses made from colored,
thermoplastic material provide a contrast and may be more easily
identified and distinguished from white or neutral-colored
backgrounds.

School settings
Several factors relating to pediatric orthoses must be considered by
the therapist. Pediatric prefabricated orthoses should be made of
materials that are easy to clean. Orthoses for children should be
durable. Consider attaching straps to the orthosis, or choose a
prefabricated orthosis with attached straps. Because multiple
caretakers (parents and school personnel) are typically involved in the
application and wear schedule, instructions for wear and care should
be clear and easy to follow. When the child is old enough, personal
and parental preferences should be considered during orthotic
selection. If the orthosis is for long-term use, the therapist must
remember that the child will grow. If possible, the therapist should
select an orthosis that can be adjusted to avoid the expense of
purchasing a new orthosis. In addition, orthoses with components
that may scratch or be swallowed by the child should be avoided.

Education Format
Educating the client and/or caregiver on the orthotic intervention plan
is linked to outcomes.
Utilizing approaches that consider health literacy to ease
understanding is helpful (refer to Chapter 6). The therapist must
consider:

• What education does the client and caregiver need to adhere

to the orthotic-wearing schedule?
• What is the learning style of the client and caregiver?
• How can the therapist adjust the educational format to match
 the client's and caregiver’s learning styles?

Educating clients and caregivers in methods consistent with their

preferred learning style may increase compliance. Learning styles
include kinesthetic, visual, and auditory. 4
Written instructions should include the purpose of the orthosis,
wearing schedule, care, precautions, and emergency contact
information. Because correct use of an orthosis affects intervention
outcomes, the client should demonstrate an understanding of
instructions in the presence of the therapist. A therapist may complete
a follow-up phone call at a suitable interval to detect any problems
encountered by the client or caregiver about the orthosis (see Chapter
6). 20

Fitting and Adjusting

If a decision is made to use a prefabricated orthosis and a selection is
made, the therapist evaluates the orthosis for size, fit, and function.
Like custom orthoses, a particular prefabricated orthotic design does
not work for every client. As professionals who provide orthoses to
clients, therapists have an obligation and duty to fit the orthosis to the
client rather than fitting the client to the orthosis. The implications of
this duty suggest that clinics should stock a variety of commercial
orthotic designs. Although a large clinic’s overhead is expensive,
limiting choices may result in poor client compliance. 34 When a
variety of orthotic designs are available, a trial-and-error approach
can be used with commercial orthoses because most clients are able to
report their preference for an orthosis after a few minutes of wear.
When fitting a client with a commercial orthosis, the therapist asks the
following questions 34 :

• Does the orthosis feel secure on your extremity?

• Does the orthosis or its straps rub or irritate you anywhere?
• When wearing the orthosis, does your skin feel too hot?
• What activities will you be doing while wearing your orthosis?
 • When you move your extremity while wearing the orthosis,
do you experience any pain?
• Does the orthosis feel comfortable after wearing it for 20 to 30
minutes?

In addition to fit and size, therapists evaluate the effect of the

prefabricated orthosis on function. Outcomes of comparison studies
addressing custom-made versus prefabricated orthoses are mixed.
8,13,14,28,32,33 More research is warranted to make conclusions.

Technical Tips for Custom Adjustments to

Prefabricated Orthoses
The following points describe common adjustments made to
commercial LTT orthoses. High-temperature thermoplastic orthoses
cannot be adjusted using equipment such as heat guns and
hydrocollators. The provider must be competent to adjust high-
temperature thermoplastic orthoses, as is a certified
orthotist/prosthetist.

1. Therapists should ensure that orthoses do not irritate soft

tissue, reduce circulation, or cause paresthesias. 33
Adjustments may include flaring ends, bubbling out pressure
areas, or the addition of padding.
2. Although soft orthoses are intended to be used as is, minor
modifications to customize the fit to a person can be
accomplished. Some soft orthoses can be trimmed with
scissors to customize fit. If a soft orthosis has stitching to hold
layers together, it will need to be resewn. (Note that it is
beneficial to have a sewing machine in the clinic.)
3. Modification methods for preformed orthoses include heating,
cutting, or reshaping portions of the LTT orthosis. Minor
modifications can be made with the use of a heat gun, fry pan,
or hydrocollator to soften LTT preformed orthoses for
trimming or slight stretching.
• Some elastic traction/tension prefabricated orthoses
may be adjusted by bending and repositioning
portions of wire, metal, or foam orthotic components.
Occasionally, technical literature accompanying the
orthosis describes how to adjust the amount of
traction. Often traction is adjusted with the use of an
Allen wrench on the rotating wheels of a hinge joint,
as shown in Fig. 3.10. When there are no instructions
describing how to adjust prefabricated orthoses, the
therapist uses creative problem-solving skills to
accomplish the desired changes.
• When a static prefabricated orthosis is used and serial
adjustments are required to accommodate increases
in passive range of motion (PROM), the orthosis must
be reheated and remolded to the client. It is
advantageous to select a prefabricated orthosis made
of material that has memory properties to allow for
the serial adjustments.
• The amount of force provided by some static-
progressive orthoses is made through mechanical
adjustment of the force-generating device. Force may
be adjusted by manipulating the orthotic turnbuckle,
bolt, or hinge.
• The force exerted by elastic traction components of a
prefabricated orthosis is also made through
adjustments of the force-generating device.
Therapists adjust the forces by changing elastic
component length by gradually moving the
placement of the Neoprene or rubber band–like
straps on an orthosis throughout the day, as shown in
Fig. 3.11.
• Adding components to prefabricated orthoses can be
helpful. For example, putty-elastomer inserts that
serve as finger separators can be used in a resting
hand orthosis. Finger separators add contour in the
 hand area to maintain the arches. A therapist may
choose to add other components, such as wicking
lining or padding.
• Prefabricated orthoses can be modified by replacing
parts of them with more adjustable materials. For
example, if a wrist orthosis has a metal stay, replacing
it with an LTT stay results in a custom fit with the
correct therapeutic position.
• It is often necessary to customize strapping
mechanisms of prefabricated orthoses. The number
and placement of straps are adjusted to best secure
the orthosis on the person. Straps must be secured
properly, but not so tightly as to restrict circulation.
Straps coursing through web spaces must not irritate
soft tissue. The research by Stern and colleagues 33 on
commercial wrist orthoses indicates that clients with
stiff joints experienced difficulty threading straps
through D-rings. Clients reported having to use their
teeth to manipulate straps. Straps that are too long
also appear to be troublesome because they catch on
clothing. 33
• Stern and colleagues 31 showed that although
commercial orthoses are often critiqued for being too
short, some persons prefer shorter forearm troughs.
Shorter orthoses seem to be preferred by clients when
wrist support, not immobilization, is needed.

After the necessary adjustments are completed and a proper fit is

accomplished, a therapist determines the wearing schedule.

Wearing Schedule
Although there are no easy answers about wearing protocols,
experienced therapists have several guidelines for decision making as
they tailor wearing schedules to each client. 23 Evidence from the
literature also provides information about wearing schedules.

• For orthoses designed to increase PROM, light tension exerted

by an orthosis over a long period of time is preferable to high
tension for short periods of time.
• For joints with hard end feels (i.e., an abrupt, hard stop to
movement when bone contacts bone during PROM) and
PROM limitations, more hours of orthotic wear are warranted
than for joints with soft end feels (i.e., a soft compression of
tissue is felt when two body surfaces approximate each other).

FIG. 3.10 Tension is adjusted with an Allen wrench on the

rotating wheels on the hinge joint of this orthosis.
 FIG. 3.11 A, The Rolyan In-Line orthosis with thumb support
can be adjusted by loosening or tightening the Neoprene straps.
B, Volar view of the Rolyan In-Line orthosis with thumb support.
Courtesy Patterson Medical, Warrenville, Illinois.

• Persons tolerate static orthoses (including serial and static-

progressive orthoses) better than dynamic orthoses during
sleep.
• When treatment goals are considered, wearing schedules
should allow for facilitation of active motion, functional use of
joints, and hygiene when appropriate.

As with any orthotic provision, the orthotic-wearing schedule is

given in verbal and written formats to the person and caregiver(s).
The wearing schedule depends on the person’s condition and
impairments and the severity (chronic or acute) of the problem. The
wearing schedule also depends on the therapeutic goal of the orthosis,
the demands of the environment, and the ability of the person and
caregiver(s).

Care of Prefabricated Orthoses

Always check the manufacturer’s instructions for cleaning the
orthosis. Give the client the manufacturer’s instructions on orthotic
care. If a client is visually impaired, make an enlarged copy of the
instructions. For soft orthoses the manufacturer usually recommends
hand washing and air drying, because the agitation and heat of some
washers and dryers can ruin soft orthoses. Because air drying the soft
orthoses takes time, occasionally two of the same orthosis are
provided so that the person can alternate wear during cleaning and
drying. The inside of LTT orthoses should be wiped out with rubbing
alcohol. The outside of LTT orthoses can be cleaned with toothpaste or
nonabrasive cleaning agents and rinsed with tepid water. Clients and
caregivers should be reminded that LTT orthoses soften in extreme
heat, as in a car interior or on a windowsill or radiator.

Precautions for Patient Safety

In addition to selecting, fitting, and scheduling the wear of a
prefabricated orthosis, the therapist educates the client or caregiver
about any precautions and how to monitor for them. There are several
precautions to be aware of with the use of commercial orthoses. These
are discussed in the following section.

Dermatological Issues Related to Orthotic Wear

Latex sensitivity
Some prefabricated orthoses and thermoplastic materials contain
latex. Latex-sensitive people, including clients and medical
professionals, are being identified. 7,19 Therapists should request a list
of both latex and latex-free products from the suppliers of commercial
orthoses used. Typically, because manufacturers are more aware of
latex sensitivity, most products do not contain latex but warrant
checking.

Allergic contact dermatitis

Dermatological issues related to Neoprene orthoses exist. Allergic
contact dermatitis (ACD) and miliaria rubra (prickly heat) are
associated in some persons when wearing Neoprene orthoses. 30 ACD
symptoms include itching, skin eruptions, swelling, and skin
hemorrhages. Miliaria rubra presents with small, red, elevated,
inflamed papules and a tingling and burning sensation. Before using
commercial or custom Neoprene orthoses, therapists should question
clients about dermatological reactions and allergies. If a person reacts
to a Neoprene orthosis, wear should be discontinued, and the
therapist should notify the manufacturer. An interface, such as
polypropylene stockinette, may resolve the problem.
Clients need to be instructed not only in proper orthotic care but in
hygiene of the body part included in the orthosis. Intermittent
removal of the orthosis to wash the body part, the application of
cornstarch, or the provision of wicking liners may help minimize
dermatological problems. Time of year and ambient temperatures are
considered by the therapist. For example, Neoprene may provide
desired warmth to stiff joints and increase comfort while improving
active and passive range of motion. However, during extreme
summer temperatures, the Neoprene orthosis may cause more
perspiration and increase the risk of skin maceration if
inappropriately monitored.

Ordering Commercial Orthoses

A variety of vendors sell prefabricated orthoses. Companies often sell
similar orthotic designs, but the item names can be quite different. To
keep abreast of the newest commercial orthoses, therapists browse
through vendor catalogs or websites, communicate with vendor sales
representatives, and seek out vendor exhibits during professional
meetings and conferences for the ideal “hands-on” experience.
Vendors often distribute samples upon request to therapists and
clinics.
 It is most beneficial to the therapist and the client when a clinic has
a variety of commercial orthotic designs and sizes for right and left
extremities. Keeping a large stock in a clinic is expensive. To cover the
overhead expense of stocking and storing prefabricated orthoses, a
percentage markup of the prefabricated orthosis is often charged in
addition to the therapist’s time and materials used for adjustments.
Clinics’ data about the most common diagnoses and past products are
used to determine what to order to maintain an appropriate
inventory. Many products have a “shelf life,” or a time period
whereby the materials age and may become brittle, less elastic, or
discolored. Thus, the clinic’s inventory must be used before the shelf
life limit to be cost efficient.
Orthotic Workroom or Cart
Having a well-organized and stocked orthotic area benefits the
therapist who makes decisions about the orthotic design and
constructs the orthosis in a timely manner. Clients who need orthotic
intervention also benefit from a well-stocked orthotic supply
inventory. Readily available materials and tools expedite the orthotic-
making process.
Clinics should consider the services commonly rendered and stock
their materials accordingly. In addition to a stocked orthotic
inventory, therapists may find it useful to have a mobile cart
organized for orthotic provision in a client’s room or in another
portion of the health care setting. The cart is used to readily transport
orthotic supplies to the client, rather than a client coming to the
therapist. For therapists who travel from clinic to clinic, suitcases on
rollers are ideal to store and transport orthotic supplies. Orthotic carts
or cases should contain items such as:

• Paper towels
• Pencils/awl/grease pencils
• Masking tape
• Thermoplastic material
• Fry pan
• Scissors (various sizes)
• Strapping materials, including Ace bandages
• Padding materials
• Heat gun
• Spatulas, metal turkey baster
• Thermometer
• Pliers
• Revolving hole punch
• Glue
• Goniometer
• Solvent or bonding agent
• Other specialized supplies as needed (e.g., finger loops,
outrigger wire, outrigger line, springs, turnbuckles, rubber
bands, and so on)
Documentation and Reassessment
Orthotic provision must be well documented. Documentation assists
in third-party reimbursement, communication to other health care
providers, and demonstration of efficacy of the intervention.
Documentation includes several elements, such as the type, purpose,
and anatomical location of the orthosis. Therapists document that they
educated clients using oral and written instructions. The topics of
client education are documented and include the wearing schedule,
orthotic care, precautions, and any home program activities. Finally,
the therapist’s judgment of how receptive and to what extent the
client understood the instructions is documented.
In follow-up visits, documentation includes any changes in the
orthotic design and wearing schedule. In addition, the therapist notes
whether problems with adherence are apparent. The therapist
determines whether the range of motion is increasing with orthotic
wearing time and draws conclusions about orthotic efficacy or
adherence to the program. Function with and without the orthosis
should be documented. For example, the therapist determines
whether the person can independently perform some type of function
because of wearing the orthosis. The therapist must listen to the
client’s reports of functional problems and solve problems to
remediate or compensate for the functional deficit. If function or range
of motion is not increased, the therapist must consider orthotic
revision or redesign or counseling the client on the importance of
wearing the orthosis.
The therapist performs reassessments regularly until the person is
weaned from the orthosis or discharged from services. Facilities use
different methods of documentation, and the therapist should be
familiar with the routine method of the facility. (Refer to the
documentation portion of Chapter 6 for more information.)

Review Questions
1. What are six handling characteristics of thermoplastics?
2. What are six performance characteristics of
thermoplastics?
3. At what temperature range are LTT materials softened?
4. What steps are involved in making a pattern for an
orthosis?
5. What equipment can be used to soften thermoplastic
materials?
6. How can a therapist prevent a tacky thermoplastic from
sticking to the hair on a person’s arms?
7. What are the purposes of using a heat gun?
8. Why should a therapist use a bonding agent?
9. Why should the edges of an orthosis be rolled or flared?
References
1. Aebischer B, Elsig S, Taeymans J. Effectiveness of
physical and occupational therapy on pain, function
and quality of life in patients with
trapeziometacarpal osteoarthritis – a systematic
review and meta-analysis. Hand Ther . 2015;21(1):5.
2. Agnew P.J, Maas F. Compliance in wearing wrist
working splints in rheumatoid arthritis. Occup Ther J
Res . 1995;15(3):165–180.
3. Callinan N, Mathiowetz V. Soft versus hard resting
hand splints in rheumatoid arthritis: pain relief,
preference and compliance. Am J Occup Ther
. 1996;50(5):347–353.
4. Fleming N.D, Mills C. Helping students understand
how they learn. The Teaching Professor . 1993;vol. 3–4.
5. Ganesan B, Al-Jumaily A, Luximon A. 3D printing
technology applications in occupational therapy.
Phys Med Rehabil Int . 2016;3(3):1085–1088.
6. Grenier M.L, Mendonca R, Dalley P. The
effectiveness of orthoses in the conservative
management of thumb CMC joint osteoarthritis: an
analysis of function pinch strength. J Hand Ther
. 2016;29:307–313.
7. Jack M. Latex allergies: a new infection control issue.
Can J Infect Control . 1994;9(3):67–70.
8. Jansen C.W, Olson S.L, Hasson S.M. The effect of use
of a wrist orthosis during functional activities on
surface electromyography of the wrist extensors in
normal subjects. J Hand Ther . 1997;10(4):283–289.
 9. Lee D.B. Objective and subjective observations of
low-temperature thermoplastic materials. J Hand
Ther . 1995;8(2):138–143.
10. McKee P, Morgan L. Orthotic
materials. In: McKee P, Morgan L, eds. Orthotics in
rehabilitation . Philadelphia: FA Davis; 1998.
11. MedWest: https://www.medwest.ca.
12. Melvin J.L. Rheumatic disease in the adult and child:
occupational therapy and rehabilitation
. Philadelphia: FA Davis; 1989.
13. Mullen TM: Radiographic and functional analysis of
movement allowed by four wrist immobilization
devices. Doctoral dissertation, 2008, Western Michigan
University, pp 77. https://doi.org/10.1002/art.24866.
14. Nordenskiöld U. Elastic wrist orthoses: reduction of
pain and increase in grip force for women with
rheumatoid arthritis. Arthritis Care Res
. 1990;3(3):158–162.
15. North Coast Medical: https://www.ncmedical.com/.
16. O’Brien L. The evidence on ways to improve patient’s
adherence in hand therapy. J Hand Ther
. 2012;25(3):247–250.
17. Orfit: https://www.orfit.com/.
18. Performance Health:
http://www.performancehealth.com.
19. Personius C.D. Patients, health care workers, and
latex allergy. Med Lab Obs . 1995;27(3):30–32.
20. Racelis M.C, Lombardo K, Verdin J. Impact of
telephone reinforcement of risk reduction education
on patient compliance. J Vasc Nurs . 1998;16(1):16–20.
21. Remington Medical: http://remintonmedical.com.
22. Schneiders A.G, Zusman M, Singer K.P. Exercise
therapy compliance in acute low back pain patients.
Man Ther . 1998;3(3):147–152.
23. Schultz-Johnson K. Splinting: a problem-solving
approach. In: Stanley B.G, Tribuzi S.M, eds. Concepts
in hand rehabilitation . Philadelphia: FA Davis; 1992.
24. Schultz-Johnson K. Personal communication . 1999.
25. Schultz-Johnson K. Personal communication . 2006.
26. Shankland B, Beaton D, Ahmed S, Nedelec B. Effects
of client-centered multimodal treatment on
impairment, function, and satisfaction of people with
thumb carpometacarpal osteoarthritis. J Hand Ther
. 2017;30:307–313.
27. Shurr D.G, Michael J.W. Prosthetics and orthotics
. Upper Saddle River, NJ: Prentice Hall; 2002.
28.
Sillen H, Backman C.L, Miller L, William C, Li L. Comparison
of two carpometacarpal stabilizing splints for
individuals with thumb osteoarthritis. J Hand Ther
. 2011;24(3):216–226.
29. Smith-
Forbes E.V, Howell D.M, Willoughby J, Armstrong H, Pitts D.G
of individuals in upper extremity rehabilitation: a
qualitative study. Arch Phys Med Rehabil
. 2016;97(8) 1262–1128.
30. Stern E.B, Callinan N, Hank M, et al. Neoprene
splinting: dermatological issues. Am J Occup Ther
. 1998;52(7):573–578.
31. Stern E.B, Sines B, Teague T.R. Commercial wrist
extensor orthoses: hand function, comfort and
interference across five styles. J Hand Ther
 . 1994;7:237–244.
32. Stern E.B, Ytterberg S, Krug H.E, et al. Finger
dexterity and hand function: effect of three
commercial wrist extensor orthoses on patients with
rheumatoid arthritis. Arthritis Care Res
. 1996;9(3):197–205.
33. Stern E.B, Ytterberg S.R, Krug H.E, et al. Commercial
wrist extensor orthoses: a descriptive study of use
and preference in patients with rheumatoid arthritis.
Arthritis Care Res . 1997;10(1):27–35.
34. Sussman C, Bates-Jensen B.M. Wound care: a
collaborative practice manual for physical therapists and
nurses . Philadelphia: Lippincott Williams &
Wilkins; 1998.
35. Wilton J.C. Hand splinting principles of design and
fabrication . Philadelphia: Saunders; 1997.
36. World Health Organization. Adherence to long-term
therapies: evidence for action . Geneva: World Health
Organization; 2003.
Appendix 3.1 Laboratory Exercise
Laboratory Exercise 3.1 Low-Temperature
Thermoplastics
Cut small squares of different thermoplastic materials. Soften them in
water, and experiment with the plastics so that you can answer the
following questions for each type of thermoplastic material.
Name of the thermoplastic material:
______________________________________________
Appendix 3.2 Form
Form 3.1 Hints for Drawing and Fitting a
Splint Pattern
Appendix 3.3 Sources of Vendors

AliMed Dynasplint
1-800-225-2610 1-800-638-6771
https://www.alimed.com/ http://www.dynasplint.ca/en/

Allegro Medical Joint Active Systems

1-800-861-3211 1-800-879-0117
https://www.allegromedical.com http://www.jointactivesystems.com/For-
Professionals/
Benik Corporation Joint Jack Company
1-800-442-8910 1-860-657-1200
https://benik.com/ http://jointjackcompany.com/

Biodynamic Technologies North Coast Medical, Inc.

1-800-879-2276 1-800-821-9319
https://www.biodynamictech.com https://www.ncmedical.com/

Chesapeake Medical Products Performance Health

1-888-560-2674 1-800-323-5547
http://www.chesapeakemedical.com https://www.performancehealth.com

Core Products International, Inc. Restorative Care of America, Inc. (RCAI)

1-877-249-1251 1-800-627-1595
https://www.coreproducts.com/ http://www.rcai.com/

DeRoyal Tetra Medical Supply Corporation

1-800-251-9864 1-800-621-4041
http://www.deroyal.com/ https://www.tetramed.com/

3-Point Products
1-410-604-6393
https://www.3pointproducts.com/
Anatomical and Biomechanical
Principles Related to Orthotic
Provision
Brenda M. Coppard

CHAPTER OBJECTIVES
1. Define the anatomical terminology used in orthotic prescriptions.
2. Relate anatomy of the upper extremity to orthotic design.
3. Identify arches of the hand.
4. Identify creases of the hand.
5. Articulate the importance of the hand’s arches and creases to
orthotic intervention.
6. Recall actions and nerve innervations of upper extremity
musculature.
7. Differentiate among prehensile and grasp patterns of the hand.
8. Apply basic biomechanical principles to orthotic design.
9. Describe the correct width and length for a forearm orthosis.
10. Describe appropriate uses of padding in an orthosis.
11. Explain the reason that orthotic edges should be rolled or flared.
12. Relate the concept of contour to orthotic fabrication.
13. Describe the change in skin and soft tissue mechanics with scar
tissue, material application, edema, contractures, wounds, and
infection.
KEY TERMS
aponeurosis
degrees of freedom
dorsal
grasp
mechanical advantage
plasticity
prehension
pressure
radial
stress
three-point pressure
torque
ulnar
viscoelasticity
volar
zones of the hand

Brad is a new practitioner in a rural hospital. He commonly receives

referrals to see clients who initially were clients in larger health
facilities. These clients are typically post-surgery and opt for follow-up
therapy at the local, smaller and rural hospital. Brad has a strong
knowledge base of anatomical and biomechanical principles. He often
reflects on the hours he spent studying diligently, and he is happy that
he did so for this client population. He is able to refer to resources from
his collection of books in his professional library that began when he was
a student.
Basic Anatomical Review for Orthotic
Intervention
Orthotic intervention requires sound knowledge of anatomical
terminology and structures, biomechanics, and the way in which
pathological conditions impact function. Knowledge of anatomical
structures is necessary in the choice and fabrication process of an
orthosis. Anatomical knowledge influences the therapeutic
intervention and home program. The following is a brief overview of
anatomical terminology, proximal-to-distal structures, and landmarks
of the upper extremity pertinent to the orthotic process. The overview
is neither comprehensive nor all-inclusive. For more depth and
breadth in anatomical review, access an anatomy text, anatomical
atlases, anatomy websites, or software programs that show and
explain anatomical structures.

Terminology
Knowing anatomical location terminology is extremely important
when a therapist receives a prescription for an orthosis or is reading
professional literature about orthotic interventions. In rehabilitation
settings the word arm usually refers to the segment of the upper
extremity from the shoulder to the elbow (humerus). The term
antecubital fossa refers to the depression at the bend of the elbow.
Forearm is used to describe the portion of the upper extremity from the
elbow to the wrist, which includes the radius and ulna. Carpal or
carpus refers to the wrist or the carpal bones. A variety of terms are
used to refer to the thumb and fingers (phalanges). Such terms include
thumb, index, middle or long, ring, and little fingers. A numbering system
is used to refer to the digits (Fig. 4.1). The thumb is digit I, the index
finger is digit II, the middle (or long) finger is digit III, the ring finger
is digit IV, and the little finger is digit V.
FIG. 4.1 Numbering system used for the digits of the hand.
 The terms palmar and volar are used interchangeably and refer to
the front or anterior aspect of the hand and forearm in relationship to
the anatomical position. The term dorsal refers to the back or posterior
aspect of the hand and forearm in relationship to the anatomical
position. The term radial indicates the thumb side, and the term ulnar
refers to the side of the fifth digit (little finger). Therefore, when a
therapist receives an order for a dorsal wrist orthosis, the physician
has ordered an orthosis that is to be applied on the back of the hand
and wrist. Another example of location terminology in an orthotic
prescription is a radial gutter thumb immobilization (thumb spica)
orthosis. This type of orthosis is applied to the thumb side of the hand
and forearm.
Literature addressing hand injuries and rehabilitation protocols
often refers to zones of the hand. Fig. 4.2 diagrams the zones of the
hand. 18 Table 4.1 presents the zones’ borders. Therapists should be
familiar with these zones for understanding literature, conversing
with other health providers, and documenting pertinent information.
Shoulder Joint
The shoulder complex consists of seven joints, including the
glenohumeral, suprahumeral, acromioclavicular, scapulocostal,
sternoclavicular, costosternal, and costovertebral joints. 10 The
suprahumeral and scapulocostal joints are pseudojoints, but they
contribute to the shoulder’s function. Mobility of the shoulder is a
compilation of all seven joints. Because the shoulder is extremely
mobile, stability is sacrificed. This is evident when one considers that
the head of the humerus articulates with approximately a third of the
glenoid fossa. The shoulder complex allows motion in three planes,
including flexion, extension, abduction, adduction, and internal and
external rotation.
 FIG. 4.2 Zones of the hand for (A) extensor and (B) flexor tendons.
From Kleinert, H.E., Schepel, S., & Gill, T. [1981]. Flexor tendon
injuries. Surgical Clinics of North America, 61[2], 267.

The scapula is intimately involved with movement at the shoulder.

Scapulohumeral rhythm is a term used to describe the coordinated series
of synchronous motions, such as shoulder abduction and elevation.
A complex of ligaments and tendons provides stability to the
shoulder. Shoulder ligaments are named according to the bones they
connect. The ligaments of the shoulder complex include the
coracohumeral ligament and the superior, middle, and inferior
glenohumeral ligaments. 17 The rotator cuff muscles contribute to the
dynamic stability of the shoulder by compressing the humeral head
into the glenoid fossa. 28 The rotator cuff muscles include the
supraspinatus, infraspinatus, teres minor, and subscapularis. Table 4.2
lists the muscles involved with scapular and shoulder movements.

TABLE 4.1

Tendon Injury Zones of the Hand

Extensor Tendon Zone
Flexor Tendon Zone Borders
Borders
Zone I Extends flexor digitorum profundus (FDP) distal to flexor Over the distal
digitorum superficialis (FDS) on middle phalanx interphalangeal (DIP)
joints
Zone II Extends from proximal end of the digital fibrous sheath to Over the middle phalanx
(no the distal end of the A1 pulley
man’s
land)
Zone III Extends from proximal end of the finger pulley system to Over the apex of the
the distal end of the transverse carpal ligament proximal interphalangeal
(PIP) joint
Zone IV Entails the carpal tunnel, extending from the distal to the Over the proximal
proximal borders of the transverse carpal ligament phalanx

Zone V Extends from the proximal border of the transverse carpal Over the apex of the
ligament to the musculotendinous junctions of the flexor metacarpophalangeal
tendons (MCP) joint
Zone VI — Over the dorsum of the
hand
Zone VII — Under the extensor
tendon retinaculum
— The distal forearm
Zone VIII
Thumb Distal to the interphalangeal (IP) joint Over the IP joint
zone
TI
Thumb Annular ligament to IP joint Over the proximal
zone phalanx
TII
Thumb The thenar eminence Over the MCP joint
zone
TIII
Thumb — Over the first metacarpal
zone
TIV
Thumb — Under the extensor
zone tendon retinaculum
TV
Thumb — The distal forearm
zone
TVI
Elbow Joint
The elbow joint complex consists of the humeroradial, humeroulnar,
and proximal radioulnar joints. The humeroradial joint is an
articulation between the humerus and the radius. The humeroradial
joint has two degrees of freedom that allow for elbow flexion and
extension and forearm supination and pronation. The humerus
articulates with the ulna at the humeroulnar joint. Flexion and
extension movements take place at the humeroulnar joint. Elbow
flexion and extension are limited by the articular surfaces of the
trochlea of the ulna and the capitulum of the humerus.
The medial and lateral collateral ligaments strengthen the elbow
capsule. The radial collateral, lateral ulnar, accessory lateral collateral,
and annular ligaments constitute the ligamentous structure of the
elbow.
Muscles acting on the elbow can be categorized as functional
groups: flexors, extensors, flexor-pronators, and extensor-supinators.
Table 4.3 lists the muscles in these groups and their innervation.
Wrist Joint
The wrist joint is frequently incorporated into an orthotic design.
Knowledge of the wrist joint structure is required to appropriately
choose and fabricate an orthosis that meets therapeutic goals and
objectives. The osseous structure of the wrist and hand consists of the
ulna, radius, and eight carpal bones. Several joints are associated with
the wrist complex, including the radiocarpal, midcarpal, and distal
radioulnar joints.
The carpal bones are arranged in two rows (Fig. 4.3). The proximal
row of carpal bones includes the scaphoid (navicular), lunate, and
triquetrum. The pisiform bone is considered a sesamoid bone. 28 The
distal row of carpal bones consists of the trapezium, trapezoid,
capitate, and hamate. The distal row of carpal bones articulates with
the metacarpals.
The radius articulates with the lunate and scaphoid in the proximal
row of carpal bones. This articulation is the radiocarpal joint, which is
mobile. The radiocarpal joint (Fig. 4.4) is formed by the articulation of
the distal head of the radius and the scaphoid and lunate bones. The
ulnar styloid is attached to the triquetrum by a complex of ligaments
and fibrocartilage. The ligaments bridge the ulna and radius and
separate the distal radioulnar joint and the ulna from the radiocarpal
joint. Motions of the radiocarpal joint include flexion, extension, and
radial and ulnar deviation. The majority of wrist extension occurs at
the midcarpal joint with less movement occurring at the radiocarpal
joint. 17
The midcarpal joint (see Fig. 4.4) is the articulation between the
distal and proximal carpal rows. The joint exists, although there are no
interosseous ligaments between the proximal and distal rows of
carpals. 8 The joint capsules remain separate. However, the
radiocarpal joint capsule attaches to the edge of the articular disk,
which is distal to the ulna. 23 The wrist motions of flexion, extension,
and radial and ulnar deviation also take place at this joint. The
majority of wrist flexion occurs at the radiocarpal joint. The midcarpal
joint contributes less movement for wrist flexion. 17
The distal radioulnar joint is an articulation between the head of the
ulna and the distal radius. Forearm supination and pronation occur at
the distal radioulnar joint.
Wrist stability is provided by the close-packed positions of the
carpal bones and the interosseous ligaments. 28 The intrinsic
intercarpal ligaments connect carpal bone to carpal bone. The extrinsic
ligaments of the carpal bones connect with the radius, ulna, and
metacarpals. The ligaments on the volar aspect of the wrist are thick
and strong, providing stability. The dorsal ligaments are thin and less
developed. 28 In addition, the intercarpal ligaments of the distal row
form a stable fixed transverse arch. 12 Ligaments of the wrist cover the
volar, dorsal, radial, and ulnar areas. The ligaments in the wrist serve
to stabilize joints, guide motion, limit motion, and transmit forces to
the hand and forearm. These ligaments also assist in prevention of
dislocations. The wrist contributes to the hand’s mobility and stability.
Having two degrees of freedom (movements occur in two planes), the
wrist is capable of flexing, extending, and deviating radially and
ulnarly.

TABLE 4.2

Muscles Contributing to Scapular and Shoulder Motions

Movement Muscles Innervation
Scapular elevation Upper trapezius Accessory, CN 1 third and fourth cervical; dorsal
Levator scapulae scapular
Scapular depression Lower trapezius Accessory CN 1

Scapular lateral Serratus anterior Long thoracic

rotation
Scapular medial Rhomboids Dorsal scapular
rotation
Scapular abduction Serratus anterior Long thoracic

Scapular adduction Middle and lower Accessory CN 1

trapezius
Rhomboids Dorsal scapular
Shoulder flexion Anterior deltoid Axillary
Coracobrachialis Musculocutaneous
Shoulder extension Teres major Lower subscapular
 Latissimus dorsi Thoracodorsal
Shoulder abduction Middle deltoid Axillary
Supraspinatus Suprascapular
Shoulder adduction Pectoralis major Medial and lateral
Latissimus dorsi Pectoral
Teres major Thoracodorsal
Coracobrachialis Lower subscapular
Musculocutaneous
Shoulder external Infraspinatus Suprascapular
rotation Teres minor Axillary

TABLE 4.3

Elbow and Forearm Musculature Actions and Nerve Supply

FIG. 4.3 Carpal bones. Proximal row: scaphoid, lunate, pisiform, and
triquetrum. Distal row: trapezium, trapezoid, capitate, and hamate.
From Pedretti, L. W. [Ed.]. [1996]. Occupational therapy: Practice skills
for physical dysfunction [4th ed., p. 320]. St. Louis, MO: Mosby.
FIG. 4.4 Radiocarpal and midcarpal joints. CA, Capitate; HA, hamate;
LU, lunate; SC, scaphoid; TP, trapezium; TQ, triquetrum; TZ,
trapezoid.
From Norkin, C., & Levangie, P. [1983]. Joint structure and function: A
comprehensive analysis [p. 217]. Philadelphia, PA: FA Davis.
Finger and Thumb Joints
Cutaneous and Connective Coverings of
the Hand
The skin is the protective covering of the body. There are unique
characteristics of volar and dorsal skin, which are functionally
relevant. The skin on the palmar surface of the hand is thick,
immobile, and hairless. It contains sensory receptors and sweat
glands. The palmar skin attaches to the underlying palmar
aponeurosis, which facilitates grasp. 7 Palmar skin differs from the
skin on the dorsal surface of the hand. The dorsal skin is thin, supple,
and quite mobile. Thus it is often the site for edema accumulation. The
skin on the dorsum of the hand accommodates to the extremes of the
fingers’ flexion and extension movements. The hair follicles on the
dorsum of the hand assist in protecting and activating touch receptors
when the hair is moved slightly. 7

Palmar Fascia
The superficial layer of palmar fascia in the hand is thin. Its
composition is highly fibrous and is tightly bound to the deep fascia.
The deep fascia thickens at the wrist and forms the palmar carpal
ligament and the flexor retinaculum. The fascia thins over the thenar
and hypothenar eminences but thickens over the midpalmar area and
on the volar surfaces of the fingers. The fascia forms the palmar
aponeurosis and the fibrous digital sheaths. 8
The superficial palmar aponeurosis consists of longitudinal fibers
that are continuous with the flexor retinaculum and palmaris longus
tendon. The flexor tendons course under the flexor retinaculum. With
absence of the flexor retinaculum, as in carpal tunnel release,
bowstringing of the tendons may occur at the wrist level (Fig. 4.5). The
distal borders of the superficial palmar aponeurosis fuse with the
fibrous digital sheaths. The deep layer of the aponeurosis consists of
transverse fibers, which are continuous with the thenar and
hypothenar fascias. Distally, the deep layer forms the superficial
transverse metacarpal ligament. 8 The extensor retinaculum is a
fibrous band that bridges over the extensor tendons. The deep and
superficial layers of the aponeurosis form this retinaculum.

FIG. 4.5 Bowstringing of the flexor tendons.

From Stewart-Pettengill, K. M., & van Strien, G. [2002]. Postoperative
management of flexor tendon injuries. In E. J. Mackin, A. D. Callahan,
T. M. Skirven, et al. [Eds.], Rehabilitation of the hand: Surgery and
therapy [5th ed., p. 434]. St. Louis, MO:, Mosby.

Functionally, the fascial structure of the hand protects, cushions,

restrains, conforms, and maintains the hand’s arches. 7 For example,
therapists often fabricate orthoses for persons post-surgery who have
Dupuytren disease, a condition in which the palmar fascia thickens
and shortens.

Joint Structure
Orthoses often immobilize or mobilize joints of the fingers and thumb.
Therefore, therapists must have knowledge of these joints. The hand
skeleton comprises five polyarticulated rays (digits/fingers) (Fig. 4.6).
The radial ray or first ray (thumb) is the shortest and includes three
bones: a metacarpal and two phalanges. Joints of the thumb include
the carpometacarpal (CMC) joint, the metacarpophalangeal (MP) joint,
and the interphalangeal (IP) joint (see Fig. 4.6 for hand and finger
joints with exception of showing CMC joint). Functionally, the thumb
is the most mobile of the digits. The thumb significantly enhances
functional ability by its ability to oppose the pads of the fingers, which
is needed for prehension and grasp. The thumb has three degrees of
freedom, allowing for flexion, extension, abduction, adduction, and
opposition. The second through fifth rays comprise four bones: a
metacarpal and three phalanges. Joints of the fingers include the MCP
joint, proximal interphalangeal (PIP) joint, and the distal
interphalangeal (DIP) joint. The digits are unequal in length. Specific
finger length varies among people. For example, some people’s index
finger is longer than the ring finger and vice versa. In any case, the
respective finger lengths contribute to the hand’s functional
capabilities.
The thumb’s metacarpotrapezial or CMC joint is saddle shaped and
has two degrees of freedom, allowing for flexion, extension,
abduction, and adduction movements. The CMC joints of the fingers
have one degree of freedom to allow for small amounts of flexion and
extension.
 FIG. 4.6 Joints of the fingers and thumb.

The fingers’ and thumb’s MCP joints have two degrees of freedom:
flexion, extension, abduction, and adduction. The convex metacarpal
heads articulate with shallow concave bases of the proximal
phalanges. Fibrocartilaginous volar plates extend the articular
surfaces on the base of the phalanges. As the finger’s MCP joint is
flexed, the volar plate slides proximally under the metacarpal. This
mechanism allows for significant range of motion. The volar plate
movement is controlled by accessory collateral ligaments and the
metacarpal pulley for the long flexor tendons to blend with these
structures.
During extension the MCP joint moves medially and laterally.
During MCP extension the collateral ligaments are slack. When digits
II through V are extended at the MCP joints, finger abduction
movement is free. Conversely, when the MCP joints of digits II
through V are flexed, abduction is extremely limited. The medial and
lateral collateral ligaments of the metacarpal heads become taut and
limit the distance by which the heads can be separated for abduction
to occur. Mechanically, this provides stability during grasp.
Digits II through V have two IP joints: a PIP joint and a DIP joint.
The thumb has only one IP joint. The IP joints have one degree of
freedom, contributing to flexion and extension motions. IP joints have
a volar plate mechanism similar to the MCP joints, with the addition
of check reign ligaments. The check reign ligaments limit
hyperextension.
Table 4.4 provides a review of muscle actions and nerve supply of
the wrist and hand. 13 Muscles originating in the forearm are referred
to as extrinsic muscles. Intrinsic muscles originate within the hand.
Each group contributes to upper extremity function.
Extrinsic Muscles of the Hand
Extrinsic muscles acting on the wrist and hand are further categorized
as extensor and flexor groups. Extrinsic muscles of the wrist and hand
are listed in Box 4.1. Extrinsic flexor muscles are most prominent on
the medial side of the upper forearm. The function of extrinsic flexor
muscles includes flexion of joints between the muscles’ respective
origin and insertion. Extrinsic muscles of the hand and forearm
accomplish flexion and extension of the wrist and the phalanges
(fingers). For example, the flexor digitorum superficialis (FDS) flexes
the PIP joints of digits II through V, whereas the flexor digitorum
profundus (FDP) primarily flexes the DIP joints of digits II through V.
Because these extrinsic muscle tendons pass on the palmar side of
the MCP joints, they tend to produce flexion of these joints. During
grasp, flexion of the MCPs is necessary to obtain the proper shape of
the hand. However, flexion of the wrist is undesirable because it
decreases the grip force—this is why many protocols require the wrist
to be in 20 to 30 degrees of extension because this position facilitates a
stronger grip than a flexed wrist position. The synergic contraction of
the wrist extensors during finger flexion prevents wrist flexion during
grasp. The force of the extensor contraction is proportionate to the
strength of the grip. The stronger the grip, the stronger the wrist
extensors contract. 25 Digit extension and flexion are a combined effort
from extrinsic and intrinsic muscles.
At the level of the wrist, the extensor tendons organize into six
compartments. 16 The first compartment consists of tendons from the
abductor pollicis longus (APL) and extensor pollicis brevis (EPB).
When the radial side of the wrist is palpated, it is possible to feel the
taut tendons of the APL and EPB.

TABLE 4.4

Wrist and Hand Musculature Actions and Nerve Supply

Muscle Actions Nerve
Flexor carpi radialis Wrist flexion, wrist radial deviation Median
Palmaris longus Wrist flexion, tenses palmar fascia Median

Flexor carpi ulnaris Wrist flexion, wrist ulnar deviation Ulnar

Extensor carpi radialis longus Wrist radial deviation, wrist extension Radial
(ECRL)
Extensor carpi radialis brevis Wrist extension, wrist radial deviation Radial
(ECRB)
Extensor carpi ulnaris (ECU) Wrist extension, wrist ulnar deviation Radial

Flexor digitorum superficialis Finger proximal interphalangeal (PIP) flexion Median

(FDS)
Flexor digitorum profundus Finger distal interphalangeal (DIP) flexion Median,
(FDP) ulnar

Extensor digitorum communis Finger metacarpophalangeal (MCP) extension Radial

(EDC)
Extensor indicis proprius (EIP) Index finger MCP extension Radial

Extensor digiti minimi (EDM) Little finger MCP extension Radial

Interosseous Finger MCP abduction Ulnar

Dorsal palmar Finger MCP adduction Ulnar

Lumbricals Finger MCP flexion and interphalangeal (IP) Median,

extension ulnar
Abductor digiti minimi Little finger MCP abduction Ulnar

Opponens digiti minimi Little finger opposition Ulnar

Flexor digiti minimi Little finger MCP flexion Ulnar

Flexor pollicis longus Thumb IP flexion Median

Flexor pollicis brevis Thumb MCP flexion Median,

ulnar
Extensor pollicis longus (EPL) Thumb IP extension Radial

Extensor pollicis brevis (EPB) Thumb MCP extension Radial

Abductor pollicis longus (APL) Thumb radial abduction Radial

Abductor pollicis brevis Thumb palmar abduction Median

Adductor pollicis Thumb adduction Ulnar

Opponens pollicis Thumb opposition Median

BOX 4.1 Extrinsic Muscles of the Wrist and Hand

 • Extensor digitorum
• Extensor pollicis longus (EPL)
• Flexor digitorum profundus (FDP)
• Flexor pollicis longus
• Extensor digiti minimi (EDM)
• Extensor carpi radialis longus (ECRL)
• Extensor carpi ulnaris (ECU)
• Palmaris longus
• Flexor digitorum superficialis (FDS)
• Extensor pollicis brevis (EPB)
• Extensor indicis proprius (EIP)
• Abductor pollicis longus (APL)
• Extensor carpi radialis brevis (ECRB)
• Flexor carpi radialis
• Flexor carpi ulnaris

The second compartment contains tendons of the extensor carpi

radialis longus (ECRL) and brevis (ECRB). A therapist can palpate the
tendons on the dorsoradial aspect of the wrist by applying resistance
to an extended wrist.
The third compartment houses the tendon of the extensor pollicis
longus (EPL). This tendon passes around the Lister tubercle of the
radius and inserts on the dorsal base of the distal phalanx of the
thumb.
The fourth compartment includes the four extensor digitorum
communis (EDC) tendons and the extensor indicis proprius (EIP)
tendon, which are the MCP joint extensors of the fingers.
The fifth compartment includes the extensor digiti minimi (EDM),
which extends the little finger’s MCP joint. The EDM acts alone to
extend the little finger.
The sixth compartment consists of the extensor carpi ulnaris (ECU),
which inserts at the dorsal base of the fifth metacarpal. A taut tendon
can be palpated over the ulnar side of the wrist just distal to the ulnar
head.
Unlike the other fingers, the index and little fingers have dual
extensor systems consisting of the EIP and the EDM in conjunction
with the EDC. The EIP and EDM tendons lie on the ulnar side of the
EDC tendons. Each finger has a FDS and FDP tendon. Five annular (or
A) pulleys and four cruciate (or C) pulleys prevent the flexor tendons
from bowstringing (Fig. 4.7).
In relationship to orthotic fabrication, when pathology affects
extrinsic musculature, the orthotic design often incorporates the wrist
and hand. This wrist-hand orthotic design is necessary because the
extrinsic muscles cross the wrist and hand joints.
Intrinsic Muscles of the Hand and Wrist
The intrinsic muscles of the thumb and fingers are listed in Box 4.2.
The intrinsic muscles are the muscles of the thenar and hypothenar
eminences, the lumbricals, and the interossei. Intrinsic muscles are
grouped according to those of the thenar eminence, the hypothenar
eminence, and the central muscles between the thenar and hypothenar
eminences. The function of these intrinsic hand muscles produces
flexion of the proximal phalanx and extension of the middle and distal
phalanges, which contribute to the precise finger movements required
for coordination.
 FIG. 4.7 Annular (A) and cruciate (C) pulley system of the hand. The
digital flexor sheath is formed by five annular (A) pulleys and three
cruciate (C) bands. The second and fourth annular pulleys are the most
important for function.
From Tubiana, R., Thomine, J. M., & Mackin, E. [1996]. Examination of
the hand and wrist [p. 81]. St. Louis, MO: Mosby.

BOX 4.2 Intrinsic Muscles of the Hand

Central Compartment Thenar Compartment Hypothenar Compartment

Muscles Muscles Muscles
Lumbricals Opponens pollicis Opponens digiti minimi
Palmar interossei Abductor pollicis brevis Abductor digiti minimi
Dorsal interossei Adductor pollicis Flexor digiti minimi brevis
Flexor pollicis brevis Palmaris brevis

The thenar eminence consists of the opponens pollicis, flexor

pollicis brevis, adductor pollicis, and abductor pollicis brevis. The
thenar eminence contributes to thumb opposition, which functionally
allows for grasp and prehensile patterns. The thumb seldom acts
alone except when pressing objects and playing instruments. 25
However, without a thumb the hand is virtually nonfunctional.
 FIG. 4.8 Intrinsic plus position of the hand. Metacarpophalangeal
flexion with proximal interphalangeal extension.
From Tubiana, R., Thomine, J. M., & Mackin, E. [1996]. Examination of
the hand and wrist [p. 308]. St. Louis, MO: Mosby.

The hypothenar eminence includes the abductor digiti minimi, the

flexor digiti minimi, the palmaris brevis, and the opponens digiti
minimi. Similar to the thenar muscles, the hypothenar muscles also
assist in rotating the fifth digit during grasp. 3
The muscles of the central compartment include lumbricals and
palmar and dorsal interossei. The interossei muscles are complex with
variations in their origins and insertions. 3 There are four dorsal
interossei and three palmar interossei muscles. The four lumbricals
are weaker than the interossei. The lumbricals originate on the radial
aspect of the FDP tendons and insert on the extensor expansion of the
finger. They are the only muscles in the human body with a moving
origin and insertion. The primary function of the lumbricals is to flex
the MCP joints. 28
Normally the interossei extend the PIP and DIP joints when the
MCP joint is in extension. The dorsal interossei produce finger
abduction, and the palmar interossei produce finger adduction.
Functionally, the first dorsal interossei is a strong abductor of the
index finger, which assists in properly positioning the hand for
pinching. Research shows the interossei are active during grasp and
power grip in addition to pinch. 19 With function of the interossei and
lumbricals, a person can place the hand in an intrinsic plus position.
An intrinsic plus position is established when the MCP joints are
flexed and the PIP joints are fully extended (Fig. 4.8). This position is
sometimes referred to as a “table top” position. Some injuries may
result in an intrinsic minus hand caused by paralysis or contractures
(Fig. 4.9). With an intrinsic minus hand the person loses the cupping
shape of the hand. 3 In addition, the intrinsic musculature may waste
or atrophy. In relationship to orthotic provision, if intrinsic muscles
are solely affected, the orthotic design often involves immobilizing or
mobilizing only the finger joints as opposed to incorporating the
wrist. To facilitate function and prevent deformity, joint positioning in
orthoses frequently warrants an intrinsic plus posture rather than an
intrinsic minus position. Throughout this textbook several orthoses
include the hand positioned in an intrinsic plus position.
Arches of the Hand
The hand has three arches, which contribute to a strong functional
grasp. The arches include (1) the longitudinal arch, (2) the distal
transverse arch, and (3) the proximal transverse arch (Fig. 4.10).
Because of their functional significance, these arches require attention
during the orthotic fabrication process for their preservation.
Therapists should never position the hand in a flat posture in an
orthosis because doing so compromises function and creates
deformity. Especially in cases of muscle atrophy (as with a tendon or
nerve injury), the orthosis should maintain the integrity and mobility
of the arches.
The proximal transverse arch is fixed and consists of the distal row
of carpal bones. The proximal transverse arch is a rigid arch acting as
a stable pivot point for the wrist and long-finger flexor muscles. 12 The
transverse carpal ligament and the bones of the proximal transverse
arch form the carpal tunnel. The finger flexor tendons pass beneath
the transverse carpal ligament. The transverse carpal ligament
provides mechanical advantage to the finger flexor tendons by serving
as a pulley. 2
 FIG. 4.9 A, Intrinsic minus position of the hand. B, Notice loss of
normal arches of the hand and wasting of all intrinsic musculature
resulting from a long-standing low median and ulnar nerve palsy.
From Aulicino, P. L. [2002]. Clinical examination of the hand. In E. J.
Mackin, A. D. Callahan, T. M. Skirven, et al. [Eds.]. Rehabilitation of the
hand: Surgery and therapy [5th ed., p. 130]. St. Louis, MO: Mosby

The distal transverse arch, which deepens with flexion of the

fingers, is mobile and passes through the metacarpal heads. 2 An
orthosis must allow for the functional movement of the distal arch to
maintain or increase normal hand function. 12
The longitudinal arch allows the DIP, PIP, and MCP joints to flex. 16
This arch follows the longitudinal axes of each finger. Because of the
mobility of their base, the first, fourth, and fifth metacarpals move in
relationship to the shape and size of an object placed in the palm.
Grasp is the result of holding an object against the rigid portion of the
hand provided by the second and third digits. The flattening and
cupping motions of the palm allow the hand to pick up and handle
objects of various sizes.
Anatomical Landmarks of the Hand
Creases of the Hand
The creases of the hand are critical landmarks for orthotic pattern
making and molding. Therefore knowledge of the creases and their
functional implications is important. Three flexion creases are located
on the palmar surface of digits II through V, and additional creases
are located on the palmar surface of the hand and wrist (Fig. 4.11).
The three primary palmar creases are the distal, proximal, and
thenar creases. As shown in Fig. 4.11, the distal palmar crease extends
transversely from the fifth MCP joint to a point midway between the
third and second MCP joints. 9 This crease is the landmark for the
distal edge of the palmar portion of an orthosis intended to
immobilize the wrist while allowing motion of the MCPs. 20 By
positioning the orthosis proximal to the distal palmar crease, the
therapist makes full MCP joint flexion possible. Proximal to the distal
palmar crease is the proximal palmar crease, which is used as a guide
during orthotic fabrication. An orthosis must be proximal to the
proximal palmar crease at the index finger, or the MCP joint will not
be free to move into flexion.
 FIG. 4.10 Arches of the hand.

The thenar crease begins at the proximal palmar crease near the
radial side of the second digit and curves around the base of the
thenar eminence (see Fig. 4.11). 9 To allow for thumb motion, this
crease should define the limit of the orthosis’ edge. If the orthosis
extends beyond the thenar crease toward the thumb, thumb
opposition and palmar abduction of the CMC joint are inhibited.
The two palmar (or volar) wrist creases are the distal and proximal
wrist creases. The distal wrist crease extends from the pisiform bone
to the tubercle of the trapezium (see Fig. 4.11) and forms a line that
separates the proximal and distal rows of the carpal bones. The
proximal wrist crease corresponds to the radiocarpal joint and
delineates the proximal border of the carpal bones, which articulates
with the distal radius. 9 The distal and proximal wrist creases assist in
locating the axis of the wrist motion. 13 Wrist creases serve as a guide
when fabricating hand-based orthoses that allow for wrist motion.
Such wrist creases should not be covered by the orthosis to allow for
full wrist flexion and extension.
The three digital palmar flexion creases are on the palmar aspect of
digits II through V (Fig. 4.11). The distal digital crease (or DIP crease)
marks the DIP joint axis, and the middle digital crease (or PIP crease)
marks the PIP joint axis. The proximal digital crease (or MCP crease)
is distal to the MCP joint axis at the base of the proximal phalanx. The
creation of the proximal and distal palmar creases results from the
thick palmar skin folding due to the force allowing full MCP flexion. 2
The flexion axis of the IP joint of the thumb corresponds to the IP
crease of the thumb. Similarly, the MCP crease describes the axis of
thumb MCP joint flexion.
 FIG. 4.11 Creases of the hand. 1, Distal digital (distal interphalangeal)
crease; 2, middle digital (proximal interphalangeal) crease; 3, proximal
digital (metacarpophalangeal) crease; 4, distal palmar crease; 5,
proximal palmar crease; 6, thenar crease; 7, distal wrist crease; 8,
proximal wrist crease.

The creases are close to but not always directly over bony joints. 12
When providing an orthosis to immobilize a particular joint, the
therapist must be sure to include the corresponding joint flexion
crease within the orthosis so as to provide adequate support for
immobilization. Conversely, when attempting to mobilize a specific
joint, the therapist must not incorporate the corresponding flexion
crease in the orthosis to allow for full range of motion. 16 When one is
working with persons who have moderate to severe edema, the
creases may dissipate. Creases may also dissipate with disuse
associated with paralysis or disuse resulting from pain, stiffness, or
psychological problems.
Grasp and Prehensile Patterns
The normal hand can perform many prehensile patterns in which the
thumb is a crucial factor. Therapists must be knowledgeable about
prehensile and grasp patterns, especially when providing orthoses to
assist the performance of these patterns.
Even though hand movements are extremely complex, they are
categorized into several basic prehensile and grasp patterns, including
fingertip prehension, palmar prehension, lateral prehension,
cylindrical grasp, spherical grasp, hook grasp, 25 and intrinsic plus
grasp. 5 Fig. 4.12 depicts these types of prehensile and grip patterns.
Remember that finer prehensile movements require less strength than
grasp movements. Pedretti 22 remarked, “The grasp and prehension
patterns that may be provided by hand orthoses are determined by
the muscles that are functioning, potential and present deformities,
and how the hand is to be used.”
Fingertip prehension is the contact of the pad of the index or
middle finger with the pad of the thumb. 25 This movement, which
clients use to pick up small objects such as beads and pins, is the
weakest of the pinch patterns and requires fine motor coordination.
An orthosis to facilitate the fingertip prehension for a person with
arthritis may include a static orthosis to block (stabilize) the thumb IP
joint in slight flexion (Fig. 4.13). 5
Palmar prehension, also known as the tripod or three jaw chuck pinch,
5,13 is the contact of the thumb pad with the pads of the middle and

index fingers. People use palmar prehension for holding pencils and
picking up small spherical objects. Orthoses to facilitate palmar
prehension include thumb spica orthoses that position the thumb in
palmar abduction, which may be hand or forearm based (Fig. 4.14).
Lateral prehension, the strongest of the pinch patterns, is the contact
between the thumb pad and the lateral aspect of the index finger. 25
Clients typically use this pattern for holding keys. Orthoses that
position the hand for lateral prehension include thumb spica orthoses
that place the thumb in slight radial abduction (Fig. 4.15).
Cylindrical grasp is used for holding cylindrical-shaped objects,
such as soda cans, pan handles, and cylindrical tools. 25 The object
contacts in the palm of the hand, and the adducted fingers flex around
the object to maintain a grasp. Orthotic provision to encourage such
motions as thumb opposition or finger and thumb joint flexion may
contribute to a person’s ability to regain cylindrical grasp (Fig. 4.16).
The spherical grasp is used to hold round objects, such as balls and
spherical-shaped fruit. 25 The object rests against the palm of the hand,
and the abducted five digits flex around the object. Orthoses that
enhance spherical grasp include orthoses addressing such motions as
finger and thumb abduction (Fig. 4.17).
The hook grasp, which is accomplished by the fingers only, involves
the carrying of such items as briefcases and suitcases by the handles.
25 The PIPs and DIPs flex around the object, and the thumb often

remains passive in this type of grasp. With ulnar and median nerve
damage, this position may be avoided rather than encouraged.
However, for PIP and DIP joints lacking flexion a therapist may
fabricate mobilization (dynamic) flexion orthoses to gain range of
motion in these joints.
The intrinsic plus grip is characterized by MCP flexion and PIP and
DIP extension. The thumb is positioned in palmar abduction for
opposition with the third and fourth fingers. 5 This grasp is helpful
when holding flat objects, such as books, trays, or sandwiches. The
intrinsic plus grip is not present with ulnar and median nerve injuries.
A therapist may facilitate the grasp by using a figure-eight orthosis,
shown in Fig. 4.18.
Biomechanical Principles for Orthotic
Intervention
Orthotic fabrication involves application of external forces on the
hand, and thus understanding basic biomechanical principles is
important for the therapist when constructing and fitting orthoses.
Correct biomechanics of orthotic design results in an optimal fit and
reduces risks of skin irritation and pressure areas, which ultimately
may lead to client comfort, compliance, and function. In addition,
knowledgeable manipulation of biomechanics increases the orthoses’
efficiency and improves orthoses’ durability while decreasing cost and
frustration. 15
 FIG. 4.12 Prehensile and grip patterns of the hand. A, Fingertip
prehension. B, Palmar prehension. C, Lateral prehension. D,
Cylindrical grasp. E, Spherical grasp. F, Hook grasp. G, Intrinsic plus
grasp.

FIG. 4.13 Static orthosis to block the thumb interphalangeal joint in

slight flexion to facilitate tip pinch.
From Pedretti, L. W. [Ed.]. [1996]. Occupational therapy: Practice skills
for physical dysfunction [4th ed., p. 327]. St. Louis, MO: Mosby.
 FIG. 4.14 Thumb spica orthosis to facilitate palmar prehension by
positioning the thumb in opposition to the index and long fingers.
From Pedretti, L. W. [Ed.]. [1996]. Occupational therapy: Practice skills
for physical dysfunction [4th ed., p. 327]. St. Louis, MO: Mosby.
 FIG. 4.15 Thumb spica orthosis to facilitate lateral prehension by
positioning the thumb in lateral opposition to the index finger.
From Pedretti, L. W. [Ed.]. [1996]. Occupational therapy: Practice skills
for physical dysfunction [4th ed., p. 327]. St. Louis, MO: Mosby.
FIG. 4.16 This dorsal wrist orthosis stabilizes the wrist to increase grip
force and minimizes coverage of the palm.
From Pedretti, L. W. [Ed.]. [1996]. Occupational therapy: Practice skills
for physical dysfunction [4th ed., p. 328]. St. Louis, MO: Mosby.
 FIG. 4.17 This dorsal wrist orthosis stabilizes the wrist and allows
metacarpophalangeal mobility required for a spherical grasp.
From Pedretti, L. W. [Ed.]. [1996]. Occupational therapy: Practice skills
for physical dysfunction [4th ed., p. 328]. St. Louis, MO: Mosby.
 FIG. 4.18 Figure-eight orthosis to facilitate an intrinsic plus grasp.
From Pedretti, L. W. [Ed.]. [1996]. Occupational therapy: Practice skills
for physical dysfunction [4th ed., p. 328]. St. Louis, MO: Mosby.

Three-Point Pressure
Most orthoses use a three-point pressure system to affect a joint
motion. A three-point pressure system consists of three individual
linear forces in which the middle force is directed in an opposite
direction from the other two forces, as depicted in Fig. 4.19. Three-
point pressure systems in orthoses are used for different purposes. 2,15
For example, an orthosis affecting extension or flexion of a joint exerts
forces in one plane or unidirectionally, as shown in Fig. 4.20. Three-
point systems can be applied to multiple directions. In other words, an
orthosis may immobilize one joint while mobilizing an adjacent joint.
An example of a multidirectional three-point pressure system is a
circumferential wrist orthosis, shown in Fig. 4.21.

Mechanical Advantage
Orthoses incorporate lever systems, which incorporate forces,
resistance, axes of motion, and moment arms. Orthoses that serve as
levers use a proximal input force (Fi), two moment arms, and an axis
or fulcrum to move a distal output force. 15 Similar to a teeter-totter,
the force side of an orthosis’ lever equals the resistance side of the
lever. The sum of the proximal (Fi) and the distal (Fo) forces equals the
magnitude (Fm) of the middle opposing force. The system’s balance is
defined as:

FIG. 4.19 Three-point pressure system is created by an orthosis’

surface and properly placed straps to secure the orthosis and ensure
proper force for immobilization.
From Pedretti, L. W. [Ed.]. [1996]. Occupational therapy: Practice skills
for physical dysfunction [4th ed., p. 336]. St. Louis, MO: Mosby.
 FIG. 4.20 Unidirectional three-point pressure system.
From Fess, E. E., & Philips, C.A. [1987]. Hand splinting: Principles and
methods [2nd ed., p. 4]. St. Louis: Mosby.

In this equation, Fi is the input force, and di is the input distance (or
the proximal force moment arm). Fo is the resistance (or output) force,
and do is the output distance (or the resistance moment arm).
Mechanical advantage is defined as:
 FIG. 4.21 Multidirectional three-point pressure systems.
From Pedretti, L. W. [Ed.]. [1996]. Occupational therapy: Practice skills
for physical dysfunction [4th ed., p. 336]. St. Louis, MO: Mosby.

Mechanical advantage principles can be applied and adjusted when

the therapist is designing an orthosis. For example, when designing a
volar-based wrist immobilization orthosis, increasing the length of the
forearm trough decreases force on the proximal anterior forearm (Fig.
4.22). Mechanical advantage results in a more comfortable orthosis for
the client. Application of this concept involves consideration of the
anatomical segment length in designing the orthosis. For example, the
length of an orthosis’ forearm trough should be approximately two-
thirds the length of the forearm. Persons wearing volar-based orthoses
should be able to flex their elbows fully without interference. 4 The
width of a thumb or forearm trough should be half the circumference
of the thumb or forearm. The muscle bulk of an extremity gradually
increases more proximal to the body, and the orthosis’ trough should
widen proportionately as it courses proximally. When making an
orthotic pattern, the therapist must maintain at least one-half the
circumference of the thumb or forearm for a correct fit.

Torque
Torque is a biomechanical principle defined as the “extent to which a
force tends to cause rotation of an object (body part) about an axis.” 21
Other terms used synonymously include moment arm or moment of
force. Torque is the product of the applied force (F) multiplied by the
perpendicular distance from the axis of rotation to the line of
application of force (d). The equation for torque is:
 FIG. 4.22 A longer forearm trough decreases the resultant pressure
caused by the proximally transferred weight of the hand to the anterior
forearm.
From Fess, E. E., Gettle, K. S., Philips, C. A., et al. [2005]. Mechanical
principles. In E. E. Fess, & C. A. Philips [Eds.], Hand splinting:
Principles and methods [3rd ed., p. 167]. St. Louis, MO: Mosby.
 It is important to consider torque for dynamic or mobilization
orthoses (see Chapter 13).

Pressure and Stress

There are four ways in which skin and soft tissue can be damaged by
force or pressure:

• Degree
• Duration
• Repetition
• Direction

Degree and Duration of Stress

Generally, low stress can be tolerated for longer periods of time,
whereas high stress over long periods of time causes damage. 6 It
must be noted that low stress and high stress are generic and imprecise
terms. Generally, the tissue that least tolerates pressure is the skin.
Skin becomes ischemic as load increases. Low stress can be damaging
if it is continuous and can eventually cause capillary damage and lead
to ischemia. The effects of continuous low force from constricting
circumferential bandages and orthoses and their straps can be
damaging at times. However, if a system can be devised to distribute
pressure over a larger area of skin, a higher load can be exerted on a
ligament, adhesion, tendon, or muscle. Such an orthotic design may
include a longer trough or a circumferential component.

Repetitive Stress
If a stress is repetitively applied in moderate amounts, it can lead to
inflammation and skin breakdown. 6 An example of a repetitive stress
may be seen in a person wearing a dynamic flexion orthosis that has
rubber band traction. If the person continually flexes the finger against
the tension, the tissue may become inflamed after some time. If
inflammation or redness occurs, the tension is adjusted by relaxing the
traction. Persons with traumatic hand injuries or pathology may not
be able to tolerate the repetitive amounts of stress a normal person
could tolerate. Poor tolerance is usually a result of damaged vascular
and lymph structures.
High stress may quickly result in tissue damage. 6 High stress can
be applied to the skin from any object, such as an orthosis or bandage.
The smaller or sharper the object is, the greater the amount of stress is
produced. High stress should be avoided at all times. For example, if a
dynamic orthosis is applying too much stress to a joint, circulation
may be restricted (potentially leading to tissue damage).

Direction of Stress
During orthotic fabrication, consider the direction of stress or force on
the skin and soft tissue. There are three directions of force to consider:
(1) tension, (2) compression, and (3) shear. 15 Compression stress
results from forces pressing inwardly on an object (Fig. 4.23A).
Tension occurs when forces on an object are applied opposite each
other (Fig. 4.23B). Shear force occurs “when parallel forces are applied
in an equal and opposite direction across opposite faces of a structure”
15 (Fig. 4.23C). Researchers suggest that shear stress is the most

damaging to skin. 6
Therapists must recognize and know how to use the stress of
orthoses in such a way as to not create soft-tissue damage. Generally,
avoid excessive stress or pressure from orthoses by employing wide
troughs placed far from the fulcrum of movement while using an
appropriate amount of tension on structures. 2 To determine the
appropriate amount of tension on structures, the orthosis’ tension
should be sufficient to take the joint to a comfortable joint end range.
This means that the tension in the orthosis should bring the joint just
to the maximum comfortable position (flexion, extension, deviation, or
rotation) that is tolerable. This position should be one the client can
tolerate for long periods of time. The client may need to work up to a
longer wearing time, but the goal is usually at least 4 hours per day.
 FIG. 4.23 A, Compression is a force pushing tissues together. B,
Tension occurs when forces pull in opposite directions (tensile forces).
 C, Shear forces are parallel to the surfaces they affect.
From Greene, D. P., & Roberts, S. L. [2005]. Kinesiology movement in
the context of activity [2nd ed., p. 21]. St. Louis, MO: Mosby.

Ideally, the 4 hours will be continuous, but it can be broken up as

necessary. Ask clients to try to wear their orthoses to improve passive
range of motion (PROM) during sleep. However, this depends on
their cognitive, sensory, and substance abuse status. The rationale for
this wearing schedule is based on studies that show that low-load
prolonged stress at the end range is very effective in increasing
PROM. Technically, for dense scars or for tissue that has adaptively
shortened over a long period of time, higher tension forces can be
used as long as the pressure is well distributed along the skin. The
skin is the structure that is the “weak link.” The skin cannot tolerate
the tension in the orthosis and becomes ischemic and therefore
painful. If the pressure is well distributed, higher forces can be used
and the tissue lengthens more quickly as a result.
Several examples depict the effects of force on soft tissues. 15 For
example, after repair of a tendon rupture a therapist may employ
early mobilization with a small amount of tension to facilitate the
alignment of collagen fibers for improving tensile strength of the
healing tendon. The tendon may be re-ruptured if the tension and
repetition applied are not well controlled. An orthosis may be applied
to assist in controlling fluctuating edema in the upper extremity.
However, if the orthosis applies too much compression force on the
underlying soft tissue over too much time, the orthosis may restrict
vascularity, possibly leading to soft-tissue necrosis. Shear stress
between a healing tendon and its sheath must be carefully monitored
to minimize and control adhesion shape.
The concepts of stress are considered with orthotic intervention.
Orthoses and straps apply external forces on tissues that in turn affect
forces or stresses exerted internally. 15 The formula for pressure is:
 Ideally, orthoses should be contoured and cover a large surface area
to decrease pressure and the risk of pressure sores. 11 Straps should be
as wide as possible to distribute pressure appropriately and to prevent
restriction of circulation or trapping of edema.
Thermoplastic orthoses can cause pressure points over areas with
minimal soft tissue or over bony prominences. To avoid this risk, the
therapist uses an orthotic design that is wider and longer. 16 A larger
design is more comfortable, because it decreases the force
concentrated on the hand and arm by increasing the surface area of
the orthosis’ force application.
Continuous well-distributed pressure is the goal of an orthosis, but
pressure over any bony prominence should be nonexistent. 9
Therapists should be cautious of pressure over bony prominences,
such as the radial and ulnar styloids and the dorsal-aspect MCPs and
the PIPs (Fig. 4.24). Therapists can use heat guns to alleviate pressure
exerted by the orthosis. This is done by heating the plastic in problem
areas and pushing the plastic away from the bony prominence.
Another technique for avoiding pressure on bony prominences is to
place the orthosis over padding, gel pads, or elastomer positioned
over bony prominences. A frequent mistake in orthotic fabrication
occurs when a pad is placed over the localized pressure area after the
orthosis is formed. 6 Remember that padding takes up space, reducing
the circumference measurement of the orthosis and increasing the
pressure over an area. Plan for the addition of padding before
application of the thermoplastic material. The orthotic design must
accommodate the thickness of the padding.
Moist substances, such as perspiration and wound drainage, can
cause skin maceration, irritation, and breakdown. Bandages help
absorb the moisture but require frequent changing for infection
control. 1 Some types of stockinettes are more effective in wicking
moisture away from skin. Polypropylene and thick terry liners are
much more effective than cotton or common synthetic stockinettes.
Therapists can fabricate an orthosis over extremities covered with a
stockinette or bandages, but the orthosis should be altered if the bulk
of dressings or bandages changes.
Rolled or round edges on the proximal and distal ends of the
orthosis cause less pressure than straight edges. 9,21 Imperfect edges
are potential causes of pressure areas and therefore should be
smoothed.
FIG. 4.24 A and B, Bony sites susceptible to pressure, which may
 cause soft-tissue damage.
From Fess, E. E., Gettle, K. S., Philips C. A., et al. [2005]. Principles of
fit. In E. E. Fess & C. A. Philips [Eds.]. Hand splinting: Principles and
methods [3rd ed., p. 261]. St. Louis, MO: Mosby.
Contour
When flat, thermoplastic materials are flexible and can be bent.
Curving and contouring thermoplastic material to an underlying
surface changes the mechanical characteristics of the material. 21,27
Contoured thermoplastic material is stronger and is better able to
handle externally applied forces (Fig. 4.25). Thermoplastic materials
have varying degrees of drapability and conformity properties, which
may affect the degree of contour the therapist is able to obtain in an
orthosis.
Mechanics of Skin and Soft Tissue
Therapists often use orthoses to effect a change in skin and soft tissue,
which may address performance deficits. It is important to have a
basic understanding of the mechanics of normal soft tissue and skin.
In addition, one should know when and how the mechanics change in
the presence of scar tissue, materials (bandages, orthoses, cuffs),
edema, contractures, wounds, and infection.
Normal skin and soft tissue have properties of plasticity and
viscoelasticity, which allow them to resist breakdown under stress in
normal situations. 6 Plasticity refers to the extent the skin can mold
and reshape to different surfaces. Viscoelasticity refers to the skin’s
degree of viscosity and elasticity, which enables the skin to resist
stress. The skin and soft tissue tolerate some force or stress, but
beyond a certain point the skin breaks down. 29
When edema is present, the hand’s normal soft tissue undergoes
mechanical changes because of the volume of viscous fluid present.
6,26 Prolonged or excessive edema can lead to permanent deformity.

Therefore, edema must be managed in conjunction with orthotic

application (e.g., elevating the affected extremity, moving unaffected
joints to actively contract the muscles to facilitate venous blood return
from the extremity). 21 Orthoses often assist in controlling edema.
Because of the increase in volume of fluid, swollen skin, joints, and
tendons have an increase in friction in relation to the resistance to
movement. “Swollen tissue, then, in addition to its increased viscosity,
is limited in its ability to be elongated, compressed, or compliant. This
is why a hand never has a normal range of motion as long as there is
edema in the tissue in and under the skin.” 6
Properties of thermoplastic material are selected carefully as they
can affect skin and soft tissue. 24 For example, when orthoses are
secured on the extremity using elastic bandages, they have the
potential to apply high amounts of stress and may lead to constriction
in the vascular and lymphatic circulation. A therapist must consider
the amount of pressure applied to skin and tissue, especially when a
second wrap of an elastic bandage covers an initial wrap. The
pressure applied by the second wrap is doubled. Pressure occurs even
when bandages are applied in a figure-eight fashion. Another
consideration is the effect that bandages have on motion. Movement
while bandages are worn can further concentrate pressure,
particularly over bony prominences. If appropriate, bandages should
be removed while exercises are being performed.
Finger cuffs or loops used with mobilization orthoses increase
pressure on the underlying skin and tissue. Bell-Krotoski and
colleagues 6 caution that using very flexible finger cuffs could increase
the shear stress on fingers. Leather finger loops may be an appropriate
choice because they simulate normal skin by being flexible while
providing some firmness to decrease the shear stress. Finger loops
should be as wide as possible to avoid edge shear and to distribute
pressure (Fig. 4.26). Chapter 13 addresses finger loops in more depth.
In joints with flexion contractures, skin on the dorsum of the joints
grows with elongation tension on the skin. 6 Skin on the volar surface
of the joints is reabsorbed by a reduction in the elongation tension.
There is a natural balance of tension in the skin and muscles. Skin will
adjust to the tension required of it. Not only will skin lose length
(contracture), but it grows new cells to lengthen. The use of stretch
gradually produces these changes. If skin is stretched to the point of
microtrauma, a scar forms. When skin stretches, it releases proteins
that result in scar formation. The scar tissue decreases the elasticity of
the skin. To counteract excessive scarring, therapists use scar massage,
mobilization techniques, and gentle stretch. Optimal regrowth
involves the use of continuous (or almost continuous) tension. 6
 FIG. 4.25 Contour mechanically increases the material’s strength.
From Fess, E. E., Gettle, K. S., Philips C. A., et al. [2005]. Mechanical
principles. In E. E. Fess & C. A. Philips [Eds.], Hand splinting:
Principles and methods [3rd ed., p. 178]. St. Louis, MO: Mosby.
 FIG. 4.26 Finger loops apply pressure to the underlying surface. They
should be as wide as possible without limiting adjacent joint mobility.
From Fess, E. E., Gettle, K. S., Philips C. A., et al. [2005]. Principles of
fit. In E. E. Fess & C. A. Philips [Eds.], Hand splinting: Principles and
methods [3rd ed., p. 274]. St. Louis, MO: Mosby.

Tissue that is newly healing can be negatively affected by

mechanical stress. Tension of a wound site may “reduce the rate of
repair, compromise tensile strength, and increase the final width of
the scar.” 14 Rather than simply removing an orthosis and returning
the extremity to function, immobilization orthoses should be
gradually weaned as the affected skin and tissue become more mobile.
6
When working with a person who has infected tissues, caution
must be taken to avoid mechanical stress from motion (as from a
mobilization orthosis). Blood and interstitial fluids are forced into
motion, and this pushes infection into deeper tissue and results in a
more widespread infection and delay in healing. In the presence of
infection, it is best to immobilize a joint with an orthosis for a few
days and then remove the orthosis to maintain normal or partial range
of motion.
 a
Self-Quiz 4.1
Answer the following.
Part I
Match the following with the correct orthosis.

a. Based on the palmar surface of the hand and forearm

b. Based on the dorsal surface of the hand and forearm
c. Based on the thumb side of the hand and forearm
d. Based on the little finger side of the hand and forearm
1. Ulnar gutter wrist immobilization orthosis
2. Volar- or palmar-based flexion mobilization orthosis
3. Dorsal MCP protection orthosis
4. Palmar-based wrist immobilization orthosis
5. Radial gutter extension mobilization orthosis

Part II
From the following diagram, label the creases of the hand.

1.
2.
3.
4.
5.
Part III
From the following diagram, label the arches of the hand.

1.
2.
3.
a
See Appendix A for the answer key.

a
Self-Quiz 4.2
For the following questions, circle either true (T) or false (F).

1. T F The forearm trough should be two-thirds the circumference

of the forearm.
2. T F Short, narrow orthoses apply less pressure to the skin’s
surface than long, wide orthoses and are therefore better.
3. T F An orthosis should be approximately two-thirds the length
of the forearm.
4. T F Avoidance of pressure over a bony prominence is preferable
to unequal pressure.
5. T F A person uses a spherical grasp when holding a soda can.
6. T F An orthotic design must accommodate padding thickness.
7. T F In joints with flexion contractures, the skin on the dorsum of
the joint shortens and exerts tension.
8. T F In the orthotic provision for persons with infection, caution
is taken to avoid mechanical stress from motion such as
mobilization orthoses.
9. T F Contour of an orthosis increases its strength.
10. T F Shear force results from forces pressing inwardly on an
object.

a
See Appendix A for the answer key.
Summary
A therapist’s knowledge of anatomical and biomechanical principles
is important during the entire orthotic process. One must be familiar
with terminology to interpret medical reports, therapy prescriptions,
and professional literature. In addition, the therapist uses medical
terminology to document evaluations and interventions. The
application of biomechanical principles to orthotic design and
construction results in better-fitting orthoses and thus contributes to
adherence with therapeutic regimens. Ultimately, adherence to such
principles impacts therapeutic outcomes.

Review Questions
1. In regard to orthotic fabrication, what do the following
terms refer to: palmar, dorsal, and radial (or ulnar)?
2. What are the three arches of the hand?
3. When therapists fabricate an orthosis for the hand, why is
support for the hand’s arches important?
4. What is the significance of the distal palmar crease when
fabricating a hand orthosis?
5. If an orthosis’ edge does not extend beyond the thenar
crease toward the thumb, what thumb motions are
possible?
6. What is an example of each of the following prehensile or
grasp patterns: fingertip prehension, palmar prehension,
lateral prehension, cylindrical grasp, spherical grasp, hook
grasp, and intrinsic plus grasp?
7. How can a therapist determine the correct length of a
 forearm orthosis?
8. What is the correct width for an orthosis that has a forearm
or thumb trough?
9. What precautions should a therapist take when using
padding in an orthosis?
10. What are two methods a therapist can use to prevent the
edges of an orthosis from causing a pressure sore?
11. Why is it important to consider contour when fabricating
an orthosis?
12. How do skin and soft-tissue mechanics change in the
presence of scar tissue, material application, edema,
contractures, wounds, and infection?
References
1. Agency for Health Care Policy and Research.
Pressure ulcers in adults: prediction and prevention (No.
92–0047) . Rockville, MD: US Department of Health
and Human Services; 1992.
2. Andrews K.L, Bouvette K.A. Anatomy for
management and fitting of prosthetics and orthotics.
Phys Med Rehab: State of the Art Rev . 1996;10(3):489–
507.
3. Aulicino P.L. Clinical examination of the
hand. In: Hunter J.M, Mackin E.J, Callahan A.D, eds.
Rehabilitation of the hand: surgery and therapy . ed 4. St.
Louis: Mosby; 1995.
4. Barr N.R, Swan D. The hand
. Butterworth: Boston; 1998.
5. Belkin J, English C.B. Hand splinting: principles,
practice, and decision making. In: Pedretti L.W, ed.
Occupational therapy: practice skills for physical
dysfunction . ed 4. St. Louis: Mosby; 1996.
6. Bell-Krotoski J.A, Breger-
Lee D.E, Beach R.B. Biomechanics and evaluation of
the
hand. In: Hunter J.M, Mackin E.J, Callahan A.D, eds.
Rehabilitation of the hand: surgery and therapy . ed 4. St.
Louis: Mosby; 1995.
7. Bowers W.H, Tribuzi S.M. Functional
anatomy. In: Stanely B.G, Tribuzi S.M, eds. Concepts
in hand rehabilitation . Philadelphia: FA Davis; 1992.
8. Buck W.R. Human gross anatomy lecture guide . Erie,
 PA: Lake Erie College of Osteopathic Medicine; 1995.
9. Cailliet R. Hand pain and impairment . ed
4. Philadelphia: FA Davis; 1994.
10. Cailliet R. Shoulder pain . ed 2. Philadelphia: FA
Davis; 1981.
11. Cannon N.M, Foltz R.W, Koepfer J.M, et al. Manual of
hand splinting . New York: Churchill
Livingstone; 1985.
12. Chase R.A. Anatomy and kinesiology of the
hand. In: Hunter J.M, Schneider L.H, Mackin E.J, eds.
Rehabilitation of the hand: surgery and therapy . ed 3. St.
Louis: Mosby; 1990.
13. Clarkson H.M, Gilewich G.B. Musculoskeletal
assessment: joint range of motion and manual muscle
strength . Baltimore: Williams & Wilkins; 1989.
14. Evans R.B, McAuliffe J.A. Wound classification and
management. In: Mackin E.J, Callahan A.D, Skirven T.M, eds.
Rehabilitation of the hand and upper extremity . ed 5. St.
Louis: Mosby; 2002.
15. Fess E.E. Splints: mechanics versus convention. J
Hand Ther . 1995;9(1):124–130.
16. Fess E.E, Gettle K.S, Philips C.A, et al. Hand and upper
extremity splinting: principles and methods . ed 3. St.
Louis: Elsevier Mosby; 2005.
17. Kapandji I.A. The physiology of the joints
. London: E&S Livingstone; 1970.
18. Kleinert H.E, Schepel S, Gill T. Flexor tendon injuries.
Surg Clin North Am . 1981;61(2):267–286.
19. Long C, Conrad P.W, Hall E.A, et al. Intrinsic-
extrinsic muscle control of the hand in power grip
and precision handling: an electromyographic study.
 J Bone Joint Surg Am . 1970;52(5):853–867.
20. Malick M.H. Manual on static hand splinting
. Pittsburgh: Hamarville Rehabilitation Center; 1972.
21. McGee P, Rivard A. Foundations of orthotic
intervention. In: Skirven T.M, Osterman A.L, Fedorczyk J.M, et
al., eds. Rehabilitation of the hand and upper extremity
. ed 6. St. Louis: Mosby; 2011:1577–1578.
22. Pedretti L.W. Hand
splinting. In: Pedretti L.W, Zoltan B, eds.
Occupational therapy: practice skills for physical
dysfunction . ed 3. St. Louis: Mosby; 1990:18–39.
23. Pratt N.E. Clinical musculoskeletal anatomy
. Philadelphia: Lippincott; 1991.
24. Schultz-Johnson K. Personal communication . March 3,
1999.
25. Smith L.K, Weiss E.L, Lehmkuhl L.D. Brunnstrom’s
clinical kinesiology . ed 5. Philadelphia: FA
Davis; 1996.
26. Villeco J.P, Mackin E.J, Hunter J.M. Edema: therapist’s
management. In: Mackin E.J, Callahan A.D, Skirven T.M, et
al., eds. Rehabilitation of the hand and upper extremities
. ed 5. St. Louis: Mosby; 2002:183–193.
27. Wilton J.C. Hand splinting principles of design and
fabrication . Philadelphia: WB Saunders; 1997.
28. Wu P.B.J. Functional anatomy of the upper extremity.
Phys Med Rehab: State Art Rev . 1996;10(3):587–600.
29. Yamada H. Strength of biological materials
. Baltimore: Williams & Wilkins; 1970.
Clinical Examination for Orthotic
Intervention
Brenda M. Coppard

CHAPTER OBJECTIVES
1. List components of a thorough clinical examination as related to
orthotic intervention.
2. Describe components of a history, an observation, and palpation.
3. Describe the resting hand posture.
4. Relate how skin, vein, bone, joint, muscle, tendon, and nerve
assessments are relevant to orthotic intervention.
5. Identify specific assessments that can be used in a clinical
examination before orthotic intervention.
6. Explain the three phases of wound healing.
7. Recognize the signs of abnormal illness behavior.
8 Explain how a therapist assesses a person’s knowledge of
orthotic precautions and wear and care instructions.

KEY TERMS
protocols
reliability
responsiveness
validity
verbal analog scale (VeAS)
visual analog scale (ViAS)

Mauri is a therapist who recently switched practice from pediatrics to an

outpatient rehabilitation clinic. During his first week, he receives a
referral for Blanche, an 82-year-old woman with a flare-up of
rheumatoid arthritis. Before scheduling an appointment with, Mauri
conceptualizes his screening and assessment plan.
Clinical Examination
A thoughtfully selected battery of clinical assessments is crucial to
therapists’ and physicians’ intervention plans. A thorough, organized,
and clearly documented examination is the basis for the development
of an intervention plan. In today’s health care system, therapists
complete examinations that are time and cost efficient. This chapter
addresses components of the assessment process in relation to orthotic
provision.
Time-efficient, informal assessments may indicate the level of hand
and upper extremity function initially observed by the therapist. 35
The results may prompt a therapist to select more sophisticated
testing procedures, as indicated by the person’s condition. 27
Generally, initial and discharge evaluations are most comprehensive
in scope, whereas regular reassessments are usually more focused.
Reassessments typically occur at consistent intervals of time. For
example, if Jose is evaluated at his Monday appointment, the therapist
may reevaluate Jose every Monday or every other Monday thereafter.
On some occasions a case manager may request the therapist to
reevaluate a client. However, the time span between assessments is
based on the person’s condition and progress. For example, a person
with a peripheral nerve injury may be reevaluated once every 3 weeks
because of the slow nature of nerve healing. Another person being
rehabilitated after a burn injury may be reevaluated every week
because this condition changes more quickly, thereby affecting
functional ability.
The assessment process for the upper extremity incorporates data
from conducting a medical history, an interview, observation,
palpation, and a selection of tests that are objective, valid, and reliable.
Form 5.1 is a check-off sheet that therapists can use when evaluating a
person with upper extremity dysfunction. Ancillary tools (such as
radiographs, computerized tomography [CT] scans, magnetic
resonance imaging [MRI] scans, electrodiagnostics, and laboratory
tests) assist in confirming the diagnosis and provide the therapist with
a broader context of the person’s condition(s). 63

History
Beginning with a medical history, the therapist gathers data from
various sources. Depending on the setting, the therapist may have
access to the person’s medical chart, surgical or radiological reports,
and the physician’s referral or prescription. The person’s age, gender,
and diagnosis are typically easy to obtain from such sources. Client
age is important because some congenital anomalies and diagnoses
are unique to certain age groups. Age may also affect the prognosis or
length of recovery. Some problems are unique to gender.
From available sources the therapist seeks out the person’s past
medical history, the dates of occurrences, current medical status, and
treatment. The history includes invasive and noninvasive treatments.
Conditions such as diabetes, epilepsy, kidney or liver dysfunction,
arthritis, and gout should be reported because they can directly or
indirectly influence rehabilitation (including orthotic intervention). 20
The therapist determines whether the current upper extremity
problem is the result of neurological or orthopedic origin, or a
combination of both. For example, Ken fell and sustained a traumatic
brain injury and experienced upper extremity fractures. Some
conditions are solely orthopedic in nature, resulting from trauma
affecting soft tissue (i.e., tendon laceration, burn). The nature of
dysfunction helps the therapist determine the orthotic approach.
With postoperative presentations, therapists must know the
anatomical structures involved and the surgical procedures
performed. Be aware that some physicians may prefer to follow
conventional rehabilitative programs for certain diagnostic
populations. Other physicians may prefer to follow rehabilitative
programs that they developed for specific postoperative diagnostic
populations. Whether standardized or nonstandardized, these
programs are known as protocols. Protocols delineate which types of
orthoses, exercises, and therapeutic interventions are appropriate in
rehabilitation programs. Protocols often indicate the timing of
interventions.

Interview
At the beginning of the interview, complete introductions, explain
what occupational therapy is, and describe the purpose of evaluation
and intervention. The goal of the interview is for the therapist to
determine the impact of the condition on the person’s function,
family, economic status, and social/emotional well-being. Most
important, the therapist asks what a person’s goals are. 63 The
therapist collects the person’s history at the time of the initial
evaluation. In addition, the therapist creates a teaching/learning
environment compatible with the client’s learning style. For example,
a therapist informs the client that she should feel comfortable about
asking any questions concerning therapy, evaluation, or intervention.
Therapists may obtain cohistories from family, parents, friends, and
caretakers of children and persons who are unable to communicate or
who have cognitive impairments and are unreliable or questionable
self-reporters. The therapist obtains the following information by
asking the person a variety of questions:

• Age
• Date of injury
• Nature of injury
• Hand dominance
• Goals
• Avocation interests
• Subjective complaints
• Support systems
• Vocation
• Functional abilities
• Family composition
• Social history
• Interventions to date
• Family/caregiver support
 Therapists ask about general health and about prior orthopedic,
neurological, psychological, or cardiopulmonary conditions. 20 Habits
and conditions such as smoking, 51,64 alcohol or drug use,
prescriptions and over-the-counter medications, stress, 20 obesity, 88
and depression 74 may influence rehabilitation. 58 The therapist asks
the client about any previous upper extremity conditions and dates of
onset to assess the current condition. The therapist asks about prior
interventions and their results. The therapist determines the client’s
insight into the condition by asking the client to describe what he or
she understands about the condition or diagnosis.
After background information is gleaned, the client is asked open-
ended questions about the present signs and symptoms. The therapist
asks probing questions about the current condition to gain insight
about the client’s level of irritability. 63 If a client reports minimal pain
at rest, transient pain upon movement, and symptoms that are not
easily provoked, the person is said to have low irritability. If pain is
present upon resting, pain increases with movement, and decreased
mobility is noted, the person has a highly irritable condition.
Determining the irritability level determines how aggressively the
surgeon and therapist may perform evaluations and interventions.

Observation
Observations are noted immediately when the person walks into a
clinic or during the first meeting between the therapist and client. For
example, the therapist observes how the person carries the upper
extremity, looking for reduced reciprocal arm swing, guarding
postures, and involuntary movements, such as tremors or tics. 68 The
therapist notes spontaneous usage of involved upper extremity. Facial
tics may be a sign of a neurological or psychological problem. Further
information is gleaned from observing facial movements, speech
patterns, and affect. For example, if there is a facial droop, the
therapist may suspect that the client has Bell palsy or has had a stroke.
The therapist always observes the person’s ability to answer questions
and follow instructions.
 A general inspection of the person’s upper quarter (including the
neck, shoulder, elbow, forearm, wrist, and hand) and joint attitude is
noted. The therapist notes the posture of the affected extremity and
looks for any postural asymmetry and guarded or protective
positioning. When clients hold a painful extremity with their other
extremity, it is considered a guarded position. Clients often guard to
avoid pain from touching, moving, or bumping into objects. A normal
hand at rest assumes a posture of 10 to 20 degrees of wrist extension,
10 degrees of ulnar deviation, slight flexion and abduction of the
thumb, and approximately 15 to 20 degrees of flexion of the
metacarpophalangeal (MCP) joints. The fingers in a resting posture
exhibit a greater composite flexion to the radial side of the hand
(scaphoid bone) 63 (Fig. 5.1). The thumbnail usually lies perpendicular
to the index finger. Observation of hand postures influences planning
for orthotic provision because a person’s hand often deviates from the
normal resting posture in the presence of injury or disease.
A variety of presentations observed by the therapist contribute to
the overall clinical picture of the person. The following are
noteworthy observational points 63 :

• Position of hand in relationship to the body: protective or

guarding posture
• Diminished or absent reciprocal arm swing
• Quality of movement
• Hand arches and creases
• Muscle atrophy
• Contractures
• Nails: ridged or smooth
• Edema, hematoma (blood clot), ecchymosis (bruise)
• Finger pads: thin or smooth (loss of rugal folds, fingerprint
lines)
• Lesions: scars, abrasions, burns, wounds
• Abnormal web spaces
• Heberden or Bouchard nodes
• Neurological deficit postures: clawhand, wristdrop, simian
 hand
• Color: pale, red, blue
• Grafts or sutures
• External devices: percutaneous pins, external fixator, orthoses,
slings, braces
• Deformities: boutonnière, mallet finger, intrinsic minus hand,
swan neck
• Pilomotor signs: appearance of “goose pimples” or hair
standing on end
• Joint deviation or abnormal rotation

Palpation
After a general inspection of the client, the therapist palpates the
affected areas when appropriate. A therapist palpates areas in which
the person describes symptoms, including any area that is swollen or
abnormal. 68 Muscle bulk is palpated on each extremity to compare
proximal and distal muscles and to compare right and left. Muscle
tone is best assessed through passive range of motion (PROM). When
assessing tone, the therapist coaches the client to relax the muscles so
that the most accurate results are obtained. The client’s skin is
examined. In the presence of ulcers, gangrene, inflammation, or
neural or vascular impairment, skin temperature may change and can
be felt during palpation. 58 In the presence of infection, draining
wounds, or sutured sites, therapists wear sterile gloves and follow
universal precautions.

Assessments
Assessment selection is a critical step in formulating appropriate
interventions. There are more than 100 assessments in the
musculoskeletal literature. 73 Time efficiency has become a
contemporary priority in choosing assessments. For example, in 2015
hand therapists who were members of the American Society of Hand
Therapists were surveyed about sensorimotor interventions and
assessments for the hand and wrist. Of the 22% who responded, 79%
of the therapists believed that occupation-based formal assessments
were important; however, they reported not using them as much as
they wanted due to time constraints in practice. 35 Perhaps more
important than time efficiency are several factors that must be
considered when selecting an assessment, including content,
methodology, and clinical utility. 73 To critically choose appropriate
assessment tools used for practice, one must understand the tool’s
psychometric development.

FIG. 5.1 Resting posture of the hand. A, Normal resting posture. Note
that the fingers are progressively more flexed from the radial aspect to
the ulnar aspect of the hand. B, This normal hand posture is lost
because of contractures of the digits as a result of Dupuytren disease.
C, Loss of the normal hand posture is due to a laceration of the flexor
tendons of the fifth digit.
From Hunter, J. M., Mackin, E. J., & Callahan, A.D. [Eds.]. [1995].
Rehabilitation of the hand: Surgery and therapy [4th ed., p. 55]. St.
Louis, MO: Mosby.
 Content of an assessment is what the tool attempts to measure.
Content is separated into three categories: type, scale, and
interpretation. The type of content focuses on data gathered by the
clinician or data reported by the client. The scale of the content refers
to the measurements or questions that constitute the tool and how
they are measured. Content interpretation addresses how scores or
measures pertain to “excellent” or “poor” outcomes. 73
Methodology of the tool relates to validity, reliability, and
responsiveness. Validity is the extent to which the assessment
measures what it intends to measure. Table 5.1 lists and defines the
various types of validity. Reliability is the consistency of the
assessment. Table 5.2 lists and defines the types of reliability.
Responsiveness refers to the assessment’s sensitivity to measuring
change or differences in status. 73
Clinical utility refers to the degree the tool is easy to administer and
the degree of ease the client experiences in completing the assessment.
Utility is a subjective component addressing the degree to which the
tool is acceptable to the client and the degree to which the tool is
feasible to the therapist. Factors that impact clinical utility include
training for competent administration, cost and administration, and
documentation and interpretation time. 73

TABLE 5.1

Definitions of Types of Validity

Type of
Definition
Validity
Construct The degree to which a theoretical construct is measured by the tool
validity
Content The degree to which the items in a tool reflect the content domain being measured
validity

Face validity Determination if a tool appears to be measuring what it is intended to measure

Criterion The degree to which a tool correlates with a gold standard or criterion test (It can
validity be assessed as concurrent or predictive validity.)

Concurrent The degree to which the scores from a tool correlate with a criterion test when
validity both tools are administered relatively at the same time
 Assessment tools are categorized in several ways. There are
standardized and nonstandardized (informal) assessment tools. Some
assessments are norm based, whereas others are criterion based. Bear-
Lehman and Abreu 3 suggest that evaluation is a quantitative and
qualitative process. Thus therapists who select assessments that solely
produce precise, objective, and quantitative measurement decrease
subjective judgments and increase their ability to obtain reproducible
findings. However, therapists are cautioned to reject the tendency to
neglect important information about their clients that may not be
quantifiable. 3 Qualitative information—such as attitude, pain
response, coping mechanisms, and locus of control (center of
responsibility for one’s behavior)—influence the evaluation process.
“The selection of the hand assessment tools to be used, the art of
human interaction between the therapist and the client, the art of
evaluating the client’s hand as a part, but also as an integrated whole,
are part of the subjective processes involved in hand assessment.” 3
Even objective evaluation tools require the comprehension and
motivation of the client.
Unfortunately, there is no universally accepted upper extremity
assessment tool or battery. Depending on the setting, a battery of
assessments may be developed ad hoc by a facility or department
practitioners. In other settings, therapists use clinical reasoning to
determine what battery of assessments will be used for each person. A
theoretical perspective and a diagnostic population can influence the
evaluation selection. 3 For example, one facility’s assessment reflects a
biomechanical perspective (e.g., goniometry, dynamometry, manual
muscle testing [MMT]), whereas another facility’s assessment reflects
a sensorimotor perspective (e.g., Hand Active Sensation Test,
stereognosis, Arm Dystonia Disability Scale). 78
The sections that follow explore common assessments performed as
part of an upper extremity battery of evaluations. There is a gamut of
assessments for conditions not presented in this text. 46

TABLE 5.2

Definitions of Types of Reliability

Definitions of Types of Reliability
Type of
Definition
Reliability
Interrater The degree to which two raters can obtain the same ratings for a given variable
reliability
Test/retest The degree to which a test is stable based on repeated administrations of the test
reliability to the same individuals over a specified time interval

Internal The degree to which each item of a test measures the same trait
consistency
Intrarater The degree to which one rater can reproduce the same score in administering the
reliability tool on multiple occasions to the same individual

Pain
Several options for evaluating pain exist, including interview
questions, rating scales, body diagrams, and questionnaires. Box 5.1
lists questions related to pain that can be asked of the client. 25
Therapists often use a combination of pain measures to obtain an
accurate representation of the client’s pain. 39
The verbal analog scale (VeAS) is used to determine the person’s
perception of pain intensity. The client rates pain on a scale from 0 to
10 (0 refers to no pain, and 10 refers to the worst pain ever
experienced). Reliability scores for retesting under the VeAS are
moderate to high, ranging from 0.67 to 0.96. 29,34 When correlated with
the visual analog scale (ViAS), the VeAS had a reliability score of 0.79
to 0.95. 29,34 Finch and colleagues 29 reported that a three-point change
in score is necessary to establish a true pain intensity change. Thus the
VeAS may be limited to detecting small changes, and clients with
cognitive deficits may have trouble following instructions to complete
the VeAS. 29,30

a
BOX 5.1 Assessment Questions Relating to Pain
Location and Nature of Pain
 • Where do you feel uncomfortable (pain)?
• Does your discomfort (pain) feel deep or superficial?
• Is your problem (pain) constant or intermittent? If constant, does
it vary in intensity?
• How long does your discomfort (pain) last?
• What is the frequency of your discomfort (pain)?
• How long have you had this problem (pain)?
• Are you experiencing discomfort (pain) right now?

Pain Manifestations
• How would you describe your discomfort (pain): throbbing,
aching/sharp, dull, electrical, and so on?
• Does the discomfort (pain) move or spread to other areas?
• Does movement aggravate the discomfort (pain)?
• Do certain positions aggravate the discomfort (pain)? If yes, can
you show me the movement or postures that cause the
discomfort (pain)?
• Do you have stiffness with your discomfort (pain)?
• Do you have discomfort (pain) at rest?
• Do you have discomfort (pain) during the morning or night?
• Does the discomfort (pain) wake you from sleep?
• Do you have discomfort (pain) during particular activities?
• Do you experience discomfort (pain) after performing particular
activities?
• What makes your discomfort (pain) worse?
• What helps relieve your discomfort (pain)?
• What have you tried to reduce your discomfort (pain)?
• What worked to reduce your discomfort (pain)?
a
Therapists working with persons experiencing chronic pain may
find that focusing on pain and repeating the word pain over and
over is not beneficial. Therapists may select questions according
to their judgment and substitute alternative words for pain when
necessary.

A ViAS is also used to rate pain intensity. A client refers to a 10-cm

horizontal line, with the left side of the line representing “no pain”
and the right side representing “pain as bad as it could be.” The client
indicates pain level by marking a slash on the line, which represents
the pain experienced. The distance from no pain to the slash is
measured and recorded in centimeters (Fig. 5.2). The ViAS “may have
a high failure rate because patients may have difficulty interpreting
the instructions.” 87 Some errors occur due to changes in length of the
line resulting from photocopying. 39 The VeAS and ViAS are
unidimensional assessments of pain (i.e., intensity). 39 Although test-
retest is not applicable to self-reported measures, researchers
demonstrated a high range of test-retest reliability (intraclass
correlation coefficient [ICC] = 0.71 to 0.99). 22,29,34 When compared
with the VeAS, concurrent validity measures ranged from 0.71 to 0.78.
22
A body diagram consists of outlines of a body with front and back
views (Fig. 5.3). The client is asked to shade or color in the location of
pain that corresponds to the painful body part. Colored pencils
corresponding to a legend can be used to represent different
intensities or types of pain, such as numbness, pins and needles,
burning, aching, throbbing, and superficial.
Self-report questionnaires are commonly used. Questionnaires such
as the Short Form-36 (SF-36), Disabilities of the Arm, Shoulder, and
Hand (DASH), and disease- or condition-specific questionnaires exist.
25
Therapists may use a more formal pain assessment, such as the
McGill Pain Questionnaire (MPQ) 26 or the Schultz Pain Assessment.
87 Although formal assessments usually take more time to administer

than screening tools, they comprehensively assess many aspects of

pain and may provide important information related to the person’s
diagnosis, intervention needs, and prognosis. 60
Melzack 49 developed the MPQ, which is widely used in clinical
practice and for research purposes. The MPQ consists of a pain rating
index, total number of word descriptors, and a present pain index. In
its original version the MPQ required 10 to 15 minutes to administer.
The MPQ is a valid and reliable assessment tool. High internal
consistency within the MPQ exists with correlations of 0.89 to 0.90. 49
Test-retest reliability scores for the MPQ are reported as 70.3%. 49

FIG. 5.2 The visual analog scale (ViAS) and an example of a

completed ViAS with a score of 7.5.

For assessment of pediatric pain, self-reporting measures are

considered the gold standard. 55 A therapist determines the child’s
concepts of quantification, classification, and matching before
administering simple pain intensity scales. 13 Nonverbal scales using
facial expressions and the ViAS are commonly used. Children’s ability
to report pain is affected by their stage in child development. Table 5.3
outlines ages and recommendations associated with the various types
of reporting in children.

Skin
A thorough examination of the surface condition and contour of the
extremity may define possible pathological conditions, which may
influence orthotic design. During the examination the therapist
observes and documents the skin’s color, temperature, and texture.
The therapist observes the skin for muscle atrophy, scarring, edema,
hair patterns, sweat patterns, and abnormal masses. Clients with
fragile skin (especially persons who are older, who have been taking
steroids for a long time, or who have diabetes) require careful
monitoring. For these persons the therapist carefully considers the
orthotic material to prevent harm to the already fragile skin (see
Chapter 16).
 FIG. 5.3 Example of a body diagram.

TABLE 5.3

Children’s Report of Pain

Children’s Report of Pain
Age Report
2 years Presence and location of pain

3 to 4 Presence, location, and intensity of pain

years
3 years old: Use a three-level pain intensity scale4 years old: Use a four- to five-item
scale
5 years Begin to use pain rating scales

8 years Rate quality of pain

Data from O’Rourke, D. (2004). The measurement of pain in infants,

children, and adolescents: from policy to practice. Physical Therapy, 84,
560–570.

Regarding skin, most adult clients are aware if they have skin
allergies. Some are allergic to bandages, adhesive, and latex (all of
which can be used in the orthotic process). To avoid skin reactions, the
therapist asks each client to disclose any types of allergy before
choosing orthotic materials. When persons are unsure of skin
allergies, the therapist should be aware that thermoplastic material,
padding, and strapping supplies may create an allergic reaction.
Therapists educate persons to monitor for any rashes or other skin
reactions that develop from wearing an orthosis. The client
experiencing a reaction should generally discontinue wearing the
orthosis and report immediately to the therapist.

Scars
Scarring often results after burns, trauma, and surgical procedures.
Scars have the potential for devastating impacts on function.
Numerous scales exist to measure scars and scarring: Patient and
Observer Scar Assessment Scale, Manchester Scar Scale, Modified
Vancouver Scar Scale, Stony Brook Scar Evaluation Scale, and Patient
Scar Assessment Questionnaire. 24,56 Most of these subjective scar
assessment scales consider factors such as scar height or thickness,
surface area, pliability, texture, pigmentation, and vascularity. It
should be noted that these scar assessments are limited in use for
studying large scars and for assessing the function effects of scars. 24,56

Veins and Lymphatics

Normally the veins on the dorsum of the hand are easy to see and
palpate. They are cordlike structures. Any tenderness, pain, redness,
or firmness along the course of veins is noted. 58 Venous thrombosis,
subcutaneous fibrosis, or lymphatic obstruction causes edema. 53

Wounds
An assessment of wounds generally includes the size, depth, color,
drainage (exudate), and odor. The therapist measures wound or
incision size (usually in centimeters) and assesses discharge from
wounds for color, amount, and odor. If there is concern about the
discharge being a sign of infection, a wound culture is obtained by the
medical staff to identify the source of infection, and appropriate
medication is prescribed. Such warning signs of potential infection
include yellow or green drainage, foul odor, and increased
temperature of the skin surface. 40
Wounds are classified by color: black, yellow, or red. 16 A black
wound consists of dark, thick eschar, which impedes epithelialization.
A yellow wound ranges in color from ivory to green-yellow (e.g.,
colonization with Pseudomonas). Typically, yellow wounds are covered
with purulent discharge. A red wound indicates the presence of
granulation tissue and is normal. Red wounds should be protected
from mechanical forces, such as tapes, dressings, whirlpool agitation,
and so on. 81
Many wounds consist of a variety of colors. 16 Intervention focuses
on treating the most serious color initially. For example, in the
presence of eschar (common after thermal and crush injuries) a
wound takes on a white or yellow-white color. Part of the intervention
regimen for eschar is mechanical, chemical, or surgical debridement,
which usually must be done before orthotic prescription. Debridement
may result in a yellow wound. The yellow wound is managed by
cleansing and dressing techniques to assist in the removal of debris.
Once the desired red wound bed is achieved, it is protected by
dressings. 83
Because open wounds threaten exposure to the person’s body
fluids, the therapist follows universal precautions. The following
precautions were derived from the Centers for Disease Control and
Prevention (CDC) 65 :

• Wear gloves for all procedures that may involve contact with
body fluids.
• Change gloves after contact with each person.
• Wear masks for procedures that may produce aerosols or
splashing.
• Wear protective eyewear or face shields for procedures
generating droplets or splashing.
• Wear gowns or aprons for procedures that may produce
splashing or contamination of clothing.
• Wash hands immediately after removal of gloves and after
contact with each person.
• Replace torn gloves immediately.
• Replace gloves after punctures, and discard the instrument
causing the puncture.
• Cleanse areas of skin with soap and water immediately if
contaminated with blood or body fluids.
• Make available mouthpieces, resuscitation bags, and other
ventilatory devices for resuscitation to reduce the need for
mouth-to-mouth resuscitation techniques.
• Take extra care when using sharps (especially needles and
scalpels).
• Place all used disposable sharps in puncture-resistant
containers.

Many upper extremity injuries result in wounds, whether from

trauma or surgery. Therefore therapists must know the stages of
wound healing. The healing of wounds is a cellular process. 81 Experts
identified three overlapping stages, 69,70,81 which consist of the (1)
inflammatory or epithelialization, (2) proliferative or fibroblastic, and
(3) maturation and remodeling phases. 69,70,81
The first stage of wound healing is the inflammatory (exudative)
phase, 69,70,72,81 which begins immediately after trauma and lasts 3 to 6
days in a clean wound. Vasoconstriction occurs during the first 5 to 10
minutes, leading to platelet adhesion of the damaged vessel wall and
resulting in clot formation. This activity stimulates fibroblast
proliferation. During the inflammatory phase for a repaired tendon,
cells proliferate on the outer edge of the tendon bundles during the
first 4 days. 71 By day 7, these cells migrate into the substance of the
tendon. In addition, there is vascular proliferation within the tendon,
which provides the basis for intrinsic tendon healing. 18 Extrinsic
repair of the tendon occurs when the adjacent tissues provide
collagen-producing fibroblasts and blood vessels. 45 Fibrovascular
tissue that infiltrates from tissues surrounding the tendon can become
future adhesions. Adhesions prevent tendon excursion if allowed to
mature with immobilization. 71
The second stage of wound healing is the fibroblastic (reparative)
phase, which begins 2 to 3 days after the injury and lasts
approximately 2 to 6 weeks. 69,70,72,81 During this stage, epithelial cells
migrate to the wound bed. Fibroblasts begin to multiply 24 to 36 hours
after the injury. The fibroblasts initiate the process of collagen
synthesis. 81 The fibers link closely and increase tensile strength. A
balanced interplay between collagen synthesis and its remodeling and
reorganization prevents hypertrophic scarring. During tendon healing
the proliferative phase begins by day 7 and is marked by collagen
synthesis. 18 In a tendon repair where there is no gap between the
tendon ends, collagen appears to bridge the repair. 71 Collagen fibers
and fibroblasts are initially oriented perpendicularly to the axis of the
tendon. However, by day 10 the new collagen fibers begin to align
parallel to the longitudinal collagen bundles of the tendon ends. 45
The final stage is the maturation (remodeling) phase. This phase is
seen typically after day 21 and can last up to 1 or 2 years after the
injury. 69–71,81 During the maturation stage the tensile strength
continually increases. Initially the scar may appear red, raised, and
thick, but with maturation a normal scar softens and becomes more
pliable. The maturation phase for healing tendons is lengthier than the
time needed for skin or muscle because the blood supply to the
tendons is much less. 71 Tendon strength increases in a predictable
fashion. 71 Smith 71 points out that in 1941 Mason and Allen first
described how tensile strength of a repaired tendon progresses. From
3 to 12 weeks after tendon repair, mobilized tendons appear to be
twice as strong as immobilized tendons. At 12 weeks, immobilized
tendons have approximately 20% of normal tendon strength. In
comparison, mobilized tendons at 12 weeks have 50% of normal
tendon strength.

Bone
When assessing a person who has a skeletal injury, the therapist
reviews the surgery and radiology reports. The therapist places
importance on knowing the stability level of the fracture reduction,
the method the physician used to maintain good alignment, the
amount of time since the fracture’s repair, and fixation devices present
in the upper extremity. A physician may request that a therapist
fabricate an orthotic after the fracture heals. On occasion the therapist
may fabricate a custom orthosis or use a commercial fracture brace to
stabilize the fracture before healing is complete. For example, for a
person with a humeral fracture a commercially available humeral cuff
may be prescribed.
The rationale for using a commercially fabricated fracture brace
rather than fabricating a custom orthosis is based on time, client
comfort, ease of application, and cost. Custom fabrication of fracture
braces can be challenging, because the client is typically in pain and
the custom orthosis involves the use of large pieces of thermoplastic
material, which can be difficult to control and often require more than
one person to apply. A commercial fracture brace saves the therapist’s
time and therefore minimizes expense. A commercial brace reduces
donning and doffing for fitting, which may be uncomfortable for the
client. Indications for fabricating a custom fracture brace include
bracing extremely small or large extremities.

Joint and Ligament

Joint stability is important to assess and is evaluated by carefully
applying a manual stress to any specific ligament. Each digital
articulation achieves its stability through the collateral ligaments and
a dense palmar plate. 9 The therapist carefully assesses the continuity,
length, and glide of these ligaments. Joint play or accessory motion of
a joint is assessed by grading the elicited symptoms upon passive
movement. The grading system is as follows 82 :

• 0 = Ankylosis
• 1 = Extremely hypomobile
• 2 = Slightly hypomobile
• 3 = Normal
• 4 = Slightly hypermobile
• 5 = Extremely hypermobile
• 6 = Unstable

Unstable joints, subluxations, dislocations, and limited PROM

directly affect orthotic provision. Lateral stress on finger joints should
be avoided. The person may wear an orthosis to prevent unequal
stress on the collateral ligaments. 11

Muscle and Tendon

Tensile strength is the amount of long-axis force a muscle or tendon
can withstand. 28 When a tendon is damaged or undergoes surgical
repair, tensile strength directly affects the amount of force an orthosis
exerts. Tensile strength mandates which exercises or activities a
person can safely perform.
Proximal musculature affects distal musculature tension in persons
experiencing spasticity. For example, wrist position influences the
amount of tension placed on finger musculature. When the therapist
attempts to increase wrist extension in the presence of spasticity, the
wrist, hand, and fingers must be incorporated into the orthotic design.
If the orthotic design addresses only wrist extension, the result may be
increased finger flexion. Conversely, if the orthotic design addresses
only the fingers, the wrist may move into greater flexion.

Nerve
Sensory evaluations determine areas of diminished or absent
sensibility. Conventional tests for protective sensibility include the
sharp/dull and hot/cold assessments. Discriminatory sensibilities
include assessment for stereognosis, proprioception, kinesthesia,
tactile location, and light touch. Two-point discrimination testing is
recommended as a quick screening for sensibility 10 (Fig. 5.4). Two-
point discrimination testing is most accurate on the fingertips. 81 In
addition, the American Society for Surgery of the Hand 2 recommends
static and moving two-point discrimination tests. The Semmes-
Weinstein Monofilament Test results in detailed mapping of the level
of functional sensibility, particularly during rehabilitation of
peripheral nerve injury (Fig. 5.5). This mapping is useful to
physicians, therapists, clients, case managers, and employers. 76 The
Semmes-Weinstein Monofilament Test is the most reliable sensation
test available and is often used as the comparison for concurrent
validity studies. 17
Therapists searching for objective sensory assessment data should
be aware that “tests that were considered objective in the past can be
demonstrated to be subjective in application dependent on the
technique of the examiner.” 5,6 For example, when administering the
Semmes-Weinstein Monofilament Test, if the stimulus is applied too
quickly, “the force can result in an overshoot beyond the desired
stimulus” 6 and affect the test results. In addition, even when the
Semmes-Weinstein Monofilament Test is administered with excellent
technique, the cooperation and comprehension of the client are
required.
Various screen tests assist the therapist in gathering information
about suspected peripheral nerve issues (Table 5.4). When peripheral
nerve injuries have occurred or are suspected, a Tinel test can be
conducted. A Tinel test can be performed in two ways. The first
method involves gently tapping over the suspected entrapment site to
help determine whether entrapment is present. The second method
consists of tapping the nerve distal to proximal. The location where
the paresthesias are felt is considered the level to which a nerve has
regenerated after Wallerian degeneration (i.e., degeneration of the
axon terminal) has occurred. A person has a positive Tinel sign if
tingling or shooting sensations in one of two areas occurs (1) at the site
of tapping or (2) in a direction distal from the tapped area. 58 If the
person experiences paresthesia or hyperparesthesia in a direction
proximal to the tapped area, the Tinel test is negative.
A Phalen sign is present if a person feels similar symptoms to a
positive Tinel test while resting elbows on the table and flexing the
wrists for 15 to 60 seconds. 66 Phalen sign may indicate a median
nerve problem. Tinel and Phalen signs can be positive in normal
subjects. 68
A Froment sign is a positive test outcome when a client is asked to
forcibly hold a piece of paper between the thumb and the radial side
of the index finger—so that the person is “pulling the paper” in
opposite direction. A positive Froment sign is noted in the thumb’s
position of flexion at the interphalangeal (IP) joint. Similar to the
Froment sign is the Jeanne sign. The Jeanne sign is positive when the
client is asked to pinch the tips of the index and thumb and the
position of the thumb presents with IP flexion and MP joint
hyperextension. Comparisons to both hands is important to conduct
(see Chapter 14).
Cervical nerve problems are ruled out before a diagnosis of
peripheral nerve injury is made. 48 For example, a person may have
signs similar to carpal tunnel syndrome in conjunction with
complaints of neck pain. In the absence of a cervical nerve screen, the
person may be misdiagnosed with carpal tunnel syndrome when the
cause of the problems is actually cervical nerve involvement. In the
absence of electrical studies, some physicians mistakenly make the
diagnosis of peripheral nerve compression.
 FIG. 5.4 The recommended instruments for testing two-point
discrimination include the Boley gauge (A) and the Disk-Criminator (B).
From Hunter, J. M., Mackin, E. J., & Callahan, A.D. [Eds.]. [1995].
Rehabilitation of the hand: Surgery and therapy [4th ed., p. 146]. St.
Louis, MO: Mosby.
 FIG. 5.5 The monofilament collapses when a force dependent on
filament diameter and length is reached, controlling the magnitude of
the applied touch pressure.
From Hunter, J. M., Mackin, E. J., & Callahan, A.D. [Eds.]. [1995].
Rehabilitation of the hand: Surgery and therapy [4th ed., p. 76]. St.
Louis, MO: Mosby.

TABLE 5.4

Screen Tests for Suspected Nerve Conditions

Name of
Test Position Positive Test Outcome
Screen Test
Tinel sign 1. Gently tapping over the suspected entrapment Tingling, numbness,
site paresthesia distal to area
2. Tapping the nerve pathway distal to proximal tapped
Phalen sign With the client resting elbows on the table and Tingling, numbness,
flexing the wrists for 15 to 60 seconds paresthesias in thumb, index
and radial side of middle
 finger (median nerve)
Froment With the client forcibly holding a piece of paper Thumb IP flexion
sign between the thumb and the radial side of the index
finger—so that the person is pulling the paper in
opposite directions
Jeanne sign With the client pinching the tips of the index and Thumb IP flexion with MCP
thumb hyperextension
IP, Interphalangeal; MCP, metacarpophalangeal.

During the fitting process, hand orthoses may cause pressure and
friction on vulnerable areas with impaired sensibility. If a person has
decreased sensibility, the therapist uses an orthotic design with long,
well-molded components. The reason for using such an orthosis is to
distribute the forces of the orthosis over as much surface area as
possible, thereby decreasing the potential for pressure areas.
When an orthosis is placed across the wrist, the superficial branch
of the radial nerve is at risk for compression. If the radial edge of the
forearm orthosis stops beyond the midlateral forearm near the
dorsum of the thumb, the superficial branch of the radial nerve can be
compressed. 11 During the evaluation of orthotic fit, therapists should
be aware of the signs of compression of the superficial branch of the
radial nerve. Orthoses that cause compression require adjustments to
decrease the pressure near the dorsum of the thumb.

Vascular Status
To understand the vascular status of a diseased or injured hand, the
therapist monitors the skin’s color (i.e., red, pale, or cyanotic) and
temperature and checks for edema. The therapist clearly defines areas
of questionable tissue viability and adapts orthoses to prevent
obstruction of arterial and venous circulation. To assess radial and
ulnar artery patency, the therapist uses an Allen test. The Allen test is
performed by having the client open and close the hand to
exsanguinate it while the therapist occludes the radial and ulnar
arteries by applying pressure on them at the wrist. The client opens
the hand until it appears white and blanched. The therapist then
releases the pressure on either the radial or ulnar artery, looking for
revascularization evidenced by a change in color from white to pink
of the hand. If the hand does not flush with the pink color, the artery
is occluded 63 (Fig. 5.6).
A therapist can take circumferential measurements proximal and
distal to the location of orthotic application. Then, after applying the
orthosis to the extremity, the therapist measures the same areas and
compares them with the previous measurements. An increase in
measurements taken while the orthosis is on indicates that the
orthosis is exerting too much force on the underlying tissues. This
situation poses a risk for circulation. When fluctuating edema is
present, the therapist should make the orthotic design larger. A well-
fitting circumferential orthosis, sometimes in conjunction with a
pressure garment, can control or eliminate fluctuating edema. In
addition, fluctuating edema may signal poor compliance with
elevation. A sling and education about its use may assist in edema
control.
The therapist can also use the Fingernail Blanch Test to assess
circulation. 63 Long-lasting blanched areas of the fingertips indicate
restricted circulation.
When a therapist applies an orthosis to the upper extremity, the
skin should maintain its natural color. Red or purple areas indicate
obstructed venous circulation. Dusty or white areas indicate
obstructed arterial circulation. Orthoses causing circulation problems
must be modified or discontinued.

Range of Motion and Strength

The therapist records active and passive motions when no
contraindications are present (Fig. 5.7) and takes measurements on
both extremities for a baseline data comparison. The therapist records
total active motion (TAM) and total passive motion (TPM). 63 Grasp
and pinch strengths are completed and documented only when no
contraindications are present (Figs 5.8 and 5.9). MMT assesses muscle
strength but should be done only when there are no contraindications.
For example, if a person with rheumatoid arthritis in an exacerbated
state is being evaluated, MMT should be avoided to prevent further
exacerbation of pain and swelling.
 FIG. 5.6 The Allen test for arterial patency.
From Skirven, T. M., Osterman, A. L., Fedorczyk, J. M., et al. [Eds.].
[2011]. Rehabilitation of the hand and upper extremity [6th ed., p. 69].
St. Louis, MO: Mosby.

FIG. 5.7 Goniometric measurements of active and passive motion are

taken regularly when no contraindications are present.
From Hunter, J. M., Mackin, E. J., & Callahan, A.D. [Eds.]. [1996].
Rehabilitation of the hand: Surgery and therapy [4th ed., p. 34]. St.
Louis, MO: Mosby.
Coordination and Dexterity
Hand coordination and dexterity are needed for many functional
performance tasks, and it is important to evaluate them. Many
standardized tests for coordination and dexterity exist, including the
Nine Hole Peg Test (Fig. 5.10), Minnesota Rate of Manipulation Test
(MRMT), Crawford Small Parts Dexterity Test, Purdue Pegboard Test,
Rosenbusch Test of Dexterity, and Valpar Component Work Samples
(VCWS) tests. Most dexterity tests are based on time measurements,
and normative data are available for these tests. In particular, the
VCWS uses a methods time measurement (MTM). MTM is a method
of analyzing work tasks to determine how long a trained worker
requires to complete a certain task at a rate that can be sustained for
an 8-hour workday.
The Sequential Occupational Dexterity Assessment (SODA) was
developed in the Netherlands. 79 The SODA is a test to measure hand
dexterity and the client’s perception of difficulty and pain while
performing four unilateral and eight bilateral activity of daily living
(ADL) tasks. 47 The authors of a study conducted on 62 clients with
rheumatoid arthritis concluded that “The SODA is also valid and
reliable for assessing disability in a clinical situation that cannot be
generalized to the home.” 47 More research is needed to test such
findings.
 FIG. 5.8 Therapists use the Jamar dynamometer to obtain reliable
and accurate grip strength measurements.
From Tubiana, R., Thomine, J. M., & Mackin, E. [1996]. Examination of
the hand and wrist [p. 344.]. St. Louis, MO: Mosby.

FIG. 5.9 The pinch meter measures pulp pinch (A) and lateral pinch
(B).
From Tubiana, R., Thomine, J. M., & Mackin, E. [1996]. Examination of
the hand and wrist [p. 344.]. St. Louis, MO: Mosby.
 FIG. 5.10 The Nine Hole Peg Test is a quick test for coordination.
From Hunter, J. M., Mackin, E. J., & Callahan, A.D. [Eds.]. [1996].
Rehabilitation of the hand: Surgery and therapy [4th ed., p. 1158]. St.
Louis, MO: Mosby.

Function
Function is assessed by observation, interview, task performance, and
standardized testing. Close observation during the interview and
orthotic fabrication gives the therapist information regarding the
person’s views of the injury and impairment. The therapist observes
the person for protected or guarded positioning, abnormal hand
movements, muscle substitutions, spontaneous movement and pain
involvement during functional tasks. During evaluation the person’s
willingness for the therapist to touch and move the affected extremity
is noted.
During the initial interview the therapist questions the person about
the status of ADLs, instrumental activities of daily living (IADLs), and
avocational and vocational activities. The therapist notes problem
areas. Having clients perform tasks as part of an evaluation may result
in more detailed information, particularly when self-reporting
accuracy is questioned by the therapist.
 The therapist may use standardized hand function assessments. The
Jebsen-Taylor Hand Function Test results in objective measurements
of standardized tasks with norms the therapist uses for comparison
(Fig. 5.11). 38 The Dellon modification of the Moberg Pick-up Test
evaluates hand function when the person grasps common objects (Fig.
5.12). 50 Similar objects in the test require the person to have sensory
discrimination and prehensile abilities. 10
Other outcome and occupation-based assessments recommended
for assessment of upper extremity injuries or conditions include the
Canadian Occupational Performance Measure (COPM), the DASH,
the SF-36, the Patient Specific Functional Scale, Handwriting
Assessment Battery (HAB), and Manual Ability Measure (MAM).
35,41,75,86

FIG. 5.11 The Jebsen-Taylor Hand Test assesses the ability to

perform prehension tasks.
 From Hunter, J. M., Mackin, E. J., & Callahan, A.D. [Eds.]. [1996].
Rehabilitation of the hand: Surgery and therapy [4th ed., p. 98]. St.
Louis, MO: Mosby.

FIG. 5.12 Items used in the Dellon modification of the Moberg Pick-up
Test.
From Hunter, J. M., Mackin, E. J., & Callahan, A.D. [Eds.]. [1996].
Rehabilitation of the hand: Surgery and therapy [4th ed., p. 608]. St.
Louis, MO: Mosby.

The COPM is a client-centered outcome measure used to assess self-

care, productivity, and leisure. 43 Clients rate their performance and
satisfaction with performance on a 1- to 10-point scale. The result is a
weighted individualized client goal plan. 42 The COPM is a top-down
assessment, which is completed before administration of tests to
evaluate performance components. Test-retest reliability was reported
as ICC = 0.63 for performance and ICC = 0.84 for satisfaction—as cited
in Case-Smith, “Validity was estimated by correlating COPM change
scores with changes in overall function as rated by caregivers (r = 0.55,
r = 0.56), therapist (r = 0.30, r = 0.33), and clients (r = 0.26, r = 0.53).”
12,62 The COPM may take more time to administer than other tools. In

addition, therapists administering the COPM should be trained in its

administration, scoring, and interpretation.
The DASH is a standardized questionnaire rating disability and
symptoms related to upper extremity conditions. 19 The measure is
available as a QuickDASH (11 items) as well as a longer version,
DASH (30 items). The DASH includes 30 predetermined questions
that explore function within performance areas. The client rates
current ability to complete particular skills, such as opening a jar or
turning a key, on a scale of 1 (no difficulty) to 5 (unable). Beaton and
colleagues 4 studied reliability and validity of the DASH. Excellent
test-retest reliability was reported (ICC = 0.96) in a study of 86 clients.
Concurrent validity was established with correlations with other pain
and function measures (r > 0.69). Internal consistency is reported at
<0.95, indicating no item redundancy. 32 The full DASH, due to its
greater precision, is recommended when therapists wish to monitor
pain and function. 19
The SF-36 measures eight aspects of health that contribute to quality
of life. 85 The SF-36 “yields an eight scale profile of functional health
and well-being scores, as well as psychometrically based physical and
mental health summary measures and a preference based health
utility index.” 85 Reliability scores range from r = 0.43 to r = 0.96. 8
Evidence of content, concurrent, criterion, construct, and predictive
evidence of validity have been established. 84 The tool has been
translated for use in more than 60 countries and languages.
The Patient Specific Functional Scale (PSFS) is a self-report measure
that was developed to elicit and record functional issues that are
important to the client. 77,89 The instrument takes 4 minutes to
complete and is easy to administer. 59 Clients identify three activities
they have difficulty in performing. Then clients rate their current lives
of difficulty associated with each of the three activities. The scoring
uses an 11-point scale from 0 (unable to perform the activity) to 10
(able to perform at the same level as before the injury/problem). The
PSFS is available in several languages 44,59 and appears to have good
ability to detect clinical change in clients with a variety of
musculoskeletal diagnoses. 1,15,31,36,77
The HAB consists of three sections with items from eight subtests. 23
Each subtest results in a profile of performance related to pen control
and manipulation, writing speed, and legibility. Administration of the
HAB requires approximately 20 minutes and another 15 minutes to
score. Although the HAB demonstrates excellent interrater reliability,
further testing is needed.
The MAM is available in two versions: MAM-16 (16 items) and
MAM-36 (36 items). 13,14,57 The MAM is occupation based in that the
assessment items are everyday tasks, such as eating a sandwich,
cutting meat, and wringing a towel. Clients use a 4-point ordinal
rating scale that asks how easy or hard it is to perform such tasks (1 =
cannot do, 2 = very hard, 3 = a little hard, 4 = easy). Administration
takes approximately 15 minutes. The MAM-36 is appropriate to use
with clients who have neurological and musculoskeletal disorders. 13
Research indicates that MAM-36 outcomes positively correlate with
improvements in task performance speeds and grip strength. 14
Therapists are interested in determining if any changes in function
are made during intervention. Decisions to continue therapy (with
implications for reimbursement) include if the client is progressing.
Thus the assessments chosen must be sensitive to note the changes
over time. For example, in a study of three patient report outcome
(PRO) measures in persons with hand fractures, the ability to describe
functional limitations in a client cohort were found. 86 The DASH and
Michigan Hand Outcomes Questionnaire (MHQ) were each able to
articulate the functional limitations in the cohort of patients with hand
fractures during a 2-month time frame.

Work
Evaluations of paid and unpaid work entail assessment of the work to
be done and how the work is performed. 52 It is estimated that 36% of
all functional capacity evaluations (FCEs) are conducted because of
upper extremity and hand injuries. 52 Some facilities use a specific
type of FCE system, such as the Blankenship System or the Key
Method. Standardized testing includes the Work Evaluations Systems
Technologies II (WEST II), the EPIC Lift Capacity (ELC), the Bennett
Hand Tool Dexterity Test, the Purdue Pegboard, the MRMT, and the
VCWS. Commercially available computerized tests can be
administered in work evaluations. Isometric, isoinertial, and isokinetic
tests can be performed on equipment tools manufactured by Cybex,
Biodex, and Baltimore Therapeutic Equipment (BTE). FCEs frequently
assess abnormal illness behavior and often include observation,
psychometric testing, and physical or functional testing. New and
experienced therapists should have specialized training in
administering and interpreting FCEs because of the standardized
nature of the examination and the legal implications of these
assessments. 41

Other Considerations
The person’s motivation, health literacy, ability to understand and
carry out instructions, and adherence may affect the type of orthosis
the therapist chooses and how client education is provided. The tools
available to assess health literacy are plentiful. 54,67,90 The Health
Literacy Tool Shed 37 (http://healthliteracy.bu.edu) is an example of
one website that contains health literacy tools, measures, instruments,
and items. Other resources online exist.
The therapist considers a person’s vocational and avocational
interests when designing an orthosis. Some persons wear more than
one orthosis throughout the day to allow for completion of various
activities. Particularly for athletes, orthotic designs are impacted by
sport regulations and team physicians. 61 Athletes may wear one
orthosis during play and a different orthosis when not playing. In
addition, some persons wear one orthotic design during the day and a
different design at night.
Related to client motivation during rehabilitation may be the
presence or absence of a third-party payment source. Whenever
possible, the therapist discusses payment issues with the client before
completing the initial visit. If a third party is paying for the client’s
services, the therapist first determines whether that source intends to
pay for any orthotic fabrication services. At times, some clients are
very motivated to adhere to the rehabilitation program if they self-pay
for the services. In other cases, when third-party reimbursement is
quite good and the client is temporarily on a medical leave from work,
the client may be less motivated and perhaps show signs of abnormal
illness behavior. Terms such as malingering, secondary gain,
hypochondriasis, hysterical neurosis, conversion, somatization disorder,
functional overlay, and nonorganic pain have been used to describe
abnormal illness behaviors. 52 With clients who appear to have
obvious psychological issues, the therapist contacts the client’s
physician for a possible referral to appropriate psychological
professionals. Gatchel and colleagues 33 reported the following red
flags, which can assist the therapist in identifying such abnormal
behaviors 7 :

• Client agitates other clients with disruptive behaviors.

• Client has no future work plan or changes to previous work
plan.
• Client is applying for or receiving Social Security or long-term
disability.
• Client opposes psychological services and refuses to answer
questions or fill out forms.
• Client has obvious psychosis.
• Client has significant cognitive or neuropsychological deficits.
• Client expresses excessive anger at persons involved in case.
• Client is a substance abuser.
• Client’s family is resistant to his or her recovery or return to
work.
• Client has young children at home or has a short-term work
history for primarily financial reasons.
• Client perpetually complains about the facility, staff, and
 program rather than being willing to deal with related
physical and psychological issues.
• Client is chronically late to therapy and is noncompliant with
excuses that do not check out.
• Client focuses on pain complaints in counseling sessions
rather than dealing with psychological issues.
Post–Orthotic Provision Evaluation and
Follow-Up
After the client has undergone the assessment process, intervention
may include the provision of an orthosis. After the orthosis is
fabricated, the therapist engages in an evaluation process of the
orthosis. The orthotic evaluation includes determining orthotic
precautions that must be relayed to the client via education. The
therapist must ensure that the client understands the importance of
the wearing regimen. The client must know how to care for the
orthosis and identify any warning signs that follow-up care is needed
from the therapist.
Orthotic Precautions
During the orthotic assessment, the therapist is aware of orthotic
precautions. An ill-fitting orthosis can harm a person. Several
precautions are outlined in Form 5.2, which a therapist uses as a
check-off sheet. The therapist must not only educate a client about
appropriate precautions but evaluate the client’s understanding of
them (i.e., health literacy—see Chapter 6). The client’s understanding
can be assessed by having him or her repeat important precautions to
follow or by role-playing (e.g., “If this happens, what will you do?”).
In follow-up visits the client can be questioned again to determine
whether precautions are understood. Form 5.3 lists orthotic fabrication
hints to follow. Adherence to the hints assists in avoiding situations
that result in clients experiencing problems with their orthoses.

Pressure Areas
After fabricating an orthosis, the therapist does not allow the person
to leave until the orthosis has been evaluated for problem areas. A
general guideline is to have the person wear the orthosis at least 20 to
30 minutes after fabrication. Red areas should not be present 20
minutes after removal of the orthosis. Orthoses often require some
adjustment. After receiving assurance that no pressure areas are
present, the therapist instructs the person to remove the orthosis and
to call if any problems arise. Persons with fragile skin are at high risk
of developing pressure areas. The therapist provides the person with
thorough written and verbal instructions on the wear and care of the
orthosis. The instructions should include a phone number for
emergencies. During follow-up visits, the therapist makes inquiries
about the orthotic fit to determine whether adjustments are necessary
in the design or wearing schedule.

Edema
The therapist completes an evaluation for excessive tightness of the
orthosis or straps. Often edema is caused by inappropriate strapping,
especially at the wrist or over the MCP joints. Strapping systems are
evaluated and modified if they are contributing to increased edema. If
the orthosis is too narrow, it may also inadvertently contribute to
increased edema. Persons can usually wear orthoses over pressure
garments if necessary. However, therapists must monitor circulation
closely.
The therapist assesses edema by taking circumferential or
volumetric measurements (Fig. 5.13). 80 When taking volumetric
measurements, the therapist administers the test according to the
testing protocol and then compares the involved extremity
measurement with that of the uninvolved extremity. If edema
fluctuates throughout the day, it is best to fabricate the orthosis when
edema is present to ensure that the orthosis accommodates the edema
fluctuation. When edema is minimal but changes during the day, the
orthotic design must be wider to accommodate the fluctuating edema.
11

Orthotic Regimen
Upon provision of an orthosis, the therapist determines a wearing
schedule for the client. Most diagnoses allow persons to remove the
orthoses for some type of exercise and hygiene. The therapist provides
a written orthotic schedule and reviews the schedule with the person,
nurse, and/or caregiver responsible for putting on and taking off the
orthosis. If the person is confused, the therapist is responsible for
instructing the appropriate caregiver regarding proper orthotic wear
and care. The therapist must evaluate the client’s or caregiver’s
understanding of the wearing schedule.
 FIG. 5.13 The volumeter measures composite hand mass via water
displacement.
From Hunter, J. M., Mackin, E. J., & Callahan, A.D. [Eds.]. [1996].
Rehabilitation of the hand: Surgery and therapy [4th ed., p. 63]. St.
Louis, MO: Mosby.

Clients wearing mobilizing (dynamic) orthoses follow several

general precautions. Therapists must be cautious when instructing
clients who must wear mobilizing (dynamic) orthoses during sleep.
Because of moving parts on mobilization orthoses, people can
accidentally scratch, poke, or cut themselves. Therefore, therapists
must design orthoses with no sharp edges and must consider the
possibility of using elastic traction (see Chapter 13).
Typically persons wear mobilizing (dynamic) orthoses for a few
minutes out of each hour and gradually work up to longer time
periods. As with all orthoses, a therapist never fabricates a mobilizing
(dynamic) orthosis without checking its effect on the person. The
therapist considers the diagnosis and appropriately schedules orthotic
wearing. Often, but not always, an orthotic regimen allows for times
of rest, exercise, hygiene, and skin relief. The therapist considers the
client’s daily activity schedule when designing the orthotic regimen.
However, intervention goals must sometimes supersede the desire for
the client to perform activities. In addition, the therapist uses clinical
judgment to determine and adjust the orthotic wearing schedule and
reevaluates the orthosis consistently to alter the intervention plan as
necessary.
Adherence
Based on the initial interview and statements from conversations, the
therapist determines whether adherence with the wearing schedule
and rehabilitation program is a problem. (Chapter 6 contains
strategies to help persons with adherence and acceptance.) If the hand
(or wrist, elbow, shoulder, etc.) demonstrates that the orthosis is not
achieving its goal, the therapist must check that the orthosis is well
designed and fits properly and then determine whether the orthosis is
being worn. If the therapist is certain about the design and fit,
adherence is probably poor. Clients returning for follow-up visits
must bring their orthoses. The therapist can generally determine
whether a client is wearing the orthosis by looking for signs of normal
wear. Signs include dirty areas or scratches in the plastic, soiled
straps, and nappy straps (caused by pulling the strap off the Velcro
hook).
Orthotic Care
Therapists are responsible for educating persons about orthotic care.
An evaluation of a person’s understanding of orthotic care is
completed before the client leaves the clinic or is discharged.
Assessment is accomplished by asking the client to repeat instructions
or demonstrate orthotic care. To keep the orthosis clean, washing the
hand with warm water and a mild soap and cleansing the orthosis
with rubbing alcohol are effective. The person or caregiver thoroughly
dries the hand and orthosis before reapplication. Chlorine
occasionally removes ink marks on the orthosis. Rubbing alcohol,
chlorine bleach, and hydrogen peroxide are good disinfectants to use
on the orthosis for infection control.
Persons should be aware that heat may melt their orthoses and
should be careful not to leave their orthoses in hot cars, on sunny
windowsills, or on radiators. Therapists discourage persons from
making self-adjustments, including the heating of orthoses in
microwave ovens (which may cause orthoses to soften, fold in on
themselves, and adhere). If the person successfully softens the plastic,
a burn could result from the application of hot plastic to the skin.
However, clients are encouraged to make suggestions to improve an
orthosis. Some therapists tend to ignore the client’s ideas. Not only
does this send a negative message to the client, but clients often have
wonderful ideas that are too beneficial to discount.

a
Self-Quiz 5.1
For the following questions, circle either true (T) or false (F).

1. T F All physicians follow the same protocol for postoperative

conditions.
2. T F Motivation may affect the person’s adherence to wearing an
orthosis, and thus determining the person’s motivational level
 is an important task for the therapist.
3. T F The resting hand posture is 10 to 20 degrees of wrist
extension, 10 degrees of ulnar deviation, 15 to 20 degrees of
metacarpophalangeal (MCP) flexion, and partial flexion and
abduction of the thumb.
4. T F Proximal musculature never affects distal musculature.
5. T F Therapists should encourage persons to carry their affected
extremities in guarded or protective positions to ensure that no
further harm is done to the injury.
6. T F A general guideline for evaluating orthotic fit is to have the
person wear the orthosis for 20 minutes and then remove the
orthosis. If no reddened areas are present after 20 minutes of
orthosis removal, no adjustments are necessary.
7. T F All orthoses require 24 hours of wearing to be most effective.
8. T F Every person should receive an orthotic wearing schedule in
written and verbal forms.
9. T F For infection control purposes, persons and therapists
should use extremely hot water to clean orthoses.
10. T F Strength of a healing tendon is stronger when the tendon is
immobilized rather than mobilized.
11. T F A red wound is a healthy wound.
12. T F A score of 10 on a verbal analog scale (VeAS) indicates that
pain does not need to be addressed in the intervention plan.
13. T F Strapping, padding, and thermoplastic materials may cause
a skin allergic reaction in some persons.
14. T F Assessments of function include the Nine Hole Peg Test and
the Semmes-Weinstein Monofilament Test.

a
See Appendix A for the answer key.
Summary
Evaluation before orthotic provision is an integral part of the orthotic
provision process. The evaluation process includes report reading,
observation, interview, palpation, and formal and informal
assessments. Evaluation before, during, and after orthotic provision
results in the therapist’s ability to understand how the orthosis affects
function and how function affects the orthosis. A thorough evaluation
process ultimately results in client satisfaction.

Review Questions
1. What are components of a thorough hand examination
before orthotic fabrication?
2. What is the posture of a resting hand?
3. What information should a therapist obtain about the
person’s history?
4. What sources can therapists use to obtain information
about persons and their conditions?
5. What should a therapist be noting when palpating a client?
6. What observations should be made when a client first
enters a clinic?
7. What types of formal upper extremity assessments for
function are available?
8. What procedure can a therapist use when assessing
whether a newly fabricated orthosis fits well on a person?
9. What precautions should a therapist keep in mind when
designing and fabricating an orthosis?
10. How can a therapist evaluate a client’s understanding of
an orthotic wearing schedule?
11. What safeguard can a therapist employ to avoid skin
reactions from orthotic materials?
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Appendix 5.1 Forms
Form 5.1 Hand Evaluation Check-Off Sheet
Form 5.2 Orthotic Precaution Check-Off Sheet
Form 5.3 Hints for Orthotic Provision
UNIT TWO
Orthosis for Conditions and
Populations
OUTLINE

6. Clinical Reasoning for Orthotic Intervention

7. Orthoses for the Wrist
8. Thumb Immobilization Orthoses
9. Hand Immobilization Orthoses
10. Elbow and Forearm Immobilization Orthoses
11. Orthoses for the Shoulder
12. Orthotics for the Fingers
13. Mobilization Orthoses: Serial-Static, Dynamic, and Static-
Progressive Orthoses
14. Orthotic Intervention for Nerve Injuries
15. Orthotic Provision to Manage Spasticity
16. Orthotic Intervention for Older Adults
17. Orthoses for the Pediatric Population
Clinical Reasoning for Orthotic
Intervention
Helene L. Lohman, and Linda S. Scheirton

CHAPTER OBJECTIVES
1. Describe clinical reasoning approaches and their application to
orthotic intervention.
2. Identify essential components of an orthotic referral.
3. Discuss reasons for the importance of communication with the
physician about an orthotic referral.
4. Discuss diagnostic implications for orthotic provision.
5. List helpful hints regarding the hand evaluation for orthotic
provision.
6. Explain factors the therapist considers when selecting an orthotic
intervention approach and design.
7. Describe what therapists problem solve during orthotic
fabrication.
8. Describe areas that require monitoring after orthotic fabrication is
completed.
9. Describe the reflection process of the therapist before, during,
and after orthotic fabrication.
10. Discuss important considerations concerning an orthotic-
wearing schedule.
11. Identify conditions that determine orthotic discontinuation.
12. Identify patient safety issues related to orthotic intervention
errors.
 13. Discuss factors that affect orthotic cost and payment.
14. Discuss how the Health Insurance Portability and Accountability
Act (HIPAA) regulations influence orthotic provision in a clinic.
15. Discuss documentation of orthotic intervention.

KEY TERMS
adherence
client safety
clinical reasoning
documentation
Health Insurance Portability and Accountability Act (HIPAA)
intervention process
orthotic intervention error

Ali works in an acute care hospital, where she follows patients in both
inpatient and outpatient care. She enjoys her job because she sees a
variety of diagnoses and is constantly challenged to apply clinical
reasoning to novel situations. On Friday, Ali has a walk-in client with
an order for an orthosis and therapy following a Dupuytren contracture
release. The order was not specific as to which orthotic type, and Ali
noticed that the patient had an open wound. Although in school she was
educated about wound care, she did not have experience with open
wounds in practice. Ali did not have much time to think about the
orthosis because she had a tight schedule that day. Ali thought, “I have
made other orthoses, and although I don’t know exactly what to do with
this diagnosis, I can figure it out because I am familiar with basic
orthotic fabrication skills. I will quickly call the physician’s office to find
out her preferences with wound care.” Ali thoughtfully considered
factors such as the location of the surgery, infection precautions,
 objectives for the orthosis, and the client’s occupational needs. Ali
consulted books and quickly called a therapist who informally mentored
her. She then successfully fabricated an appropriate orthosis while
following wound-care precautions.

Note: This chapter includes content from previous contributions

from Sally E. Poole, MA, OTR, CHT, and Joan L. Sullivan, MA, OTR,
CHT.
In clinical practice there is no simple design or type of orthosis that
applies to all diagnoses. Orthotic design and wearing protocols vary
because each injury is unique. Clinical reasoning about which
orthosis to fabricate involves considering the physician’s referral, the
surgical and rehabilitation protocol, and the therapist’s conceptual
model. Clinical reasoning also involves the assessment of the client’s
needs based on objective and subjective data gathered during the
evaluation process and knowledge about the payment source.
Instructors often teach students only one way to do something
when there may be multiple ways to achieve a goal. For example, this
book emphasizes the typical methods that generalist clinicians use to
fabricate common orthoses. Learning a foundation for orthotic
fabrication is important. In clinical practice, however, the therapist
should use a problem-solving approach and apply clinical reasoning
to address the needs of each client who requires an orthosis. Clinical
reasoning may include integration of knowledge of biomechanics,
anatomy, kinesiology, psychology, conceptual models, and pathology.
Clinical reasoning also involves orthotic intervention protocols and
techniques, clinical experience, and awareness of the client’s
motivation, adherence, and lifestyle (occupational) needs.
This chapter first overviews clinical reasoning models and then
addresses approaches to clinical reasoning from the moment the
therapist obtains an orthotic referral until the client’s discharge. This
chapter also presents prime questions to facilitate the clinical
reasoning process that therapists undertake during intervention
planning throughout the course of therapy.
Clinical Reasoning Models
Clinical reasoning helps therapists approach the complexities of
clinical practice. Clinical reasoning involves professional thinking
during evaluation and intervention. 38 Professional thinking is the
ability to distinctly and critically analyze the reasons for whatever
actions therapists make and to reflect on the decisions afterward. 40
Skilled therapists reflect throughout the entire orthotic intervention
process (reflection in action), not solely after the orthosis is completed.
45 Clinical reasoning also entails understanding the meaning a

disability, such as a hand injury, has from the client’s perspective. 33

With clinical reasoning, therapists consider available evidence in
the literature to critically reflect on whether orthoses can help their
clients. Based on a review of various studies, 7 therapists consider
client characteristics and outcomes with orthotic intervention.
Therapists analyze how clients that they are following relate to those
discussed in the studies.
Various approaches to clinical reasoning are depicted in the
literature. Facione discussed an “argument and heuristic analysis
model of decision making” for critical thinking. 18 System 1 involves
automatic quick reactive thinking, and System 2 involves logical
reflective thinking. Both types of critical thinking can be used with
orthotic fabrication. Therapists apply System 1 to think quickly as the
working time with thermoplastic materials is very short. Yet to
appropriately fabricate orthoses, therapists must use System 2 to
logically and reflectively consider factors such as which orthosis to
provide, length of provision, wearing schedule, and principles of
fabrication.
One clinical reasoning model in occupational therapy literature
includes interactive, narrative, pragmatic, conditional, and procedural
reasoning. Although each of these approaches is distinctive,
experienced therapists often shift from one type of thinking to another
to critically analyze complex clinical problems, 21 such as with orthotic
intervention.
Interactive reasoning involves getting to know the client as a human
being to understand the impact that the hand condition has on the
client’s life. 21 Understanding this impact can help identify the proper
orthosis to fabricate. For example, for a client who is very sensitive
about appearance after a hand injury, the therapist may select a skin-
tone thermoplastic material that blends with the skin and attracts less
attention than a white thermoplastic material.
With narrative reasoning the therapist reflects on the client’s
occupational story (or life history), taking into consideration activities,
habits, and roles. 38 For assessment and intervention, the therapist first
takes a top-down approach 52 by considering the roles that the client
had before the hand condition and the meaning of occupations in the
client’s life. The therapist also considers the client’s future and the
impact that the therapist and the client can have on it. 21 For example,
through discussion or a formal assessment interview, a therapist
learns that continuation of work activities is important to a client with
carpal tunnel syndrome. Therefore, the therapist fabricates a wrist
immobilization orthosis to position the wrist in neutral and has the
client practice typing on a computer while wearing the orthosis.
With pragmatic reasoning the therapist considers practical factors,
such as payment, public policy regulations, documentation,
availability of equipment, and the expected discharge environment.
Pragmatic reasoning includes considerations of the therapist’s values,
knowledge, and skills. 38,44 For example, a therapist may need to
review the literature and research evidence if the therapist is
unknowledgeable about a diagnosis that requires an orthosis. If a
therapist does not have the expertise to fabricate an orthosis for a
client with a complicated injury, the therapist might consider referring
the client to another therapist who has the expertise.
In addition, a therapist may need to make ethical decisions, such as
whether to fabricate an orthosis for a terminally ill 98-year-old client.
This ethical decision involves the therapist’s values about age and
terminal conditions. In today’s ever-changing health care
environment, there is a trend toward cost containment. Budgetary
shortages may require therapists to ration clinical services.
Prospective payment systems for reimbursing the costs of
rehabilitation, such as in skilled nursing facilities (SNFs), are a reality.
Therapists fabricate orthoses quickly and efficiently to save costs. The
information provided throughout this book may assist with pragmatic
reasoning.
With conditional reasoning the therapist reflects on the client’s
“whole condition” by considering the client’s life before the injury, the
disease or trauma, current status, and possible future life status. 34
Reflection is multidimensional and includes the condition that
requires orthotic intervention, the meaning of having the condition or
dysfunction, and the social and physical environments in which the
client lives. 22 The therapist then envisions how the client’s condition
might change as a result of orthotic provision and therapy. Finally, the
therapist realizes that success or failure of the intervention ultimately
depends on the client’s adherence to the orthotic requirements. 21,38
Evaluation and intervention with this clinical reasoning model begin
with a top-down approach, considering the meaning of having an
injury in the context of a client’s life.
Procedural reasoning involves finding the best orthotic intervention
approach to improve functional performance, taking into
consideration the client’s diagnostically related performance areas,
components, and contexts. 20,21,38 Much of the material in this chapter,
which summarizes the intervention process from referral to
discontinuation of an orthosis, can be used with procedural reasoning.
To demonstrate clinical reasoning, Table 6.1 summarizes each
approach and includes questions for the therapist to either ask the
client or reflect on during orthotic provision and fabrication. As stated
at the beginning of this discussion, each approach is explained
separately. However, experienced therapists combine these
approaches, moving easily from one to another. 34
Clinical Reasoning Throughout the
Intervention Process
The following information assists with pragmatic and procedural
reasoning.

Essentials of Orthotic Referral

The first step in the problem-solving process is consideration of the
orthotic referral. The ideal situation is to receive the orthotic referral
from the physician’s office early to allow ample time for preparation.
However, the first time the therapist sees the referral is often when the
client arrives for the appointment. In these situations, the therapist
makes quick clinical decisions. Aside from client demographics, Fess
and colleagues 19 suggested that therapists also need to determine the
following information:

• Diagnosis
• Date of the condition’s onset
• Medical or surgical management
• Purpose of the orthosis
• Type of orthosis (immobilization, mobilization, restriction,
torque transmission)
• Anatomical parts the orthosis should immobilize or mobilize
• Precautions and other instructions
• Duration of orthotic intervention
• Wearing schedule

In addition to this list, therapists should take into account

occupational considerations.

TABLE 6.1

Clinical Reasoning Approaches a

Clinical Reasoning Approaches a
a Examples are inclusive, not exclusive.

Therapist/Physician Communication About

Orthotic Referral
A problem that many therapists encounter is an incomplete orthotic
referral that lacks a clear diagnosis. Even an experienced therapist
becomes frustrated upon receiving a referral that states “Provide
orthosis.” A proper referral would answer these questions for the
therapist:

• Orthosis for what purpose?

• For what body part(s)?
• For how long?

An open line of communication between the physician and the

therapist is essential for good orthotic selection and fabrication. Most
physicians welcome calls from the therapist when calls are specific. If
the physician’s referral does not contain the pertinent information, the
therapist is responsible for requesting this information (Box 6.1). The
therapist prepares a list of questions before calling; and if the
physician is not available, the therapist conveys the list to the
physician’s administrative assistant, nurse, or physician assistant and
agrees on a specific time to call again. Sometimes the contact staff
member at the physician office can read the chart notes or fax an
operative report to the therapist. With electronic medical records,
radiographic reports, operative reports, and any other relevant reports
are accessible for review. The therapist must never rely solely on the
client’s perception of the diagnosis and orthotic requirements.
In some cases, the physician expects the therapist to have the
clinical reasoning skills to select the appropriate orthosis for the
specific clinical diagnosis. Sometimes a therapist receives a physician’s
order for an inappropriate orthosis, a nontherapeutic wearing
schedule, or a less than optimal material. The therapist is responsible
for always scrutinizing each physician referral. If the referral is
inappropriate, the therapist should apply clinical reasoning skills to
determine the appropriate orthotic intervention approach. The
therapist makes successful independent decisions with a knowledge
base about the fundamentals of orthotic intervention and with the
ability to locate additional information. Then the therapist calls the
physician’s office and diplomatically explains the problem with the
referral and suggests a better orthotic intervention approach and
rationale.

BOX 6.1 Examples of Incomplete and Complete

Orthotic Referrals

CMC, Carpometacarpal; L, left; MCP, metacarpophalangeal; UE,

upper extremity.

Diagnostic Implications for Orthotic Provision

The therapist identifies the client’s diagnosis after reviewing the
orthotic order. Often, the therapist can begin the clinical reasoning
process by using a categorical orthotic intervention approach
according to the diagnosis. The first category involves chronic
conditions, such as hemiplegia. In such situations an objective of the
orthotic provision may be to prevent contracture. The second category
involves a traumatic or acute condition that may encompass surgical
or nonsurgical intervention. For example, the client may have
tendinosis and require a nonsurgical orthotic intervention for the
affected extremity.
Regardless of whether the condition is acute or chronic, it is
important that the therapist have an adequate knowledge of
diagnostic protocols. By knowing protocols, therapists are aware of
precautions for orthotic intervention. For example, for a client with
carpal tunnel syndrome, the therapist knows to place the wrist in a
neutral position. If the therapist placed the wrist in a functional
position of 30 degrees extension, it could cause more pain by putting
too much pressure on the median nerve. Therapists should keep
abreast of current intervention trends through review of evidence in
literature, continuing education, and communication with physicians.
In all cases the orthotic provision approach is individually tailored to
each client, beginning with categorization by diagnosis and then
adapting the approach according to the client’s performance,
cognition, and occupational needs.

Factors Influencing the Orthotic Approach

The following sections offer specific hints that elaborate on areas of
the orthotic evaluation the therapist can use with clinical reasoning.
(See Chapter 5 for essential components to include in a thorough hand
evaluation.)

Age
The client’s age is important for many reasons. Barring other
problems, most children, adolescents, and adults can wear orthoses
according to the respective protocol. An infant or toddler, however,
can usually get out of any orthosis at any time or place. Extraordinary
and creative methods are often necessary to keep orthoses on these
youngsters. 3 Older clients, especially those with diminished
functional and cognitive capacities, may require careful monitoring by
the caregiver to ensure a proper fit and adherence with the wearing
schedule. For more information about working with older adults refer
to Chapter 16 and for pediatrics refer to Chapter 17.

Occupation
From the interview with the client, family, and caregiver (and from
medical record review), the therapist surmises the impact that an
orthosis may have on occupational function, economic status, and
social well-being. The therapist carefully considers the meaning that
the upper extremity condition has for the client, how the client has
dealt with medical conditions in the past, how the client’s condition
may change because of the orthotic provision, and the client’s social
environment. Thus, when choosing the orthotic design and material,
the therapist considers the client’s lifestyle needs. The following are
some specific questions to reflect on when determining lifestyle needs:

• What valued occupations, such as work or sports, will the

client engage in while wearing the orthosis?
• Do special considerations exist because of rules and
regulations for work or sports?
• In what type of environment will the client wear the orthosis?
For example, will the orthosis be used in extreme
temperatures? Will the orthosis get wet?
• Will the orthosis impede a hand function necessary to the
client’s job or home activities?
• What is the client’s normal schedule, and how will wearing an
orthosis impact that schedule?

If a physician refers a client for a wrist immobilization orthosis

because of wrist strain, the therapist might contemplate the following
question: Is the client a construction worker who does heavy manual
work or a computer operator who does light, repetitious work? A
construction worker may require an orthosis of stronger material with
extremely secure strapping. The computer operator may benefit from
lighter, thinner thermoplastic material with wide soft straps. In some
situations, the client may best benefit from a prefabricated orthosis.
The therapist determines the client’s activity status, including when
the client is wearing an orthosis that does not allow for function or
movement (such as a positioning orthosis). If the client must return to
work immediately, albeit in a limited capacity, the orthosis must
always be secure. Proper instructions regarding appropriate care of
the limb and the orthosis are necessary. This care may involve
elevation of the affected extremity, wound management, and periodic
range of motion (ROM) exercises while the client is working.
 When the client plans to continue in a sports program (professional,
school, or community-based), the therapist checks the rules and
regulations governing that sport. Rules and regulations usually
prevent athletes from wearing hard thermoplastic material during
participation in the sport unless the orthotic design includes exterior
and interior padding. Therapists need to communicate with the coach
or referee to determine appropriateness of an orthosis 63 and perhaps
consider alternative interventions, such as applying Kinesio tape to
the area.

Expected Environment
The therapist must consider the client’s discharge environment. Some
clients return to their own homes and have families and friends who
can lend assistance if necessary. For those clients returning to
inpatient units or nursing homes, therapists consider instructing the
staff in the care and use of the orthoses. If clients return to psychiatric
units or prison wards, consider whether supervision is necessary so
that orthoses are not used as weapons to harm themselves or others.

Activities of Daily Living Responsibilities

The therapist considers the following question: Is the client able to
successfully complete all activities of daily living (ADLs) and
instrumental activities of daily living (IADLs) if an orthosis needs to
be worn? For example, the therapist may consider how a client can
successfully prepare a meal wearing an orthosis that immobilizes one
extremity. In that case, the therapist may address one-handed meal-
preparation techniques.

Client Adherence and Motivation

Orthotic provision requires adherence on many levels, including
attending therapy sessions, following wearing schedules and home
programs, and adhering to safety expectations. 39 The terminologies of
adherence and compliance are often discussed interchangeably, but
there are differences with the definitions. Compliance can be
perceived as follow-through with intervention instructions.
Adherence can be perceived as more client centered as the client
collaborates with the intervention. Adherence is currently the more
utilized term. 31 The World Health Organization (WHO) defines
adherence as “numerous health-related behaviours” 62 and discusses
five dimensions of adherence related to factors and interventions that
include “(1) social economic, (2) health system and health care team,
(3) therapy, (4) condition, and (5) patient.” 62
Other considerations affecting adherence with intervention
regimens include external factors, such as socioeconomic status and
family support. Internal factors such as the client’s perception of the
severity of the condition are also considered. Knowledge, beliefs, and
attitudes about the condition can influence adherence. 8,24
There is a limited amount of research investigating how adherence
relates to clients with hand injuries 23,29 or with orthotic provision. A
systematic review 39 considered adherence with orthotic wear in
adults. Six studies met the selection criteria for a total of 490 subjects.
The author concluded that there was “no consistent correlation [with
adherence to orthotic wear] to age or gender” or to “socioeconomic
and condition related factors.” 39 However, the author found some
evidence supporting the importance of intervention factors (such as
the comfort of the orthosis) and impact of the orthosis on lifestyle and
occupations.
Another factor addressed in research is the psychosocial construct
of locus of control, which proposes a relationship between a client’s
perception of control over intervention outcomes and the likelihood
that the client will adhere to intervention. This perception of control
can be internally or externally based. 8 For example, an internally
motivated client would follow an orthotic schedule based on self-
motivation. An externally motivated client may need encouragement
from the therapist or caregiver to follow an orthotic-wearing schedule.
Often not discussed with adherence are organizational variables and
clinic environment issues, such as transportation problems,
interference with daily schedule, wait time, inconsistent therapists,
and clinic location. 29
The therapist can positively influence the client’s adherence and
motivation to wear an orthosis. Establishing goals together may
encourage the client to follow through with the intervention. Perhaps
completing an occupation-focused assessment, such as the Canadian
Occupational Performance Measure (COPM), can encourage the client
to wear the orthosis. 30 If the goals determined by the COPM are
improvement of hand function, the therapist discusses how the
orthosis will meet these goals. Furthermore, it is important for the
therapist to examine intervention goals in relation to the client’s goals
because there might be disparity between them. 29 Sometimes the
client will have input about the orthotic design, which should be
considered seriously by the therapist. Therapists should convey to
clients that success with rehabilitation and orthoses involves shared
responsibility. To attain the therapeutic goal, the therapist must
always reiterate the client’s responsibilities in the intervention plan.
In addition, the therapist should perceive the client as an individual
with a lifestyle beyond the clinic, not just as a client with an injury.
Paramount to adherence is education about the medical necessity of
wearing the orthoses. The therapist should consider the client’s
perspectives on the impact of the orthoses on lifestyle. Education
should be repetitive throughout the time the client wears the orthosis.
23,48 When the therapist and the physician communicate clearly about

the type of orthosis necessary, the client receives consistent

information regarding the rationale for wearing the orthosis.
Demonstrating how the orthosis works and explaining the goal of the
orthosis enhances client adherence.

BOX 6.2 Examples of Factors That May Influence

Adherence With Orthotic Wear
Organizational/Clinic Environment
 • Time involved with orthotic wear
• Interference with life tasks
• Inconsistent therapists
• Transportation issues
• Long wait time for therapy
• Inconvenient clinic location
• Noisy clinic with little privacy

Client
• Belief in the efficacy of wearing an orthosis
• Belief in one’s ability to follow through with the orthosis-wearing
schedule
• Poor social support

Intervention
• Orthosis is uncomfortable
• Orthosis is cumbersome
• Orthosis is poorly made

Therapeutic Relationship and Communication

• Inconsistent communication between therapists and physicians
concerning the orthosis
• Poor understanding, difficulty reading, or being forgetful about
instructions on orthotic wear and care

Adapted from Kirwan, T., Tooth, L., & Harkin, C. (2002). Compliance
with hand therapy programs: Therapists’ and patients’ perceptions.
Journal of Hand Therapy, 15(1), 31–40.
 Adherence involves both therapist and client (Box 6.2). 29 Rather
than labeling clients as noncompliant or uncooperative, therapists
must make serious attempts to help clients better cope with their
injury. The therapist should be an empathetic listener as the client
learns to adjust to the diagnosis and to the orthosis. The therapist can
ask questions of the client to assist in eliciting pertinent information
about orthotic adherence, fit, and follow-up (Box 6.3).
Others can also have an impact on client adherence. Sometimes a
peer wearing an orthosis can be a positive role model to help a client
who is not adhering to the intervention plan. A supportive spouse or
caregiver encourages adherence. Furthermore, physician support
influences adherence. Sometimes a client may need more structured
psychosocial support from mental health personnel.
Selection of an appropriate design may alleviate a client’s difficulty
in adjusting to an injury and wearing an orthosis. Therapists should
ask themselves many questions as they consider the best design. (See
the questions listed in the section on procedural reasoning in Table
6.1.)
In addition to orthotic design, material selection (e.g., soft versus
hard) may influence satisfaction with an orthosis. 10 People with
rheumatoid arthritis who wear a soft prefabricated orthosis consider
comfort and ease of use when involved in activities, which are
important factors for orthotic satisfaction. 49 (See the discussion of
advantages and disadvantages of prefabricated soft orthoses in
Chapter 3.)

BOX 6.3 Questions for Follow-up Telephone

Calls or Email Communication Regarding Clients
With Orthoses
The following open- and closed-ended questions may assist the
therapist in eliciting pertinent information from clients about orthotic
adherence, fit, and follow-up. Closed-ended questions usually elicit a
brief response, often a yes or no.
 • Have you been wearing your orthosis according to the schedule I
gave you? If no, why aren’t you wearing your orthosis?
• Have you noticed any reddened or painful areas after removing
your orthosis? If so, where?
• Is the orthosis easy to put on and take off?
• Are there any tasks you want to do but cannot do when wearing
your orthosis?
• Do you have any concerns about your orthotic-wearing schedule
or care?
• Are there any broken or faulty components on your orthosis?
• Do you have any questions for me?
• Do you know how to reach me?
• Have you noticed any increased swelling or pain since you’ve
been wearing the orthosis?

Open-ended questions elicit a qualitative response that may give

the therapist more information.

• Will you tell me about a typical day and when you put your
orthosis on and take it off?
• What concerns, if any, might you have about your orthotic wear
and care schedule?
• What precautions have you been taking in regard to monitoring
your orthotic wear?
• How is the orthosis affecting your activities at home and at work?
• Are there any areas to improve with our clinic management that
would help with your follow-through with orthotic wear?
• Can you tell me how you would contact me if you need to do so?
• Do you have any questions for me?

Making the orthosis aesthetically pleasing helps with adherence. A

client is less likely to wear an orthosis that is messy or sloppy. This is
especially true of children and adolescents for whom personal
appearance is often an important issue. Therapists need to think of an
orthosis as a representation of their work, because other people will
see it in public and may inquire about it.
Thermoplastic and strapping materials are now available in a
variety of colors and sometimes imprinted with patterns. Clients, both
children and adults, who are coping successfully with the injury may
want to have fun with the orthosis and select one or more colors.
However, a client who is having a difficult time adjusting to the injury
may not want to wear an orthosis in public at all, let alone an orthosis
with a color that draws more attention.
Finally, fabrication of a correctly fitting orthosis on the first attempt
eases a client’s anxiety. The therapist is responsible for listening to the
client’s complaints and adjusting the orthosis. A therapist’s attitude
about orthotic adjustments makes a difference. If the therapist seems
relaxed, the client may consider adjustment time a normal part of the
orthotic fabrication process. Encouraging effective communication
with the client facilitates understanding and satisfaction about
orthotic provision.

Cognitive Status
Besides adherence, the client’s cognitive status is a consideration that
can influence orthotic provision. When a client is unable to attend to
the therapy program and follow the orthotic intervention regimen
because of cognitive status, the therapist must educate the family,
caregiver, or staff members. Education includes medical reasons for
the orthotic provision, wearing schedule, home program, precautions,
and cleaning. Education leads to better cooperation. Sometimes the
therapist selects designs and techniques to maximize the client’s
independence. For example, instructions are written directly on the
orthosis. Symbols, such as suns and moons to represent the time of
day, can be used in written instructions of wearing schedules. 46
Simple communication strategies (such as showing the client a sheet
with a smiley face, neutral face, or frowning face) can be used to
determine how the client feels about orthotic comfort.
Health Literacy
An important consideration in today’s health care environment is
health literacy. Health literacy, or the ability to “obtain, process, and
understand health information,” 56 influences communication
between the therapist and the client. Older adults, people from lower
economic groups, minorities, people with limited English speaking
and reading abilities, people with chronic conditions, and people
experiencing stress are at risk for low health literacy. 35 Consider the
stress a client may feel following a traumatic hand injury and not
being able to work.
Therapists who are aware of the health literacy requirements of
their clients focus orthotic education in a manner that is
understandable, resulting in better adherence to the intervention plan.
Simply asking clients about their reading abilities is one way to open
the conversation about health literacy 35 and orthotic education.
Additionally, asking clients about their learning styles, 57 such as
preferring demonstration, visual information, written information, or
a combination, helps focus the format and approach to orthotic
education. When providing educational handouts or home programs,
therapists must be careful to simplify language and not use medical
language. For example, some people in the public may not be familiar
with the word orthosis, or even splint. So, the therapist should use
words that are familiar to the person. Handouts are easier to
understand when pictures and graphics accompany narrative. 57 For
example, the therapist includes a picture of the correct way to secure
straps when donning the orthosis in a patient education handout.
Another useful health literacy technique is called “teach back,” in
which the therapist asks the client to demonstrate any therapeutic
activities that have been taught. From the demonstrations, therapists
become aware if the education needs to change or be simplified. For
example, therapists ask clients to show them how they will put on the
orthosis. Sometimes chunking the education in manageable segments
or starting with the most important learning concept will increase
retention. 35 For example, presenting safety precautions about the
orthosis first may help the client’s learning and retention.
Orthotic Intervention Approach and
Design Considerations
The five approaches to orthotic design are dorsal, palmar, radial,
ulnar, and circumferential. The therapist must determine the type of
orthosis to fabricate, such as a mobilization orthosis or immobilization
orthosis. Understanding the purpose of the orthosis clarifies these
decisions. For example, when working with a client who has a radial
nerve injury, the therapist may choose to fabricate a dorsal torque
transmission orthosis (wrist flexion: index-small finger
metacarpophalangeal [MCP] extension/index-small finger MCP
flexion, wrist extension torque transmission orthosis) 2 to substitute
for the loss of motor function in the wrist and MCP extensors. Based
on clinical reasoning, the therapist may also choose to fabricate a
palmar-based wrist extension immobilization orthosis once the client
regains function of the MCP extensors. The wrist orthosis allows the
client to engage in functional activities.
In addition to the information that the therapist obtains from a
thorough evaluation, other factors dictate orthosis choice. To
determine the most efficient and effective orthosis choice, the therapist
must consider the physician’s orders, the diagnosis, the therapist’s
judgment, the payment source, and the client’s function.

Physician’s Orders
Physicians often predetermine the orthotic-application approach
based on their training, surgical technique, and evidence in the
literature. As discussed, sometimes the therapist may apply clinical
reasoning to determine a different orthotic design or material than
what was ordered. In that case, the therapist calls the physician.

Diagnosis
Frequently the diagnosis mandates the approach to orthotic design.
The diagnosis determines the number of joints that the therapist must
involve. The least number of joints possible should be restricted while
allowing the orthosis to accomplish its purpose. Diagnosis also
determines positioning and whether the orthosis should be of the
mobilization or immobilization type. For example, using one early
mobilization protocol for a flexor tendon repair, the therapist places
the orthosis on the dorsum of the forearm and hand to protect the
tendon and to allow for rubber band traction. The wrist and MCP
joints should be in a flexed position. (Alternatively, some physicians
now prefer a neutral wrist position to block extension.) These orthoses
protect the repair and allow early tendon glide. In this example the
repaired structures and the need to begin tendon gliding guide the
approach. (See Chapter 13 for more information on mobilization
orthotic fabrication with tendon repairs.)

Therapist’s Judgment
The therapist determines the orthotic design and type based on
knowledge and experience. For example, after a carpal tunnel release,
the therapist can place a wrist immobilization orthosis dorsally or
volarly directly over the surgical site. As an advocate of early scar
management, the therapist chooses a palmar orthosis and adds
silicone elastomer or Otoform to the orthosis.

Client’s Function
The client’s primary task responsibilities may influence the type of
orthosis. A construction worker’s wrist has different demands placed
on it than the wrist of a computer operator with the same diagnosis.
Not only does the therapist choose different materials for each client,
but the design approach may be different. A thumb-hole volar wrist
immobilization orthosis decreases the risk of the orthosis migrating
up the arm during the construction worker’s activities, because it
tightly conforms to the hand. The computer operator may prefer a
dorsal wrist immobilization orthosis to allow adequate sensory
feedback and unimpeded flexibility of the digits during keyboard use.
(See Chapter 7 for patterns of wrist orthoses.)
Table 6.2 outlines a variety of positioning choices for orthotic
design. However, therapists should not view these suggestions as
strict rules. For example, a skin condition (such as eczema) may
necessitate that a mobilization extension orthosis be volarly based
rather than dorsally based.
Clinical Reasoning Considerations for
Designing and Planning the Orthosis
The orthotic designing and planning process involves many clinical
decisions about materials and techniques the therapist can use. (Refer
to chapters throughout this book for more specific information about
materials and techniques.) Initial considerations are often related to
infection control procedures.

Infection Control Procedures

The therapist considers whether dressing changes are necessary and
consults with the physician’s office for any guidance. If so, the
therapist follows universal precautions and maintains a sterile
environment. The therapist should be aware that skin maceration
under an orthosis can occur more easily in the presence of a draining
wound. With skin maceration the therapist first carefully applies a
dressing to absorb the fluid. Orthotic fabrication should take place
over the dressing, and the therapist should instruct the client in how
to apply new dressings at appropriate intervals. 47 Before the
application of the thermoplastic material, the therapist can place a
stockinette over the client’s bandages to prevent the thermoplastic
material from sticking to the bandages.
If the client has a draining or infected wound, the therapist does not
use regular strapping material to hold the orthosis in place to absorb
bacteria. Instead, the therapist uses gauze bandages that are replaced
at each dressing change. If a client is unwilling or unable to change a
dressing, the therapist can instruct a family member or friend to do so.
If assistance is not possible, the client may need to visit the therapist
more frequently.

Time Allotment for Orthotic Fabrication and

Client and Nursing or Caregiver Education
The therapist considers the time required for orthotic fabrication and
education. Fabrication time varies according to the complexity of the
orthosis and the client’s ability to comply with the fabrication process.
For example, squirmy babies and people with spasticity are more
difficult to fabricate an orthosis for and require more time. In these
cases, it may be beneficial to have an additional staff member or a
caregiver help position the client.
Orthotic fabrication time is also dependent on the therapist’s
experience. If possible, a beginning therapist should schedule a large
block of time for orthotic fabrication. As therapists gain clinical
experience, they require less time to fabricate orthoses. With any
orthotic application, the therapist should allow enough time for
educating the client, family, and caregiver about the wear schedule,
precautions, and their responsibility in the rehabilitation process. As
discussed, education helps with adherence.

TABLE 6.2

Common Positioning Choices in Orthotic Design

CMC, Carpometacarpal.

Batteson 6 found that in an institutional setting, a nurse training

program (developed by the occupational therapist) that addressed
orthotic fabrication was very helpful in increasing adherence with an
orthotic-wearing schedule. This program included orthotic rationale,
common orthotic care questions, and familiarization with
thermoplastic materials. A nurse liaison was identified to deal
specifically with the client’s orthosis concerns. In addition, an orthotic
resource file developed by the therapist was made available to the
nurses. A similar system could be created on the computer.
Postfabrication Monitoring
The therapist uses clinical reasoning skills to thoroughly evaluate and
monitor the fabricated orthosis. In particular, the therapist must be
aware of pressure areas and edema.

Monitoring Pressure
Regardless of its purpose or design, the orthosis requires monitoring
to determine effects on the skin. A client wearing an orthosis is
superimposing a hard lever system on an existing lever system that is
covered by skin, a living tissue that requires an adequate blood
supply. The therapist must therefore follow mechanical principles
during orthotic fabrication to avoid excessive pressure on the skin.
With fabrication, therapists weigh the pros and cons of the amount of
orthotic coverage. With minimal coverage from an orthosis, there is
increased mobility. Increased coverage by an orthosis allows for more
protection and better pressure distribution. To reduce pressure, the
therapist designs an orthosis that covers a larger surface area. 19
Warning signs of an ill-fitting orthosis are red marks, indentations,
and ulcerations on the skin.
A well-fitting orthosis, after its removal, may leave a red area on the
client’s skin. This normal response to the pressure of the orthosis
disappears within seconds. When an orthosis exerts too much
pressure on one area (usually occurs over a bony prominence) the
redness may last longer. For clients of color, in whom redness is not
easily visible, the therapist may lightly touch the skin to determine the
presence of hot spots or warmer skin. Another way to check skin
temperature is with a thermometer. With any orthosis the therapist
checks the skin after 20 to 30 minutes of wearing time before the client
leaves the clinic. If red areas are present after 20 to 30 minutes of
wearing the orthosis, adjustments need to be made.
A client with intact sensibility who has an ill-fitting orthosis usually
requests an adjustment or simply discards the orthosis because it is
not comfortable. For a condition in which sensation is absent,
vigorous orthotic monitoring is critical. 9,19 The therapist teaches the
client and the family to remove the orthosis every 1 to 2 hours to
check the skin to avoid skin breakdown.

Monitoring for Skin Maceration

Wet, white, macerated skin can occur when the skin under an orthosis
holds too much moisture. Skin maceration occurs for many reasons,
such as a child drooling on an orthosis. When this happens to a client
with intact skin who has simply forgotten to remove the orthosis, the
therapist can easily correct the problem by washing and drying the
area. Educating the client about proper care of the hand and
providing a polypropylene stockinette to absorb moisture should
resolve this situation.

Monitoring Edema
A therapist frequently needs to fabricate an orthosis for an edematous
extremity. Edema is often present after surgery, in the presence of
infection, with severe trauma (e.g., from a burn), or with vascular or
lymphatic compromise. A well-designed, well-fitting orthosis can
reduce edema and prevent the sequelae of tissue damage and joint
contracture. A poorly designed or ill-fitting orthosis can contribute to
the damaging results of persistent edema. Generally, the design and
fit principles already discussed in this text apply.
The therapist considers the method used to hold the orthosis in
place. Soft, wide straps accommodate increases in edema and are
better able to distribute pressure than rigid, nonyielding Velcro straps.
11 When too tight, strapping can contribute to pitting edema as a

result of hampered lymphatic flow. 13 For severe edema the therapist

may gently apply a wide elastic wrap to keep the orthosis in place.
The continuous contact of the wrap helps reduce edema. 13 Therapists
should be cautioned that straps applied at intervals may further
restrict circulation and cause “windowpane” edema distally and
between the straps. When using Ace wraps or compressive gauze, the
therapist must apply them in a spiral pattern and use gradient distal-
to-proximal pressure. The therapist must properly monitor the
orthosis and wrap to ensure that the wrap does not roll or bunch. 31
Pressure created by rolling or bunching could cause constriction and
further edema and stiffness.
If the lymphatic system is not damaged, edema reduction usually
begins relatively quickly with appropriate wound healing (i.e., no
infection), proper elevation, and gentle active exercises as permitted.
As edema resolves, the therapist remolds the orthosis to fit the new
configuration of the extremity. The therapist asks the client with
severe edema to return to the clinic daily for monitoring and
intervention. When the edema appears to be within the normal
postoperative range, the therapist asks the client to return to the clinic
in 3 to 5 days for an orthotic check. Helping the client understand the
frequency and purpose of the orthotic adjustments is also important.
Again, education is an important part of the edema-reduction
regimen. 32

Monitoring Physical and Functional Status

When a client’s physical or functional status changes, an orthotic
adjustment is often necessary. If a client is receiving intervention for a
specific injury and it is effective, the orthosis requires adjustments in
conjunction with improvement. For example, if a client has a median
nerve injury in which the thumb has an adduction contracture, the
therapist fabricates a thumb carpometacarpal (CMC) palmar
abduction mobilization orthosis 2 to gradually widen the tight web
space. As intervention progresses and thumb motions increase, the
therapist adjusts the orthosis to accommodate the gains in motion. 42
Evaluation and Adjustment of Orthoses
After fabricating the orthosis, the therapist carefully evaluates the
design to determine fit and necessary adjustments. The therapist looks
carefully at the orthosis when the client is and is not wearing it and
considers whether the orthosis serves its purpose. The orthosis should
be functional for the client and should accomplish the goals for which
it was intended. It should also have a design that uses correct
biomechanical principles and should be cosmetically appealing. (Refer
to specific chapters in this book for hints and orthosis-evaluation
forms.)
Therapists learn from self-reflection before, during, and after each
orthosis is made. Reflection helps fine-tune critical thinking skills. The
following are reflective questions that the therapist can consider after
orthotic fabrication:

• Did the orthosis accomplish the purpose for which it was

intended?
• Is it correctly fitted according to biomechanical principles?
• Did I select the best materials for the orthosis?
• Did I take into consideration fluctuating edema?
• Is it cosmetically appealing?
• Is it comfortable for the client and free of pressure areas?
• Have I addressed how orthotic intervention impacts the
client’s valued occupations?
• Have I addressed functional considerations?
• What would I do differently if I were to refabricate this
orthosis?
• Did I properly educate the client/caregiver about the orthosis?

If major adjustments are required, the therapist should avoid using

a heat gun except to smooth the orthotic edges. If the therapist has
selected the appropriate simple orthotic design and has used a
thermoplastic product that is easily reheatable and remoldable, the
water-immersion method is the best way to adjust the orthosis. Years
of experience demonstrate that reheating the entire orthosis in water
and reshaping it is more efficient than spot heating. The activity of the
therapist reheating and adjusting one spot often affects the adjacent
area, thereby producing another area requiring adjustment. This cycle
may not end until the orthosis is useless. When possible, the therapist
should use an orthosis product that is reheatable in water and easily
reshapable to obtain a proper fit for the client.
Orthotic-Wearing Schedule Factors
Development of an orthotic-wearing schedule for a client is sometimes
extremely frustrating for a novice therapist, because there are no
magic numbers or formulas for each type of orthosis or diagnostic
population. The therapist tailors and customizes the wearing schedule
to the individual and exercises clinical judgment. Only general
guidelines for orthotic-wearing schedules exist.
In the case of joint limitation, the therapist increases the wearing
frequency and time as much as the client can tolerate. Alternatively,
the therapist adjusts the intervention plan to try a different orthosis. If
motion is increasing steadily, the therapist may decrease the orthotic-
wearing time, allowing the client to engage in function by using the
limited joint or joints. If the orthosis improves function or the
extremity requires protection, the client wears the orthosis when
necessary. The following are questions to consider when determining
a wearing schedule:

• What is the purpose of the orthosis?

• Does the therapist anticipate that the client will be compliant
with an orthotic-wearing schedule?
• Does the client have any medical contraindications or
precautions for removing the orthosis?
• Which variables may affect the client’s tolerance of the
orthosis?
• Does the client need assistance to apply or remove the
orthosis?
• Is the orthosis for day or night use, or both?
• Does the client need to apply or remove the orthosis for
functional activities?
• How often does the client need to perform exercise and
hygiene tasks?

Answers to these questions should guide the development of a

wearing schedule. The therapist should keep in mind that the wearing
schedule may require adjustment as the client’s condition progresses.
In any situation the therapist should discuss the wearing schedule
with the client and caregiver (Box 6.4).

BOX 6.4 Sample Wearing Schedule

Person’s name:
Name of orthosis:
The purpose of this orthosis is to maintain the hand in a
functional position.
Prescribed wearing schedule:
8 a.m.to 12 p.m. On a
12 p.m. to 2 p.m. Off Provide PROM
2 p.m. to 6 p.m. On
6 p.m. to 8 p.m. Off Provide PROM
8 p.m. to 12 p.m. On
12 a.m. to 2 a.m. Off Provide PROM
2 a.m. to 6 a.m. On
6 a.m. to 8 a.m. Off Provide PROM
Wear the orthosis on the right upper extremity. Please contact J.
Smith at [phone number] in the Occupational Therapy
Department if any of the following occur:
• Pink or reddened areas
• Complaints of increased pain because of the orthosis
• Increased swelling with orthotic wear
• Skin rash
• Complaints of decreased sensation because of the
orthosis

PROM, Passive range of motion.

a
Skin check to be performed.
Discontinuation of an Orthosis
No distinct rules exist concerning discontinuation of an orthosis.
Frequently the physician makes the decision to discontinue an
orthosis. Other times the physician defers to the clinical judgment of
the therapist to determine when an orthosis is no longer beneficial.
Specific protocols, such as for a flexor tendon repair, indicate when an
orthosis is discontinued. In such cases the therapist should contact the
physician for a discharge order. Sometimes physicians order an
orthosis to be discontinued “cold turkey.” If the therapist clinically
reasons that the client would benefit from being weaned off the
orthosis, the physician should be contacted. The therapist should
communicate the rationale for the weaning and ask for approval. The
following are questions to consider when making the clinical decision
to discontinue an orthosis:

• Have the client and the caregivers been compliant with the
orthotic-wearing schedule? If not, why?
• What are the original objectives for orthotic provision, and has
the client accomplished them?
• Will the same objectives be compromised or accomplished
without an orthosis?

Adherence of the person and the caregiver is essential for success

with an orthotic-wearing regimen. If the client is not wearing the
orthosis, the therapist first uses clinical reasoning to identify the
reasons for nonadherence. For example, the nonadherence of an older
client in an institutional setting could be the result of one or more of
the following factors:

• Poor communication among the staff about the wearing

schedule
• Poor staff follow-through with the wearing schedule
• The older adult’s lack of understanding about the orthosis’
 purpose
• Discomfort of the orthosis
• The older adult’s fear of hidden costs associated with the
orthosis
• The older adult’s dislike of the orthosis’ cosmetic appearance

Reasons for nonadherence could be beyond this list, and it would be

up to the therapist to ascertain the problem. After identifying the
reason or reasons for nonadherence, the therapist can work on
possible solutions.
An important factor in determining when to discontinue the
orthosis is a careful review of the orthosis’ objectives. For example, a
therapist fabricates a mobilization orthosis for a client who has a
proximal interphalangeal (PIP) soft-tissue flexion contracture of the
middle finger. The objective is mobilization of the PIP joint to help
correct the flexion deformity. Gradually the orthosis facilitates
lengthening of the restricting structures, and extension is restored. By
monitoring ROM and evaluating the orthosis’ line of pull, the
therapist determines that the orthosis has maximally helped the client
and that the original intervention objectives were accomplished. At
that time the therapist calls the physician for an order to discontinue
the orthosis.
Therapists must consider whether accomplishment of the objectives
is possible without the orthosis. Timely discontinuation of any
orthosis is important. Therapists should keep in mind that
inappropriately provided or poorly fabricated orthoses can restrict
movement, make postural compromises by causing atrophy in one
muscle group and overuse in another, and injure other parts of the
anatomy. In addition, preventing the client’s dependence on an
orthosis is important. When the client has the functional capabilities,
therapists should adjust the orthotic-wearing schedule to gradually
wean the client away from the orthosis. 41
Cost and Payment Issues
Two issues exist regarding the cost of orthoses. First, how does the
therapist arrive at the price of an orthosis? Second, how does the
therapist receive payment for an orthosis? To calculate the price of an
orthosis, the therapist totals the direct and indirect costs (Box 6.5).
Direct costs include items such as the thermoplastic material,
strapping material, stockinette, rivets, shipping costs, tax, and so on. A
hospital or clinic purchases supplies at wholesale cost. However, a
percentage markup may appear on the cost. (This assists with
replenishing the inventory.) Indirect costs include nondisposable
supplies (such as scissors and fry pans), the time required for the
average therapist to make the orthosis, and overhead costs (such as
rent and electricity).

BOX 6.5 Hints for Determining Direct and

Indirect Costs

Because of tighter control of health-care dollars, many therapists are

finding that payment for orthoses is becoming increasingly difficult. It
is important that when necessary the therapist take an active role in
the outcome of a payment policy of an insurance plan regarding the
orthosis. This may help obtain payment for the orthosis. For example,
the therapist communicates with the case manager the purpose of the
orthosis.
The therapist must remember, however, that the plan belongs to the
client, not to the therapist. If an insurance plan reimburses costs
partially or not at all, the therapist should inform the client of the
responsibility for paying the balance of the cost. Some facilities make
accommodations for people who are uninsured or underinsured and
need orthotic provision, or there might be a pro bono clinic available
in the area. In addition, the therapist should provide specific
documentation to insurance companies about the affected extremity
and the type of orthosis and purpose of the orthosis. 17
It is important that therapists know how to effectively navigate the
system to receive payment for orthotic fabrication. If an orthosis is
ordered, it needs to be made. If the client declines the orthosis for any
reason, appropriate documentation and communication with the
referring physician is highly recommended. The therapist and the
client should work out financial aspects with the facility and
communicate with the appropriate clients, such as billing personnel. If
the therapist works in a private clinic, billing and payment may be
more challenging and require diligence to understand the variable
nuances of the individual payer sources. Payment is always
determined by the payer source. Generally, when billing, insurance
companies expect a line item bill detailing all charges applied,
including therapy codes, such as Current Procedural Terminology
(CPT) codes 12 and supply charges. CPT codes are numeric codes
covering tasks and services for payment.
For outpatient services, coding systems such as CPT codes are used
for payment of orthotics. With Medicare Part B (outpatient therapy)
therapists currently access Level I and Level II codes of the Healthcare
Common Procedure Coding System (HCPCS) codes, 12 and the term
orthotics is used with billing—not splinting. For Level I codes,
therapists currently utilize the Medicare Physician Fee Schedule
(MPFS) to determine the proper CPT codes. Different pricing exists for
the MPFS between states. Level II HCPCS codes address products and
supplies, including orthotics. 12 There are specific guidelines for filing
a claim depending on the setting where the services are provided,
such as for hospital outpatient, SNF Part B, in private practice, or in a
physician’s office practice. Billing is site specific, depending on what
population is served with respect to individual insurance scenarios.
Additionally, as payment is often linked closely with changes in
public policy, therapists must keep abreast of these changes.
For some clients with upper extremity problems that occurred on
the job, rehabilitation is reimbursed from the workers’ compensation
system. Therapists must keep in mind that in every state workers’
compensation laws are interpreted differently. Therefore, it is
important to be familiar with the state guidelines. Most state workers’
compensation plans cover medical costs related to the injury, such as
medical care (including receiving an orthosis), vocational
rehabilitation, and temporary disability. (The amount varies from
state to state. 4 ) Many states have adopted a managed care system.
With case managers the therapist should provide consistent and clear
communication about the client’s progress.
Some insurance companies simply refuse to pay for orthoses, and
others ask for so much documentation that more time is required to
prepare the bill than to make the orthosis. For example, some
insurance companies ask therapists for original invoices for the
purchase of thermoplastic and strapping materials. Developing
outcome studies or finding evidence in the literature may help obtain
payment from insurers. Giving these outcomes to insurers will
increase their understanding of the importance of orthotic
intervention in its relation to function. The American Society of Hand
Therapists 2 published Splint Classification Systems, a book about
naming and designing orthoses. This book helps terminology become
more uniform. 2
Policy Regulations: The Health Insurance
Portability and Accountability Act
This broad health legislation enacted in 1996 covers many areas with
Title II, or Administrative Simplification, influencing therapy practice.
Title II includes three main parts: Transaction Rule, Privacy Rule, and
Security Rule. The first part, Transaction Rule, affects billing
procedures. It mandates uniform national requirements for formats
and codes for electronic transmission. 61
Privacy Rule is another major component of Administrative
Simplification and directly influences clinical practice. Privacy rules
involve protection of client-identifying or confidential information
and client rights about their health information. These rules regulate
how protected health information (PHI) or any client-identifying
information is presented in written, verbal, or electronic format. 53
Therapists should obtain the client’s consent before using PHI for
intervention, payment, or health care operations. However, if a client
objects or fails to provide consent, therapists are permitted to use PHI
for intervention, payment, or health care operations without the
client’s consent. In most other circumstances, with very few
exceptions, therapists may not disclose PHI without the client’s
written authorization to do so. 54
Numerous privacy rights with respect to the client’s health
information are written into the regulations. For example, clients have
a right to request to see their medical record. See Box 6.6 for a listing
of client protections. Therapy clinics should have policies in place to
protect the privacy of client information. Requiring working charts to
be kept in a locked cabinet with the documents shredded after
intervention completion is an example of an internal policy protecting
privacy. 15 Other guidelines for protecting client privacy apply to use
of electronic health records (EHRs). Some areas of client information
are excluded from the law, such as allowing clients to sign in for
intervention, calling out a client’s name to go into the orthotic
fabrication room, or sharing information with another health
professional about the orthosis. 15,51 However, reasonable efforts to
avoid these types of disclosures should be taken. For instance, instead
of calling out, “Mr. Edward Jones, the therapist will see you now to
customize your resting hand orthosis,” a better approach would be,
“Edward, the therapist will see you now.”

BOX 6.6 Client Protections

The following are key client protections with a brief description:

• Access to medical records: See or obtain copies of medical

records, and ask for corrections of errors.
• Notice of privacy practice: Covered providers must provide
information on how personal medical information will be used
and patient rights under HIPAA regulations.
• Limits on use of personal medical information: Sets guidelines on
minimal standards of health care information sharing.
• Prohibition on marketing: Sets guidelines on disclosing of client
information for marketing purposes.
• Stronger state laws: State laws that are stronger than HIPAA are
followed.
• Confidential communications: Clients can request that
confidentiality be kept (e.g., asking the therapist to call his or her
work instead of home).
• Complaints: Clients have a right to file a formal complaint.

HIPAA, Health Insurance Portability and Accountability Act.

Incidental disclosures (information that is heard with reasonable

efforts to not be overheard) or sharing information that is limited are
not considered in violation of the Health Insurance Portability and
Accountability Act (HIPAA) law. 51 An example of an incidental
disclosure is an occupational therapist discussing information about
an orthosis bill with the secretary in the waiting room. These
disclosures are not considered liable under the law as long as there are
no other reasonable options (i.e., no other area for individual privacy
to discuss the bill). 50 Because therapy often takes place in an open
area with several people involved in conversations, some of which
potentially involve sharing of PHI, it needs to be clear in the consent
form about the clinic setup. 37, , 38 Therapists working in clinics with
an open area can employ simple strategies to allow more privacy,
such as partitioning off a private area or using a private room
available for intervention, communicating with lower voices, and
being careful with leaving sensitive messages on answering machines.
64 As York states, “creating a culture of privacy and maintaining good

rapport with patients will go a long way to preventing HIPAA

complaints as well as other types of legal problems.” 64
The third main part of Administrative Simplification, the Security
Rule, involves the policies and procedures that a facility has in place
to protect the PHI through “administrative, technical and physical
safeguards.” 61 The Security Rule mainly focuses on “electronic
protected health information,” 61 such as who has access to computer
data in a clinic. The simplification provisions include national
identifiers for health care providers and practitioners. 55 Finally,
therapists must keep abreast of their state privacy laws. If they are
stricter, they take priority over the HIPAA regulations. 64

Documentation
Orthotic application must be well documented. Documentation
assists in third-party payment and communication with other health
care providers, helps ascertain the medical-legal necessity, and
demonstrates the efficacy of the intervention. This section provides an
overview of general documentation principles to be used with
orthotics whether documentation is in written or in electronic format.
Orthotic documentation should be specific and should include
several elements, such as the onset of the medical condition that
warrants an orthosis; the medical necessity for the orthosis; the level
of function before the orthosis; the client’s rehabilitation potential
with the orthosis; and type, purpose, and anatomical location of the
orthosis. Therapists should also document that they have
communicated with the client an oral and written wearing schedule
and have had discussions about precautions. Any input that the client
provides to the intervention plan, such as mutual goal setting, should
be documented.
Orthotic documentation, including goal setting, should be related to
function. It is not sufficient to document that a client’s ROM has
improved to a certain level because of wearing an orthosis. The
therapist should specifically document how the improved ROM has
helped the client perform specific functional activities. For example,
the therapist may document that because of improved wrist motion
from wearing an orthosis, the client is able to work on a computer. As
with any documentation, the therapist should consider legal
implications. Documentation should be thorough, complete, and
objective. The therapist should always remember, “If it wasn’t
documented, it didn’t happen.” For example, the therapist should
document the specific measurements by which the hand is positioned,
the diagnosis and type of orthosis fabricated and any client
communication. Also, for example, if the client has a reddened area
because of wearing an orthosis, the specific location and size of the
reddened area as well as any orthotic adjustments made should be
documented. Any communication or advice about the orthosis from
the physician should be documented with the time and date of the
call. 16
Documentation for follow-up visits should include the date and
time that the client is supposed to return and a notation that the date
and time have been discussed with the client. This helps protect the
therapist if there are claims of negligence with follow-up care. 16
Documentation for follow-up visits should also include any changes
in the orthotic design and wearing schedule. In addition, the therapist
should note whether problems with adherence are apparent.
Documenting evidence of adherence includes documenting
instructions provided and objective client’s or caregiver’s behavior
that contradicts instructions. For example, the therapist might
document that the client stated that he or she did not follow the
orthotic-wearing schedule. Documenting dates and times that the
orthotic-wearing schedule is not being followed for a client in a SNF is
an example of specific documentation. If this happens, the therapist
may further educate the caregivers and note when and what type of
education was completed. If the caregivers still do not properly follow
the schedule, the therapist should come up with another plan and
involve the caregivers in the decision-making process to ensure
adherence.
Another objective observation for a client followed in any setting is
notation of signs of wear, such as scratching, light soil, or strap wear.
With documentation, it is inappropriate to criticize other health care
professionals, such as documenting that contractures developed
because the nursing staff did not apply an orthosis. 16
The therapist should perform orthotic reassessments regularly until
completion of the client’s weaning from the orthosis or discharge from
services. Documentation after the reassessments should be timely and
based on guidelines from the insurer. 16 Finally, the therapist should
keep in mind that different facilities use different methods to
document, and the therapist should be familiar with the routine
method of the facility. (See Examples 6.1 and 6.2 for illustrations of a
narrative and a SOAP note for an orthosis, respectively.)
Orthotic Intervention Error and Client
Safety Issues
Orthotic intervention errors occur in occupational therapy. 43
Examples of these errors include fabricating the wrong type of
orthosis for the condition or failure to follow through with the
orthotic-wearing schedule. Either of these errors could cause client
harm, such as severe pain or breakdown of the skin. Although many
errors are the direct result of individual failure, most errors are caused
by system problems. System errors may occur due to diagnostic error,
equipment/product failure, or miscommunication of medical orders,
to name a few.
Orthotic intervention errors can easily result from incorrect or
inadequate communication. A physician, for example, may order a
right-hand orthosis when it is meant for the left hand. If the therapist
fails to question the physician order, an orthosis may be fabricated for
the wrong site. Wrong patient, wrong site, or wrong procedure is one
of the leading sentinel events reported to the Joint Commission on
Accreditation of Healthcare Organizations (The Joint Commission). 27
According to data collected by The Joint Commission, team
miscommunication is at the root of a great proportion of all errors
made in health care. 28 Occupational therapists often lack
assertiveness when communicating with physicians, and this failure
to adequately communicate can result in patient harm. 14
Understanding the nature of hierarchical organizational structures
and the need for coordination of care through “interdisciplinary care
management” and “coordinated communication” are vital to client
safety . 26 Occupational therapists need to participate in team training.
22 Team training allows therapists to have the knowledge, skill, and

attitude competencies, 36 as well as assertiveness and adaptability

capability to enhance communication, team effectiveness, and the
culture of safety. 18
 To create this culture of safety, occupational therapists must also
debunk or dispel the myth of performance perfection. To err is
human! After all, health care delivery is a very complex system. In
complex systems, errors are inevitable regardless of how well trained,
well intentioned, or ultracareful the individual therapist may be. In
the case of the therapist acting on the physician’s wrong order, it
would be unjust to simply require the last treating practitioner to be
fully accountable for the error. In this situation, blaming and
sanctioning would only encourage the therapist and/or physician to
hide the error rather than disclose and report it.
Today’s undisclosed near miss or minor error can become
tomorrow’s egregiously harmful error. Only by acknowledging error
can health practitioners individually and collectively learn from that
error and make individual and system practice changes to prevent
errors in the future. Furthermore, truthful disclosure of error to clients
by the therapist or a disclosure team is not only an ethical obligation
but organizations (such as The Joint Commission, the University of
Michigan Health System, and the Veterans Health Administration)
and several states now mandate disclosure. 1,58
Part of the disclosure process should be expressions of sympathy
and a formal and authentic apology. There is an advocacy
organization, The Sorry Works! Coalition, 59 that provides disclosure
and apology educational programs to practitioners to assist them in
communicating with clients who have been harmed by an error. 60 In
the past, health care practitioners were actually cautioned by their
malpractice insurance carriers not to apologize, because an apology
might increase the chances of being sued. 5 Currently at least 36 states
have enacted statutes that prevent some or all information given in an
apology from being used if a client sues a practitioner. 25 Clients want
to receive apologies and to be told the truth when an error occurs that
causes them harm. Many health care organizations that have
instituted disclosure programs now have evidence that disclosing
errors can lower liability lawsuit expenses.
Ultimately, creating an environment where practitioners are
encouraged and supported for promoting safety, reporting errors, and
truthfully disclosing them to clients is everyone’s goal. This practice
safety goal should always be a guidepost for clinical reasoning when
orthotic fabrication failures occur.

a
Self-Quiz 6.1
For the following questions, circle either true (T) or false (F).

1. T F An infant can follow an orthotic-wearing program without

extraordinary methods.
2. T F Determining a client’s lifestyle needs for orthotic design and
material is important.
3. T F Paramount to a client’s cooperation is education about the
medical necessity for wearing an orthosis.
4. T F If a client has a wound that requires dressing changes, the
therapist should fabricate the orthosis over the dressing and
instruct the client to apply new dressings at appropriate
intervals.
5. T F The only sign of an ill-fitting orthosis is red marks.
6. T F A well-fitting orthosis, upon removal, may leave a red area
on the client’s skin.
7. T F In the presence of severe edema, the therapist should use
circumferential straps.
8. T F The therapist should use a heat gun for all necessary
adjustments.
9. T F If motion is decreased because of joint limitation, the
therapist should decrease the frequency or time the client wears
the orthosis.
10. T F When deciding to discontinue an orthosis, the therapist
must consider the original objectives of the orthotic fabrication.
11. T F To calculate the cost of an orthosis, the therapist should
consider the direct and indirect costs.
12. T F Payment is always determined by the payer source.
13. T F If a client develops a reddened area because of wearing an
 orthosis, the therapist should just document that fact and note
specifics about location or size of the affected area.
14. T F Calling out a client’s name in a waiting room to go back into
the orthotic fabrication area is considered in violation of
HIPAA.

a
See Appendix A for the answer key.

Review Questions
1. How would a therapist apply the various clinical
reasoning models to orthotic provision?
2. What does an orthosis referral include?
3. How can the therapist facilitate communication with the
physician’s office about the orthosis referral?
4. Why is knowing the client’s age important to the therapist
when fabricating an orthosis?
5. Which lifestyle needs of the client must the therapist
consider with orthotic provision?
6. How can the therapist enhance the adherence of a client
wearing an orthosis?
7. What are the infection control procedures that a therapist
should follow with orthotic provision?
8. What should therapists monitor when providing an
orthosis for a client during the following conditions:
pressure, edema, and physical status of a client?
9. What are the four directions of orthotic design?
10. What are some helpful hints for adjusting after orthotic
fabrication?
11. What are the factors that the therapist should consider
when establishing a client on an orthotic-wearing
schedule?
12. What are the factors that a therapist should consider for
orthosis discontinuation?
13. What are the cost and payment issues the therapist must
keep in mind?
14. How might HIPAA influence communication with clients
about orthoses in a clinical setting?
15. What documentation issues should the therapist be aware
of with orthotic intervention?
16. What is the best way to morally manage an orthotic
fabrication error that causes harm to a client?
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Appendix 6.1 Case Studies
Case Study 6.1 a

Read the following scenario, and answer the questions based on information
in this chapter.
Steven, a 46-year-old construction worker who has problems with
alcohol consumption, awakened from a drinking binge after he fell
asleep with his arm over the top of a chair to find that his right hand
and wrist were limp. He showed his wife how he could no longer
extend his wrist to do activities and stated, “Maybe I had a stroke.”
Hoping that his function would improve, he waited a few days and
then decided to see his primary physician. Steven asserted to his
physician that he thought he had a stroke and was concerned about
his ability to do work. The physician examined Steven’s arm and
stated, “I can’t say for certain whether it was a small stroke or a nerve
injury. In the past with issues like this, I have referred patients to an
occupational therapist at an outpatient therapy clinic.” Occupational
therapy was ordered for intervention and orthotic fabrication. The
order was vague as to what type of orthosis.
You are a new therapist at the outpatient clinic. Initial evaluation
reveals decreased sensation in the pathway of the radial nerve, absent
wrist extension, metacarpophalangeal (MCP) finger extension, and
thumb abduction and extension. Please refer to Chapter 13 for
information on nerve injuries.

1. What injury do you assume Steven has sustained, and how did
he sustain it?
2. How do you clarify the physician’s order if you are unsure
about it?
3. As a new therapist unsure about which one, where would you
find the information about an appropriate orthosis for this
patient?
4. After completion of the orthosis, you send Steven home with a
 home exercise program and instructions about orthotic wear.
What type of education and orthotic-wearing schedule will
you provide? Why?
5. Upon return to the clinic, Steven states that he does not like
wearing the orthosis because, as he states, “It does not fit with
my macho image, and it seems like it is taking forever to do
any good.” He reports minimal wear of the orthosis. How will
you handle his nonadherence?

Case Study 6.2 a

Read the following scenario, and answer the questions based on information
in this chapter.
Marie, a 57-year-old woman, is employed as a department store
clerk. She works part-time except for the winter holiday season. She
has been in good health except for having diabetes, which is well
regulated. Her job demands involve unloading boxes, stocking new
merchandise, and operating a cash register. During the winter holiday
season, Marie worked 40-hour weeks. In addition, she was busy at
home decorating and baking. One week before Christmas she noted
pain radiating up her dominant right forearm and around the radial
styloid.
Marie complained to her employer of pain when moving the thumb
and when turning her forearm up. Marie was seen by the company
physician, who diagnosed her condition as de Quervain tenosynovitis.
She was provided with a prefabricated thumb immobilization
orthosis, which she did not wear due to it being uncomfortable and
causing some chafing on the volar surface of the thumb
interphalangeal (IP) joint. Two weeks later, when symptoms did not
improve, the company physician ordered occupational therapy. The
order read: “Fabricate an R thumb orthosis and provide a home
exercise program.” The following initial therapy note purposely
displays flawed documentation.

10-13
Client was followed on 10-13 for fabrication of an orthosis and to
provide a home exercise program. Client was wearing a prefabricated
orthosis. Reddened areas were noted on the thumb. Client was
instructed in a home exercise program, orthotic precautions, and a
wearing schedule. It doesn’t appear that the client will be compliant
with wearing the orthosis.
Results of the evaluation are as follows:

DIP, Distal interphalangeal; FA, forearm; L, left; MP, metacarpal; R, right: ROM, range of
motion; UE, upper extremity; WNL, within normal limits.

Goals

• Long-term goal: Patient will follow provided orthotic-wearing

schedule by discharge from therapy.
• Short-term goal: Patient will show decreased symptoms from
de Quervain tenosynovitis.

To encourage clinical reasoning skills, answer the following

questions about the case. See Chapter 8 for specifics about orthoses for
de Quervain tenosynovitis.

1. List a minimum of five areas of the documentation that could

be improved by being more specific or more complete.
2. Based on the interactive clinical reasoning approach, what are
 two questions that will facilitate an understanding of the
impact that having de Quervain tenosynovitis and wearing an
orthosis has on Marie’s work and home life?
3. What are some concerns about adherence you may have based
on Marie’s history with her prefabricated orthosis? How will
you approach any adherence concerns?
4. Considering that the referral came from work, what type of
insurance might Marie have?
Appendix 6.2 Examples
Example 6.1
The following is an initial progress note (IPN) following orthotic
fabrication. Although this note is an exemplar for written
documentation, the same information should be included in electronic
format.
February 24, 20__, 4:00 pm
This 42-year-old female was seen by an occupational therapist for
fabrication of a right wrist immobilization orthosis on the dominant R
UE. Client has a history of carpal tunnel syndrome since August 20,
20__. Client reports being independent in ADLs, work, and leisure
tasks before condition developed. Client displays problems related to
carpal tunnel syndrome, including decreased R grip strength, R hand
swelling at end of day, pain, tingling, decreased sensation in the area
of the median nerve, and a positive Phalen sign. (Refer to the
summary report of the Semmes-Weinstein Monofilament Test.) Client
displays problems with cooking meals and typing on computer at
work. Client currently requires help from her daughter for such tasks
as opening cans and jars and cutting food with a knife. Client is
employed as a secretary, and job demands primarily involve
computer work. At work, client tolerates 20 minutes of typing on
computer before pain and tingling develop in the R hand. Client
stated, “It is difficult for me to type on the computer and cook a
meal.” B UE AROM was WNL except for the following R UE motions:

• Thumb: Opposition to ring finger—unable to oppose little

finger
• R finger TAMs (Normal = 250 to 265 degrees):
• Index = 230 degrees
• Middle = 230 degrees
• Ring = 240 degrees
• Little = 270 degrees
 • R wrist:
• Flexion = 0 to 50 degrees (Normal = 0 to 80 degrees)
• Wrist extension (WNL)
• Radial deviation = 0 to 15 degrees (Normal = 0 to 20
degrees)
• Ulnar deviation (WNL)

Grip strength was tested with Jamar dynamometer. R grip strength

= 30 pounds (10th percentile for age and gender) and L grip strength =
64 pounds (Normal = 75th percentile for age and gender). MMT
results are as follows:

• R abductor pollicis = 3 (fair)/5, L = 5 (normal)/5

• R opponens pollicis = 3 (fair)/5, L = 5 (normal)/5

A R volar-based, neutral wrist immobilization orthosis was

fabricated. Client presented with no pressure marks or rash after
orthotic application. Client was evaluated for functional hand motions
while wearing the orthosis. The orthosis did not restrict finger and
thumb motions. Client received verbal and written instructions about
orthotic-wearing schedule and a form to document wearing
adherence. Client could independently don and doff her orthosis.
Client received verbal and written instructions for a home exercise
program, orthosis precautions, and ergonomic adaptations for home
and work environments. Client’s understanding of all instructions
appeared to be good. Client will be followed two more times per
physician order to monitor orthosis and program and ergonomic
adaptations.

OT Goals

LTGs: Client will report a decrease in R hand pain and tingling to

complete home and work activities independently by [date].
STGs:
• Client will independently complete computer tasks at
 work while wearing R wrist orthosis for 3 hours daily
and taking hourly exercise breaks by [date].
• Client will independently cook a meal while wearing
R wrist orthosis and report reduced pain by [date].
• Client will properly position B UEs during computer
work activities and utilize ergonomic office equipment
by [date].
• Client will comply with orthotic-wearing schedule
90% of the time as evidenced by the orthotic-wearing
schedule adherence sheet by [date].

ADLs, Activities of daily living; AROM, active range of motion; B,

bilateral L, left; LTG, long-term goal; MMT, manual muscle testing;
OT, occupational therapy; R, right; STG, short-term goal; TAM, total
active motion; UE, upper extremity; WNL, within normal limits.

Example 6.2
The following is an OT SOAP note. Although this note is an exemplar
for written documentation, the same information can be included in
electronic format.
February 24, 20__, 4:00 pm
S (subjective): “My right hand tingles and hurts all the time.” Client
also reports difficulty cooking meals and typing on the computer
while at work.
O (objective): Client presents with an Hx of carpal tunnel
symptoms in dominant, R, hand since August 20, 20__. Client reports
being independent in ADLs, work, and leisure tasks before condition
developed. Client displays a positive R Phalen sign with decreased
sensation in the R median nerve distribution area. (Refer to Semmes-
Weinstein Monofilament Test summary sheet.) B UE AROM was
WNL, except for the following motions:

R thumb opposition to ring finger—unable to oppose little finger

R finger TAMs (Normal = 250 to 265 degrees):
 • Index = 230 degrees
• Middle = 230 degrees
• Ring = 240 degrees
• Little = 270 degrees
• R wrist: Flexion = 0 to 50 degrees (Normal = 0 to 80
degrees)
• Wrist extension (WNL)
• Radial deviation = 0 to 15 degrees (Normal = 0 to 20
degrees)
• Ulnar deviation (WNL)

Grip strength was tested with Jamar dynamometer. R grip strength

= 30 pounds (10th percentile for age and gender). L grip strength = 64
pounds (75th percentile for age and gender). MMT results as follows:

• Abductor pollicis: R = 3 (fair)/5, L = 5 (normal)/5

• Opponens pollicis: R = 3 (fair)/5, L = 5 (normal)/5

Client displays problems related to carpal tunnel syndrome,

including decreased R grip strength, R hand swelling at end of day,
and problems with cooking meals and typing on computer at work.
Client currently requires help from her daughter for such tasks as
opening cans and jars and cutting food with a knife. At work, client
tolerates 20 minutes of typing on computer before pain and tingling
develop in the R hand.
A R volar-based, neutral wrist immobilization orthosis was
fabricated. Client presented with no pressure marks or rash after
orthotic application. Client was evaluated for functional hand motions
while wearing the orthosis. The orthosis does not restrict finger and
thumb motions. Client received verbal and written instructions about
orthotic-wearing schedule and a form to document wearing
adherence. Client was able to independently don and doff orthosis.
Client received verbal and written instructions for a home exercise
program, orthosis precautions, and ergonomic adaptations for home
and work environments. Client’s understanding of all instructions
appeared to be good.
A (assessment): Client seems to have a good rehabilitation potential
as she reports motivation to comply with OT intervention. Client is
able to complete functional activities while wearing the R wrist
immobilization orthosis. Symptoms may decrease with orthosis wear
and with implementation of the home exercise program and
ergonomic home and work adaptations.
P (plan): Client will be followed two more times per physician
order to monitor orthosis and program and ergonomic adaptations.

OT Goals

LTGs: Client will report a decrease in R hand pain and tingling so

as to complete home and work activities independently by
[date].
STGs:
• Client will independently complete computer tasks at
work while wearing R wrist orthosis for 3 hours daily
and taking hourly exercise breaks by [date].
• Client will independently cook a meal while wearing
R wrist orthosis and report reduced pain by [date].
• Client will properly position B UEs during computer
work activities and utilize ergonomic office equipment
by [date].
• Client will comply with orthotic-wearing schedule
90% of the time as evidenced by the orthotic-wearing
schedule adherence sheet by [date].

(John Smith, OTR)

ADLs, Activities of daily living; AROM, active range of motion; B,
bilateral; Hx, history; L, left; LTG, long-term goal; OT, occupational
therapy; OTR, registered occupational therapist; R, right; STG, short-
term goal; TAM, total active motion; UE, upper extremity; WNL,
within normal limits.
a See Appendix A for answers.
a See Appendix A for answers.
Orthoses for the Wrist
Helene L. Lohman

CHAPTER OBJECTIVES
1. Discuss diagnostic indications for wrist immobilization orthoses.
2. Identify major features of wrist immobilization orthoses.
3. Describe the fabrication process for a volar or dorsal wrist
orthosis.
4. Relate hints for a proper fit for a wrist immobilization orthosis.
5. Review precautions for wrist immobilization orthotic intervention.
6. Use clinical reasoning to evaluate a problematic wrist
immobilization orthosis.
7. Use clinical reasoning to evaluate proper fit of a fabricated wrist
immobilization orthosis.
8. Apply knowledge about the application of wrist immobilization
orthoses to case studies.
9. Explain the importance of evidence-based practice and how it
informs wrist orthotic provision.
10. Describe the appropriate use of prefabricated wrist orthoses.

KEY TERMS
carpal tunnel syndrome (CTS)
circumferential
complex regional pain syndrome (CRPS)
dorsal
forearm trough
hypothenar bar
metacarpal bar
radial nerve injuries
rheumatoid arthritis (RA)
tendinopathy
tendinosis
ulnar
volar

You are dining with your good friend, Julia. She tells you she has been
experiencing night pain in her right wrist, thumb, index, and middle
fingers. You ask her to describe the pain, and she says it feels like pins
and needles and sometimes her fingers become numb. Immediately you
inquire what she has been doing lately. Julia is a student in a rigorous
professional speech language therapy program. Besides much repetitive
typing on the computer, she works part-time in a lawn and gardening
business. That job involves repetitive pinching and wrist flexion with
weeding as well as sustained grip and vibration when using an electric
lawn mower. You suspect she might have carpal tunnel syndrome (CTS)
and advise her to see her physician. A week later you see Julia again. She
informs you that she was diagnosed with CTS and asks you what types
of therapy could help alleviate the symptoms. You tell her that based on
evidence, an effective intervention in early stages of CTS is to wear an
orthosis that positions her wrist in neutral.

Note: This chapter includes content from previous contributions

from Robert Gilmore, OTS.
Maintaining the wrist in proper alignment is essential because the
wrist is important to the health and balance of the entire hand. During
functional activities the wrist is positioned in extension for grasp and
prehension. Therefore the wrist extension immobilization type 0
orthosis 3 or the wrist cock-up orthosis is one the most common
orthoses fabricated in clinical practice. Wrist immobilization orthoses
usually maintain the wrist in either a neutral or a mildly extended
position, depending on the protocol for a diagnostic condition and the
person’s intervention goals. A wrist immobilization orthosis positions
the wrist while allowing full metacarpophalangeal (MCP) flexion and
thumb mobility. Thus the person can continue to perform functional
activities with the added support and proper positioning of the wrist
that the orthosis provides. Positioning the wrist in 0 to 30 degrees of
wrist extension in an orthosis promotes functional hand patterns for
completing functional activities. 46,56
Therapists fabricate wrist immobilization orthoses to provide volar;
dorsal; ulnar; circumferential forearm, wrist, and hand; and
occasionally radial support (Figs. 7.1–7.4). Therapists also use wrist
immobilization orthoses as bases for mobilization and static
progressive orthotic intervention (see Chapter 13). Although some
wrist immobilization orthoses are commercially available, they cannot
provide the exact fit of custom-made orthoses. However,
commercially available or prefabricated orthoses made from soft
material may be more comfortable in certain situations, especially in a
work or sports setting. Commercially available orthoses are not as
restrictive and allow more functional hand use. 71 Some people with
rheumatoid arthritis (RA) may also prefer the comfort of a soft wrist
orthosis due to its ability to reduce pain and provide stability during
functional activities. 11,51,72
FIG. 7.1 A to C, A volar wrist immobilization orthosis.
 FIG. 7.2 A and B, A dorsal wrist immobilization orthosis.

This chapter gives an overview of wrist immobilization orthoses

according to type, features, and diagnoses. The chapter addresses
technical tips, troubleshooting tips, the use of prefabricated orthoses,
the impact on occupations, and the application of a wrist mobilization
and serial static approach. Interspersed throughout this chapter are
discussions of evidence to understand current wrist orthosis
provision.
FIG. 7.3 A and B, An ulnar wrist immobilization orthosis.
FIG. 7.4 A and B, A circumferential wrist immobilization orthosis.
Volar, Dorsal, Ulnar, Circumferential,
and Dart Thrower’s Wrist Orthoses
In clinical practice the therapist must decide whether to fabricate a
volar, dorsal, ulnar, or circumferential wrist immobilization orthosis.
Each has advantages and disadvantages. 21

Volar
The volar wrist immobilization orthosis (see Fig. 7.1) depends on a
dorsal wrist strap to secure the wrist in the orthosis. An appropriate
design furnishes adequate support for the weight of the wrist and
hand. In cases in which the weight of the hand (flaccidity) must be
held by the orthosis or in which the person is pulling against it
(spasticity), the strap may not be adequate to hold the wrist in the
orthosis. However, a well-designed volar wrist orthosis with a
properly placed wide wrist strap will support a flaccid wrist. 64 The
volar design is best suited for circumstances that require rest or
immobilization of the wrist when the person still has muscle control of
the wrist. 21
A volar wrist orthosis’ greatest disadvantage is interference with
tactile sensibility on the palmar surface of the hand and the loss of the
hand’s ability to conform around objects. 64 In the presence of edema,
one must use this design carefully because the dorsal strap can
impede lymphatic and venous flow. 21 To address the presence of
edema, a strap adaptation is made by circumferentially wrapping a
continuous strap that is gently overlapping from distal to proximal
until the whole hand/splint is covered.

Dorsal
Some therapists fabricate dorsal orthoses with a large palmar bar that
supports the entire hand. This large palmar bar tends to distribute
pressure well and is necessary for comfort and function. However, a
large palmar bar does not free up the palmar surface as much for
sensory input as a dorsal orthosis fabricated with a thinner palmar bar
(see Fig. 7.2). Dorsal wrist orthoses designed with a standard strap
configuration can be better tolerated by persons who have edematous
hands because of the pressure distribution. Either the volar or the
dorsal design may be used as a base for mobilization (dynamic)
orthotic intervention. However, these designs can sometimes lead to
orthotic migration and suboptimal orthotic performance.

Ulnar
The ulnar wrist orthosis is easy to don and doff and can be applied if
the person warrants more protection on the ulnar side of the hand,
such as with sports injuries (see Fig. 7.3). This ulnar orthotic design is
sometimes used for a person who has carpal tunnel syndrome (CTS)
or ulnar wrist pain. 42 It can also be used as a base for mobilization
orthoses.

Circumferential
A circumferential orthosis is helpful to prevent migration, especially
when used as a base for mobilization orthoses. Circumferential wrist
orthoses also provide good forearm support, control edema, provide
good pressure distribution, and eliminate edge pressure. 65 Some
people may feel more confined in a circumferential orthosis. When
fabricating a circumferential orthosis, the therapist is conscious of a
possible pressure area over the distal ulna and checks that the fingers
and thumb have full motion (see Fig. 7.4). 40 Among many
circumferential orthosis design options are a bivalve design and a
“zipper” orthosis. The bivalve design provides rigid immobilization
and allows for easy adjustments when edema levels change, so a new
orthosis does not need to be fabricated (Fig. 7.5A). A zipper orthosis is
made from perforated thermoplastic material and can provide
stabilization and support. Zipper orthoses work well with edema that
does not change. Some zipper orthoses can get fully wet in water and
they have no straps to get caught on items (Fig. 7.5B).

Dart Thrower’s
Researchers defined a plane of wrist motion closely related to
performance of activities of daily living (ADLs) called the dart-
throwing motion. This motion occurs in the plane from “radial
deviation and extension” to “ulnar deviation and flexion” 48,66 A
hinged type of wrist orthosis called a dart orthosis is based on the
defined plane of dart-thrower’s motion. Dart orthoses aid the
rehabilitative process by restricting the radiocarpal joint and
scapholunate ligament movements. It is hypothesized that with the
early protected motion provided by dart orthoses, they speed up
functional wrist recovery after injuries to the ligaments of the
proximal carpal row and the wrist. 9,66 Dart thrower’s orthoses present
a new intervention approach for some wrist conditions. However,
further research is necessary to demonstrate their efficacy (Fig. 7.6).
Features of the Wrist Immobilization
Orthosis
Understanding the features of a wrist immobilization orthosis helps
therapists design orthotic interventions appropriately. Whether
fabricating a volar, dorsal, ulnar, or circumferential wrist orthosis, the
therapist must be aware of certain features of the various components
of the wrist immobilization orthosis—such as a forearm trough,
metacarpal bar, and hypothenar bar (Figs. 7.7 and 7.8). 28 With a volar
or dorsal immobilization orthosis the forearm trough should be two-
thirds the length of the forearm and one-half the circumference of the
forearm to allow for appropriate pressure distribution. It is sometimes
necessary to notch or flare the area near the distal ulna on the forearm
trough to avoid a pressure point.
The hypothenar bar helps to place the hand in a neutral resting
position by preventing extreme ulnar deviation. The hypothenar bar
should not inhibit MCP flexion of the ring and little fingers. The
metacarpal bar supports the transverse metacarpal arch. When
supporting the palmar surface of the hand, the metacarpal bar is
sometimes called a palmar bar. With a volar wrist immobilization
orthosis, the therapist positions this bar proximal to the distal palmar
crease and distal and ulnar to the thenar crease to ensure full MCP
flexion. On the ulnar side of the hand, it is especially important that
the metacarpal bar be positioned proximal to the distal palmar crease
to allow full little finger metacarpal flexion.
On the radial side it is important for the position of the metacarpal
bar to be proximal to the distal palmar crease and distal to the thenar
crease to allow adequate index and middle MCP flexion and thumb
motions. On a dorsal wrist immobilization orthosis, the therapist
positions this bar slightly proximal to the MCP heads on the dorsal
surface of the hand when it winds around to the palmar surface. The
same principles apply when positioning the metacarpal bar on the
volar surface of the hand (proximal to the distal palmar crease, and
distal and ulnar to the thenar crease).
The therapist should also carefully consider the application of
straps to the wrist orthosis. Straps are applied at the level of the
metacarpal bar, exactly at the wrist level, and at the proximal end of
the orthosis. The straps attach to the orthosis with pieces of self-
adhesive Velcro hook. The therapist should note that the larger the
piece of self-adhesive hook Velcro, the larger the interface between it
and the thermoplastic material. This larger interface helps ensure that
it remains in place and does not peel off (see Figs. 7.1 and 7.7). With
the identification of potential pressure or shear problems, the therapist
applies padding to the orthosis.
 FIG. 7.5 A, A bivalve circumferential design. B, A “zipper” orthosis
option for making a circumferential orthosis (Sammons Preston &
Rolyan).
A courtesy Mojca Herman. B from Bednar, J. M., & Von Lersner-
Benson, C. [2002]. Wrist reconstruction: Salvage procedures. In E. J.
Mackin, A. D. Callahan, T. M. Shirven, et al. (Eds.), Rehabilitation of
the hand and upper extremity [5th ed., p. 1200]. St. Louis, MO:
Mosby.
FIG. 7.6 A dart orthosis. Developed by Deborah A. Schwartz OTD,
 OTR/L CHT. (From Schwartz, D. A. [2016]. An alternative fabrication
method of the dart thrower’s motion orthosis [also known as the dart
orthosis]. Journal of Hand Therapy , 29[3], 339–347.)

Diagnostic Indications
The clinical indications for a wrist immobilization orthosis vary
according to the diagnosis. The therapist can apply the wrist
immobilization orthosis for any upper extremity condition that
requires the wrist to be in a static position. Application of this orthosis
addresses a variety of goals, depending on the client’s intervention
needs. These goals include decreasing wrist pain or inflammation,
providing support, enhancing digital function, preventing wrist
deformity, minimizing pressure on the median nerve, and minimizing
tension on involved structures.
In some cases, a wrist mobilization orthosis serial static approach is
used to increase passive range of motion (PROM). Specific diagnostic
conditions that may require a wrist immobilization orthosis can
include, but are not limited to, tendinopathy, distal radius fracture,
wrist sprain, radial nerve palsy, RA and wrist arthroplasty, and nerve
compression at the wrist (CTS). Wrist orthoses for complex regional
pain syndrome (CRPS) may be applied if the person is posturing in
flexion, but application of orthoses for this condition is controversial
because immobilization may increase the pain cycle. 23
 FIG. 7.7 A volar wrist immobilization orthosis with identified
components.

The specific wrist positioning depends on the diagnostic protocol,

physician referral, and person’s intervention goals. When the goal is
functional hand use during orthotic wear, the therapist avoids
extreme wrist flexion or extension because either position disrupts the
normal functional position of the hand. Extreme positions can
contribute to the development of CTS. 28,29 An exception to this rule is
when the orthotic goal is to increase PROM. In that case an extreme
position may be indicated. However, extreme positions may preclude
function. The therapist must judge whether the trade-off is worth the
loss of function. 65 Another consideration is choice of the
thermoplastic material thickness. Generally, for most of the diagnoses
discussed in this chapter, ⅛-inch thickness provides the proper
amount of support. Thinner material (e.g., 1⁄16 inch) works well with
skin that might be prone to breakdown. Thinner material may be
useful when fabricating a wrist orthosis for CTS on an older adult
with thinner skin, when fabricating an orthosis on a small hand (e.g., a
child), or for someone with RA.
The therapist performs a thorough hand evaluation before fitting a
person with a wrist immobilization orthosis and provides the person
with a wearing schedule, instructions about orthotic maintenance and
precautions, and an exercise program based on needs. Physicians and
experienced therapists may have detailed guidelines for positioning
and wearing schedules. Every hand and diagnosis is slightly different,
and thus orthotic positioning and wearing protocols vary. Table 7.1
lists suggested wearing schedules and positioning protocols of
common hand conditions that may require wrist immobilization
orthoses.
 FIG. 7.8 A dorsal wrist immobilization orthosis with identified
components.

Wrist Orthotic Intervention for Carpal Tunnel

Syndrome
CTS is a common and painful wrist and hand condition caused by
increased compression of the median nerve as it passes through the
very narrow carpal tunnel. To relieve pressure, wrist orthotic
provision is typically part of conservative intervention, and research
supports its use. According to recent evidence-based clinical
guidelines for CTS from the American Academy of Orthopaedic
Surgeons (AAOS), strong evidence supports wrist orthotic provision
to improve patient outcomes, specifically with conservative
management. 1 The AAOS report highlights two high-quality studies
31,44 with findings that full-time 31 or nighttime orthotic wear 44 as

compared to no wear resulted in statistically significant change in

reduction of pain and improvement in functional abilities. Quality
measures for CTS recommend orthotic intervention for conservative
management. 52 A recent Cochrane systematic review, however,
suggests further research about the efficacy of wrist orthoses for CTS.
57
Research has consistently suggested that for orthotic intervention
with CTS the wrist should be positioned as close as possible to zero
degrees (neutral) to avoid added pressure on the median nerve.
13,15,29,39,52 This neutral position may help with blood circulation. 53

Additionally, recent research for a newer approach to CTS orthotic

provision includes MCP immobilization to rest the lumbricals in a
neutral position. 7,12,13,30

TABLE 7.1

Conditions That May Require a Wrist Immobilization Orthosis

AAOS, American Academy of Orthopaedic Surgeons; IP, interphalangeal; MCP,
metacarpophalangeal.
 FIG. 7.9 A fabricated wrist immobilization (lumbrical positioning)
orthosis with the wrist and metacarpophalangeals in a neutral position.
From Brininger, T. L., Rogers, J. C., Holm, M. B., et al. [2007]. Efficacy
of fabricated customized splint and tendon and nerve gliding exercises
for the treatment of carpal tunnel syndrome: A randomized controlled
trial. Archives of Physical Medicine and Rehabilitation, 88[11], 1429–
1436.

One must be careful when applying prefabricated wrist orthoses for

CTS because some orthoses place the wrist in a functional position of
20 to 30 degrees of extension. 52,54,80 Therefore, if it is possible to adjust
the wrist angle of the orthosis, it should be modified to a neutral
position. Some of the prefabricated orthoses have a compartment in
which a metal or thermoplastic insert is placed, and the insert allows
adjustments for wrist position. However, prefabricated orthoses that
have their angles adjusted may become unstable, less rigid, and less
comfortable than a custom-molded orthosis. 77
Another consideration with the wrist immobilization orthotic
provision is the amount of finger flexion allowed. Research suggests
that finger flexion affects carpal tunnel pressure, especially when the
fingers fully flex to form a fist. 4,13 The rationale is that the lumbrical
muscles may sometimes enter the carpal tunnel with finger flexion.
20,67
When orthoses are provided to clients with CTS, the clients should
be instructed to avoid flexing their fingers “beyond 75% of a full fist.”
4 Therefore therapists should check finger position with orthotic

provision. Osterman and colleagues 54 advised therapists to fabricate a

volar wrist orthosis with a metacarpal or MCP block to decrease finger
flexion when CTS symptoms do not improve (Fig. 7.9). Recent
research is finding positive results with this MCP-blocking wrist
orthosis. Some studies 12,30 compared the wrist orthosis with MCP
block to the traditional wrist orthosis. The study by Golriz et al. 30 (24
patients) found that after a wear period of 6 weeks both orthoses were
equal in relationship to the impact on grip and pinch strength.
However, the wrist orthosis with the MCP block showed more
improvement with pain reduction and functional performance. The
study by Bulut et al. 12 (54 patients) found significant improvement
with resting pain, grip/pinch strength, and function when wearing the
wrist orthosis with the MCP block. These studies suggest that
therapists should consider research findings with respect to inclusion
of the MCP block when fabricating a custom orthosis for CTS.
With wrist orthotic provision for a person who has CTS, the
therapist considers home and occupational demands carefully,
keeping in mind that the wrist contributes to the overall function of
the hand. 63 If an orthosis is worn at work, durability of the orthosis
and the ability to wash it may be salient. Some people may benefit
from the fabrication of two orthoses (one for work and one for home),
especially if their job demands are in an unclean environment. Many
who use computers tolerate orthoses that support the wrist position in
the plane of flexion and extension but allow 10 to 20 degrees of radial
and ulnar deviation for effective typing. Fabricating a slightly wider
metacarpal bar on a custom-made wrist orthosis allows for a small
area of mobility on the radial and ulnar sides of the hand. 62 However,
with this orthotic adaptation the client is instructed to be cautious
when using a wrist orthosis with repetitive activity because it may
cause proximal muscle pain or inflammation due to the altered
biomechanics of the upper extremity. If increased pain or
inflammation occurs, the therapist instructs the client to decrease
orthotic use at the computer. Rather, the client should simulate the
position of the wrists as if the client wearing the orthosis. 23 Finally,
the client simulates work and home tasks while wearing the wrist
immobilization orthosis, and the therapist checks for functional fit. 62
Therapists consider orthotic-wearing schedules. Options of
scheduling include nighttime wear only, wear during activities that
irritate the condition, a combination of the latter two schedules, or
constant wear. The AAOS and other researchers recommend
nighttime wear at the minimum, and day wear during activities that
aggravate the condition. 2 Individuals who sleep with the wrist flexed
or extended may benefit from nighttime wear. 62 With nighttime wear,
therapists caution clients to avoid pulling the straps too tight, which
may inadvertently increase symptoms. In another study, subjects were
found to benefit most from full-time wear of the orthosis, but
adherence to the wearing schedule was an issue. 77 Length of time for
orthotic wear may be prescribed by the person’s physician. It is
generally suggested that the orthosis be worn for 6 to 8 weeks with
effectiveness of wear shown for up to 1 year. 43,52
In addition to orthotic provision, researchers consider other
interventions, such as neural gliding. A systematic review of 13
clinical trials meeting the inclusion criteria to evaluate the
effectiveness of neural gliding exercises for CTS 8 found that limited
evidence exists about the effectiveness of neural gliding. A
conservative approach is recommended with the usage of wrist
orthoses. Researchers suggest that neural gliding can be used as an
adjunct intervention with a conservative approach to address pain
and function.
Intervention combining lumbrical stretches along with wrist
orthoses that have an MCP block may be an effective option for
conservative management of CTS. Baker et al. 7 found that for mild to
moderate CTS, a custom-fabricated wrist orthosis with an MCP block
immobilizing the MCPs at 0 degrees combined with intensive
lumbrical muscle stretches was more effective long term than the
same MCP-blocking orthosis combined with general hand exercises or
a traditional wrist cock-up orthosis combined with either lumbrical
stretches or general stretches. A regimen of lumbrical stretches and
provision of a wrist orthosis with an MCP block decreased the
incidence of surgery.
Other effective intervention measures for CTS are the modification
of activities (so that the person does not make excessive wrist and
forearm motions, especially wrist flexion). It is also important to avoid
sustained pinch or grip activities and to use good posture whenever
possible with all ADLs. Because CTS is generically a disease of
decreased blood supply to the soft tissues, an environment that is cold
will additionally deprive nerves of blood. Thus staying warm is an
important part of CTS care, and orthoses provide local warmth. 64
When conservative measures are ineffective, additional medical
management includes corticosteroid injection or the possibility of
surgery.

Wrist Orthotic Intervention Post Carpal Tunnel

Surgery
Some therapists and physicians recommend 36 no wrist
immobilization orthosis postoperatively to clients because of concerns
about the impact of immobilization on joint stiffness and muscle
shortening. 32 A recent Cochrane systematic review of rehabilitation
after CTS surgical release of 22 trials and 1521 participants found
either limited or low evidence for many postoperative interventions,
including orthoses. 57
Possible reasons for postoperative wrist orthotic provision may be
to prevent extreme nighttime wrist postures (flexion and extension),
to manage inflammation, 32 and to support the wrist during stressful
activities. Other reasons include maintenance of gains from exercise,
47,65 prevention of tendon bowstringing, and facilitation of rest during

the healing phase. Some therapists instruct clients to gradually wean

from orthotic wear (when the orthosis is no longer meeting the
person’s therapeutic goals) to prevent stiffness and to allow the
person to return to work and ADLs more quickly. Weaning is often
done over the course of 1 week, gradually decreasing the hours of
orthotic wear. 64
A series of studies has been conducted to examine orthotic
intervention for CTS. (Table 7.2 outlines some of the research evidence
for CTS that can benefit from wrist orthoses.) Intervention for CTS is a
relatively highly researched area. Therapists must stay current on the
evidence that influences intervention approaches. Therapists should
critically question how the research was performed and by whom as
well as limitations. 45 Awareness of research also points to the fact that
studies emphasize the importance of orthotic intervention with early
intervention for mild to moderate CTS 53 because orthoses are less
beneficial with ongoing parasthesias. 16

Wrist Orthotic Intervention for Radial Nerve

Injuries
Radial nerve injuries most commonly occur from fractures of the
humeral shaft, fractures and dislocation of the elbow, or compressions
of the nerve. 68 Other reasons for radial nerve injuries include
lacerations, gunshot wounds, explosions, and amputations. The classic
picture of a radial nerve injury is a wrist drop position whereby the
wrist and MCP joints are unable to actively extend. If the wrist is
involved, a physician may order a wrist orthosis to place the wrist in a
more functional position. The exact wrist positioning is highly
subjective, and it is up to the therapist and the client to decide on the
amount of extension that maximizes function.
Commonly approximately 30 degrees of extension is considered a
position of function for this condition because it facilitates optimum
grip and pinch. 18 For nighttime wear a resting hand or hand
immobilization orthosis (refer to Chapter 9) is fabricated to support
the MCPs in extension and the thumb joints in extension. Although a
wrist orthosis is one option for radial nerve injuries, there are many
other options that therapists should critically consider. These include
the location of the orthosis (volar versus dorsal), type of orthosis (e.g.,
wrist immobilization, tenodesis, or mobilization), and whether to
fabricate one or two orthoses. More details about these other types of
orthotic intervention options for a radial nerve injury are discussed in
Chapter 14.

Wrist Orthotic Intervention for Tendinopathy,

Tenosynovitis, and Tendinosis
Tendinopathy (deterioration of the tendon along with tiny microtears
and collagen degeneration surrounding the tendon) typically refers to
the disease of a tendon. Two terms have evolved to further describe
tendon pathology. Tenosynovitis (inflammation of the tendon and its
surrounding synovial sheath) clinically presents as pain, tenderness,
weakness, and inflammation. 6 Tendinosis is defined as a
noninflammatory “degeneration of the collagen tissue due to aging,
microtrauma or vascular compromise.” 5 Unlike tenosynovitis, which
can often be successfully treated within several weeks, tendinosis can
take several months to improve.
The term tendinopathy is used to refer to many tendon problems and
can involve the muscles on the volar (flexor muscles) and dorsal
(extensor muscles) surfaces of the forearm. A common site for
tendinopathy is the lateral and medial elbow and rotator cuff tendons
of the upper extremity. 37 Tendinopathy often leads to substitution
patterns and muscle imbalance. 35 These conditions commonly occur
because of cumulative and repetitive motions in work, home, and
leisure activities. Having tendinopathy can result in an overuse cycle.
The overuse cycle begins with friction, microscopic tears, pain, and
limitations in motion, followed by resting the involved area,
avoidance of use, and development of weakness. When activities
resume, the cycle repeats itself. 35
These conditions can benefit from conservative management,
including wrist orthotic intervention. Resting the wrist in an orthosis
helps to take tension off the muscle-tendon unit. Orthotic intervention
for tendinopathy minimizes tendon excursion and thus decreases
friction at the insertion of the muscles. Orthotic intervention can serve
as a reminder to decrease engagement in painful activities. It is
beneficial to ask clients to pay attention to those activities that are
limited by an orthosis because they are often aggravating factors for
tendinopathy. Thus clients should become more cognizant of
aggravating activities and modify them so as not to enhance the
condition. 64 Clients should also be cautioned not to tense their
muscles and fight against the orthosis when wearing it or it may
aggravate the tendinopathy. Rather, the muscles should be relaxed.
Orthoses provided for tenosynovitis during acute flare-ups are worn
as needed to avoid and reduce pain. Orthotic intervention to avoid
pain is beneficial, but continuous orthotic usage prevents the
nourishment of collagen that is associated with pain-free arcs of
motion. Therefore, orthotic provision for these conditions should
allow for removal for hygiene and pain-free range of motion (ROM)
exercises followed by gradual weaning. 23

TABLE 7.2

Evidence-Based Practice About Wrist Orthotic Intervention

AMED, Allied and Complementary Medicine Database; CTQ, Carpal Tunnel Symptom
Severity and Function Questionnaire; CTS, carpal tunnel syndrome; DARE, Database of
Abstracts of Reviews of Effects; DASH, Disabilities of the Arm, Shoulder, and Hand; DF,
dorsal flexion; MCP, metacarpophalangeal; NHS EED, NHS Economic Evaluation Database;
PF, palmar flexion; RA, rheumatoid arthritis; ROM, range of motion; SF-12, short form-12; UE,
upper extremity; ViAS, visual analog scale.

Contributed by Whitney Henderson.

Generally, when fabricating orthoses for flexor carpi radialis (FCR)

or flexor carpi ulnaris (FCU) tendinopathy, it is recommended that the
client’s wrist be positioned at neutral or 10 degrees of flexion 23 to rest
the tendons. 34 Therapists can fabricate a volar wrist orthosis for FCR
and an ulnar gutter wrist orthosis for FCU. Wrist extensor
tendinopathy, including extensor carpi radialis brevis (ECRB) or
extensor carpi radialis longus (ECRL), benefits from a fabricated
orthosis in 20 to 30 degrees of wrist extension because this normal
resting position provides a balance between the flexors and extensors.
For extensor carpi ulnaris (ECU) tendinopathy, therapists can
fabricate an ulnar gutter wrist orthosis in 20 to 30 degrees of wrist
extension.

Wrist Orthotic Intervention for Rheumatoid

Arthritis
For clients with rheumatoid arthritis (RA), general reasons for
orthotic provision include pain control, edema reduction, and
prevention of deformity. 27 Orthoses for RA provide mechanical joint
support and enhance function. Sometimes they are used for
postoperative positioning. 25 When an orthosis is prescribed for a
person with RA, application of clinical reasoning helps to determine
the objective(s) for provision as multiple purposes can exist for a
single orthosis. 25
Wrist immobilization orthoses for RA are typically fabricated in a
functional position of 0 to 30 degrees of wrist extension, thus
promoting synergistic wrist-extension and finger-flexion patterns.
This position allows the greatest level of function in relationship to
grip for ADLs. 46,56 Wearing a wrist orthosis may be used to control
pain during activities. 38 Orthotic wear is especially helpful in
protecting the wrist during demanding tasks. 72 For people with
radiocarpal or midcarpal arthritis, a wrist orthosis fabricated out of
thin 1⁄16-inch thermoplastic material is recommended. 38 For a total
wrist arthrodesis a volar wrist orthosis is provided when the cast is
removed (usually at approximately week 6 to 8 following surgery).
Surgeons vary in their prescriptions for length of splint wear time
based on tissue healing and patient needs.
Wrist orthotic intervention for a person with RA can be quite
challenging because of the tendency for the carpal structures of the
rheumatoid arthritic wrist to sublux volarly and ulnarly. 26 In
addition, there can be related digital involvement to consider, such as
MCP volar subluxation and/or ulnar drift. In the early stages of this
ulnar drift, the wrist joint should be positioned as close to neutral with
respect to radial and ulnar deviation as can be comfortably tolerated.
However, some experts recommend positioning the wrist in slight
ulnar deviation to promote more neutral MCP positioning. 23 With
consistent access to the person, the therapist can progress the wrist
into neutral on successive visits. This position helps eliminate the
development of a zigzag deformity. The zigzag deformity develops
when the carpal bones deviate ulnarly and the metacarpals deviate
radially, which exacerbates the ulnar deviation of the MCP joints. 26
(See Fig. 7.10A for an illustration of the deformity and Fig. 7.10B for
one orthotic suggestion.)
If only the MCP joints (not the interphalangeal (IP) joints) are
involved, the therapist may consider fabricating a wrist orthosis in a
neutral position that extends beyond the distal palmar crease and
ends proximal to the proximal interphalangeal (PIP) crease to support
the MCP joints. 58 Another recommendation for someone with a
zigzag deformity is to fabricate an orthosis on the entire hand (see
Chapter 9).
When fabricating a wrist orthosis for a person with RA, the
therapist uses a thermoplastic material with a high degree of
conformability and drapability to help prevent pressure areas.
Alternatively, the long working time of highly rubber-based
thermoplastic materials helps the therapist create a more cosmetic and
well-fitting orthosis. 64 The therapist carefully monitors for the
development of pressure areas over many of the small bones of the
hand and wrist, as shown in Fig. 7.11. 26 Another consideration for
orthosis fabrication for an individual who has RA is using an orthotic
sock or stockinette underneath the orthosis or lining the orthosis with
padding. If the individual has been on a steroid regimen for a long
period of time, the skin is likely to be thinner and more fragile, which
increases the potential for superficial burns during the orthotic
intervention process. 19 Some people with RA may prefer a
prefabricated orthosis that is easy to apply and is perceived to be
more comfortable than a fabricated orthosis because it is made from
softer material and has more flexibility. Further discussion later in this
chapter addresses the functional implications of commercial or
prefabricated wrist orthoses with RA.
Finally, a recently available systematic review of 23 qualifying
studies (n = 1492) for wrist orthoses with RA provides insight about
orthotic usage. Strong evidence exists that wrist orthoses provide pain
reduction; moderate evidence exists for improved grip strength; and
insufficient evidence exists on functional impact. Impaired dexterity
associated with fine motor tasks was reported with wearing wrist
orthoses. However, wrist orthoses assisted daily tasks that required
strength, such as heavy lifting. 59 A Cochrane systematic review of
occupational therapy for RA verified that in general orthoses for RA
decrease pain. 75

Wrist Orthotic Intervention for Fractures

A Colles fracture is a fracture of the distal radius usually occurring
because of falling on an outstretched hand. Orthoses for Colles
fractures are individualized, based on the person’s skeletal and soft
tissue status. The initial goal of rehabilitation after a fracture of the
distal radius is to regain functional wrist extension. 41 To achieve this
goal, fabricate the orthosis to position the wrist in slight extension.
Wrist orthotic intervention post fracture provides protection, pain
relief, and rest to the extremity. 49 Custom-fabricated orthoses are best
because prefabricated orthoses may not fit comfortably and may block
ROM of the fingers and thumb. 40 Sometimes a serial static orthotic
intervention approach may be necessary to regain PROM. (Refer to
the discussion later in this chapter for more details about serial static
orthotic intervention and also refer to Chapter 13.) With any open
wound, therapists must follow wound precautions and physician
preferences for management (see Chapter 5). If pins or hardware are
present and an orthosis is ordered, the therapist fabricates an orthosis
to avoid the area or creates a dome or bubble in the material to avoid
contact with the open wound. Caution is taken to ensure that the
orthosis stability and purpose is not compromised.
FIG. 7.10 A zigzag deformity with rheumatoid arthritis. B, An orthosis
for a zigzag deformity that combines thermoplastic material and straps
to help reposition the digits away from ulnar deviation into radial
alignment and the wrist away from radial deviation into ulnar
alignment.
A, Reprinted from the Clinical Slide Collection on the Rheumatic
Diseases, copyright 1997. Used by permission of the American College
of Rheumatology. From Cameron, M., & Monroe, L. [2007]. Physical
rehabilitation, St. Louis: W.B. Saunders. B, Photos by Jeanine
Beasley.
 FIG. 7.11 Potential areas of fingers, hand, wrist, and forearm include
(A) dorsal metacarpophalangeal joints, thumb web space, ulnar styloid,
radial styloid, thumb carpometacarpal joint, center of palm (especially
with flexion wrist contractures), and (B) proximal edge of orthosis.
From Fess, E. E., Gettle, K., Philips, C., et al. [2005]. Hand and upper
extremity splinting: Principles and methods [3rd ed.]. St. Louis, MO:
Mosby.

The therapist fabricates a well-designed custom dorsal or volar

orthosis for Colles fractures. Moscony and Shank 49 recommend a
volar wrist orthosis after the removal of a cast for approximately 1-2
weeks, whereas Laseter 40 recommends fabricating a dorsal wrist
orthosis because it helps control edema and allows for functional
motions of the finger joints. If the person needs more support, a
circumferential wrist orthosis is considered. 41 Using a circumferential
orthosis is highly supportive and very comfortable. The
circumferential orthosis tends to limit forearm rotation more than a
volar or dorsal wrist orthosis. 65 The client is weaned from any
orthosis as soon as possible. 40,41 To encourage regaining function,
Weinstock 79 recommends that the orthosis be part of therapeutic
intervention until 30 to 45 degrees of active extension is obtained. If
PROM of the wrist/forearm remains limited after approximately 6 to 8
weeks, it may be appropriate to discuss the possibility of mobilization
orthotic provision with the physician (see Chapter 13).
Wrist orthoses are used with Colles fractures after surgery. External
fixation, dorsal plating, and volar fixed-angle plating are examples of
surgical fixation approaches. With surgically inserted dorsal plating,
wrist orthoses are used to rest the wrist between exercises. Wrist
orthoses may be indicated for rest and protection after volar fixed-
angle plating insertion. The therapist collaborates with the referring
physician on the orthotic-wearing schedule. For any of these surgical
fixation procedures, static progressive wrist orthoses may be indicated
to gradually improve wrist extension. 49

Wrist Orthotic Intervention for Wrist Sprains

A grade I sprain results in a substance tear with minimal fiber
disruption and no obvious tear of the ligament fibers. A mild grade II
sprain results in tearing of the ligament fibers. Persons with grade I
and II sprains may initially benefit from wearing a wrist
immobilization orthosis. With grade I sprains the person will likely
wear the orthosis for 3 weeks. For grade II sprains 6 weeks of wear
may be indicated. This wrist orthosis helps rest the hand during the
acute healing phase and removes stress from the healing ligament(s).
The physician may allow removal during bathing, depending on
severity.

Wrist Orthotic Intervention for Complex

Regional Pain Syndrome Type I (Reflex
Sympathetic Dystrophy)
Complex regional pain syndrome describes a complex grouping of
symptoms impacting an extremity and characterized by extreme
prolonged pain, diffuse edema, stiffness, trophic skin changes, and
discoloration. 50 Complex regional pain syndrome (CRPS) types I
and II are terms coined by the World Health Organization (WHO) to
distinguish between sympathetically mediated and non–
sympathetically mediated pain. CRPS type I is a sympathetically
mediated pain 46 and refers to pain from an injury that lasts longer
and hurts more than is anticipated. Type II refers to pain related to a
nerve injury. Symptoms are similar for both types of pain. 50
 Orthotic intervention may be a part of the rehabilitation program
for CPRS. However, the current approach for intervention is that
orthoses are suggested only if it is painful for the person to perform
functional movements. Typically, a volar wrist orthosis in functional
extension as tolerated is provided. 23 The therapist applies clinical
reasoning skills to determine which orthosis meets the various
therapeutic goals. (Refer to the discussion on the use of resting hand
orthoses with this condition in Chapter 9.) Other purposes for
providing wrist immobilization orthoses in addition to pain relief are
for muscle spasm relief, to promote circulation and tissue nutrition,
and for regaining a functional resting wrist position. 61,76,78 Recovering
a functional resting hand position is important for normal hand
motions and for the prevention of deforming forces as a result of
muscle imbalance. To increase wrist extension to a more functional
position, the therapist may need to provide serial static wrist orthoses
over time to achieve the goal of a functional resting wrist position.
Wrist Joint Contracture: Serial Orthotic
Intervention with a Wrist Orthosis
When a wrist is not properly moving (such as after removal of a cast
for a Colles fracture), the therapist may consider serial static wrist
orthotic intervention. 60 With serial static orthotic intervention, the
therapist intermittently remolds the orthosis to facilitate increases in
wrist extension (Fig. 7.12). The orthosis is first applied with the wrist
positioned at the maximal amount of extension that the current soft-
tissue length allows and the person can tolerate. The person is
instructed to wear the orthosis for long periods of time, with periodic
removal for exercise and hygiene, until the wrist can move beyond
that amount of extension.
The orthosis is readjusted to position the soft tissues at their
maximum length. 21 Positioning living tissue at maximum length
causes the tissue to remodel to a longer length. 63 This process is
repeated until optimal wrist extension is regained. Thus serial static
orthotic intervention is beneficial for PROM limitations because it
provides long periods of low load stress at or near the end of the soft-
tissue length. 63 Serial static wrist orthotic intervention is only one
approach that can improve wrist PROM. Refer to Chapter 13 for other
approaches, such as fabricating static progressive orthoses.
FIG. 7.12 A and B, Serial wrist orthotic intervention.
Fabrication of a Wrist Immobilization
Orthosis
The initial step in the fabrication of a wrist immobilization orthosis
(after evaluation of the person’s hand) is the drawing of a pattern.
Pattern making is important in customizing an orthosis because every
person’s hand is different in shape and size. Pattern making also saves
time and minimizes waste of materials.
A common mistake of a novice therapist during fabrication of a
wrist immobilization pattern is drawing the forearm trough narrower
than the natural curve of the forearm muscle-bulk contour. This
mistake can occur with anyone but especially with a person who has a
large forearm. If the forearm trough is not one-half the circumference
of the forearm, the orthosis will not provide adequate support. In
addition, the therapist must follow the natural angle of the MCP
heads with the pattern.
A volar wrist immobilization pattern presents another orthotic
intervention option (Fig. 7.13A). It is sometimes called a thumb-hole
wrist orthosis. 70 The therapist constructs the orthosis by punching a
hole with a leather punch in the heated thermoplastic material and
pushing the thumb through the hole. The therapist rolls the material
away from the thumb and thenar eminence far enough that it does not
interfere with functional thumb movement and yet allows adequate
wrist support (see Fig. 7.13B). In one research study this thumb-hole
wrist orthosis was found to be the most restrictive of wrist motion and
slowest with dexterity performance compared with volar and dorsal
wrist orthoses with metacarpal bars. 70 Fig. 7.14A shows a pattern for
a dorsal wrist immobilization orthosis. Fig. 7.14B is a pattern for an
ulnar wrist immobilization orthosis. Fig. 7.14C depicts a pattern for a
circumferential wrist immobilization orthosis.
FIG. 7.13 A, A volar wrist immobilization pattern for a thumb-hole
orthosis. B, A volar wrist immobilization thumb-hole orthosis.
 FIG. 7.14 A, A dorsal wrist immobilization pattern. B, An ulnar wrist
immobilization pattern. C, A circumferential wrist immobilization pattern.

Novice therapists may learn to fabricate orthosis patterns by

following detailed written instructions and looking at pictures of
patterns. As therapists gain experience, they can easily draw patterns
without copying from pictures. (See Figs. 7.1–7.4 for pictures of
completed orthosis products.) The following instruction is for
construction of a volar wrist immobilization orthosis (Fig. 7.15 and
Fig. 7.7 ) and is similar to instruction for a dorsal wrist immobilization
orthosis (see Figs. 7.8 and 7.14A). Table 7.3 provides an overview of
safety considerations for any wrist orthotic provision.

1. Position the person’s hand palm down on a piece of paper. The

wrist should be as neutral as possible with respect to radial
and ulnar deviation. The fingers should be in a natural resting
position (not flat) and slightly abducted. Draw an outline of
the hand and forearm to the elbow.
2. While the person’s hand is still on the paper, mark an A at the
radial styloid and a B at the ulnar styloid. Mark the second
and fifth metacarpal heads C and D, respectively. Mark the
olecranon process of the elbow E. Remove the hand from the
pattern. Mark two-thirds the length of the forearm on each
side with an X. Place another X on each side of the pattern
approximately 1 to 1½ inches outside and parallel to the two
previous X markings for the approximate width of the
orthosis, and label each F. These markings are to accommodate
for the side of the forearm trough.
 FIG. 7.15 A detailed pattern for a volar wrist immobilization
orthosis.

3. Draw an angled line connecting the marks of the second and

fifth metacarpal heads (C to D). Extend this line approximately
1 to 1½ inches from the ulnar side of the hand, and mark it G.
On the radial side of the hand, extend the line straight out
approximately 2 inches, and mark it H.

TABLE 7.3

Patient Safety Considerations for Wrist Orthotic Intervention

4. On the ulnar side of the orthosis, extend the metacarpal line

from G down the hand and forearm of the orthotic pattern,
making sure the pattern follows the person’s forearm muscle
bulk. End this line at F.
5. Measure and place an I approximately ¾ inch below the mark
for the head of the index finger (C). Extend a line parallel from
I to the line between C and H. Curve this line to meet H. This
area represents the extension of the metacarpal bar and usually
measures approximately ¾ inch down from C to the outline on
the other side of the metacarpal bar. Draw a curved line that
simulates the thenar crease from I to A. Extend the line past A
approximately 1 inch, and mark it J.
6. Draw a line from J down the radial side of the forearm, making
sure the line follows the increasing size of the forearm. Curve
out like drawing a “bell” to ensure that the orthosis design is
adequate to fit the forearm. To ensure that the orthosis is two-
 thirds the length of the forearm, end the line at F.
7. For the bottom of the orthosis, draw a straight line connecting
both F marks.
8. Make sure the pattern lines are rounded at H, G, J, and the two
Fs to prevent any pressure or discomfort.
9. Cut out the pattern.
10. Position the person’s upper extremity with the elbow resting
on a pad (folded towel or foam wedge) on the table and the
forearm in a neutral position—rather than in supination or
pronation, which results in a poorly fitted orthosis. Make sure
that the fingers are relaxed and the thumb is lightly touching
the index finger. Place the wrist immobilization pattern on the
person as shown in Fig. 7.16A . Check that the wrist has
adequate support, with the pattern ending just proximal to the
MCP joint. On the dorsal surface of the hand, check whether
the hypo-thenar bar on the ulnar side of the hand ends just
proximal to the fifth metacarpal head. The metacarpal bar on
the radial side of the hand should point to the triquetrum or
distal ulna bone after it wraps through the first web space. On
the volar surface of the hand, check below the thumb
carpometacarpal (CMC) joint to determine whether the
pattern provides enough support at the wrist joint. Make sure
the forearm trough is two-thirds the length and one-half the
width of the forearm. Make necessary adjustments (i.e.,
additions or deletions) on the pattern.
11. Trace the pattern onto the sheet of thermoplastic material.
12. Heat the thermoplastic material.
13. Cut the pattern out of the thermoplastic material.
14. Measure the person’s wrist using a goniometer to determine
whether the wrist has been placed in the correct position. The
therapist should instruct and practice with the person
maintaining the correct position (see Fig. 7.16B).
15. Reheat the thermoplastic material.
16. Mold the form onto the person’s hand. To fit the orthosis on
the person, place the person’s elbow in a resting position on a
 pad on the table with the forearm in a neutral position. Make
sure the fingers are relaxed and the thumb is lightly touching
the index finger (see Fig. 7.16C). The advantage of this
approach is that the therapist can better monitor the wrist
position visually during orthosis formation.
17. Make sure that the wrist remains correctly positioned as the
thermoplastic material hardens. During the formation phase,
roll the metacarpal bar just proximal to the distal palmar
crease, and roll the thermoplastic material toward the thenar
crease. Flare the distal end of the orthosis on a flat surface to
prevent skin breakdown (see Fig. 7.16D).
18. Make necessary adjustments on the orthosis (see Fig. 7.16E–F).
19. Cut the Velcro into approximately ½-inch oval pieces for the
metacarpal bar area and 1½-inch oval pieces for the forearm
trough. Heat the adhesive with a heat gun to encourage
adherence before putting them on the orthosis (see Fig. 7.16G).
Using a solvent on the thermoplastic material, scratch the
thermoplastic material to remove some of the nonstick coating
to help with adherence of the Velcro pieces For an adult, add
two 2-inch straps on the forearm trough and one narrower
strap on the dorsal surface of the hand, thus connecting the
metacarpal bar on the radial side to the hypothenar bar on the
ulnar side of the hand. A child’s orthosis requires straps that
are narrower than an adult’s. The strap placed at the wrist is
located exactly at the wrist joint and not proximal to it to
ensure a good fit (see Fig. 7.16H).

Technical Tips for a Proper Fit

• Choose a thermoplastic material that has a high degree of
conformability to allow a close fit and to prevent migration.
Some therapists may prefer a rubber-based moderate drape
thermoplastic material.
• Use caution when cutting a pattern out of thermoplastic
material that stretches easily. Leave stretchable thermoplastic
material flat on the table when cutting to prevent the material
from stretching and the orthosis from losing the original shape
of the pattern and remember to take the material out of the
pan vertically and not horizontally.
 FIG. 7.16 A, Placing of the wrist immobilization pattern on the
person. B, Before forming the orthosis, the therapist should
measure the person’s wrist with a goniometer to obtain the
correct amount of extension. C, A position for molding the wrist
immobilization orthosis. D, Flaring the distal end of the orthosis
on a flat surface. E, Marking of the orthosis to make an
adjustment. F, Cutting off excess thermoplastic material to make
 an adjustment. G, Heating of the Velcro tabs with a heat gun to
help them adhere to the orthosis. H, The therapist should place
two straps on the forearm trough with one at the wrist level, one
approximately 2⁄3 down the trough, and one strap on the dorsal
surface of the hand that connects the metacarpal bar to the
hypothenar bar.
B from Reese, N. B., & Bandy, W. D. [2002]. Joint range of
motion and muscle length testing. London: W.B. Saunders.

• When positioning the client, one option is to position the

person’s elbow joint on a towel with the elbow flexed 90
degrees and the forearm in neutral. Another option is to
position the person’s forearm resting on a rolled towel on a
table in a supinated position, allowing the wrist to fall into
extension. The first position allows for more careful
observation of wrist position, but the orthotic material may
stretch. The second option provides a more comfortable
relaxed position for the person.
• Mold the orthosis sequentially. For a volar wrist
immobilization orthosis, form the hypothenar bar (Fig. 7.17A),
wrap the metacarpal bar around the palm to the dorsal side of
the hand (see Fig. 7.17B), roll down the metacarpal bar (see
Fig. 7.17C), and then form the thenar area (see Fig. 7.17D). See
the specific comments in this section for hints about each of
these areas.
FIG. 7.17 A, The formation of the hypothenar bar. B, Wrapping
the metacarpal bar around the palm. C, Rolling the metacarpal
bar. D, Forming the thenar area.
• As the orthosis is being formed, be sure to follow the natural
curves of the longitudinal, distal, and proximal arches. Having
the person lightly touch the thumb to the index finger during
molding helps conform the orthosis to the arches of the hand
(see Fig. 7.16C). Mold the thermoplastic material to conform
naturally to the center of the palm. Be careful not to flatten the
transverse arch, which could cause metacarpal contractures.
However, overemphasizing the transverse carpal arch can
create a focal pressure point in the central palm that will be
intolerable for the person.
• For a volar wrist immobilization orthosis, position the
metacarpal bar on the volar surface just proximal to the distal
palmar crease. This position allows adequate wrist support
and full MCP flexion. In addition, make sure the metacarpal
bar follows the natural angle of the distal transverse arch (see
Fig. 7.17C). On the dorsal surface, position the metacarpal bar
just proximal to the natural angle of the MCP heads. A
correctly conformed dorsal metacarpal bar helps to hold the
wrist in the correct position. If the metacarpal bar does not
conform and there is a gap, the wrist will be mobile. For
comfort, some clients may prefer that the metacarpal bar is
shorter and the strap longer on the dorsal surface due to the
bony prominence of the metacarpals on the dorsum of the
hand.
• Always determine whether the person has full finger flexion
when wearing the orthosis by having him or her flex the MCP
joints. If any areas of the metacarpal bar are too high, the
therapist makes adjustments.
 FIG. 7.18 The metacarpal bar and hypothenar bar help position
and hold the wrist.

• Make sure the hand and wrist are positioned correctly by

taking into consideration the position of a normal resting
hand. On volar and dorsal wrist immobilization orthoses, the
metacarpal bar (which wraps around the radial side of the
hand) and the hypothenar bar (on the ulnar side) help position
and hold the wrist (Fig. 7.18). If adequate support is lacking
 on either side, the wrist may be in an incorrect position.
• A frequent fabrication mistake is to allow the wrist to deviate
radially or ulnarly. This mistake can occur because of a lack of
careful monitoring of the person’s wrist position as the
thermoplastic material is cooling. The therapist should closely
monitor the wrist position in any orthosis that positions the
wrist in neutral because it is easy for the wrist to move in
slight flexion. A quick spot check before the thermoplastic
material is completely cool can address this problem.
• If a mistake occurs with an orthotic material that easily
stretches, be extremely careful with adjustments to avoid
further compromising of wrist position. For thermoplastic
material with memory, remold the entire orthosis rather than
spot heating the wrist area because doing the latter tends to
cause the material to buckle. Sometimes adjustments can be
done by heating the entire orthosis made from material
without memory.
• After the formation of the palmar and wrist part of the
orthosis is complete, the therapist can begin to work on other
areas of the orthosis, such as the forearm trough. A problem
that can easily be corrected just before the thermoplastic
material is cooled is twisting of the forearm trough. If this
problem is not corrected, the orthosis will end up with one
edge of the forearm trough higher than the other (Fig. 7.19).
 FIG. 7.19 This forearm trough was twisted.

• After the thermoplastic material has cooled, determine

whether the person can fully oppose the thumb to all fingers.
The thenar eminence should not be restricted or flattened.
Wrist support should be adequate to maintain the angle of the
wrist. To check whether the thenar eminence area is rolled
enough, have the person move the thumb in opposition to the
little finger, and sustain the hold while evaluating the roll.
 Also observe that the thenar crease is visible to allow for full
thumb mobility. Adjustments should be made to allow
complete thumb excursion. Otherwise, a potential for a
pressure sore to develop exists, especially in the area of the
thumb web space (Fig. 7.20).
• Occasionally after the thermoplastic material is cooled, the
therapist will note areas that are too tight in the forearm
trough, which can potentially result in pressure sores. To
easily correct this problem, the therapist pulls apart the sides
of the forearm trough.

Troubleshooting Wrist Immobilization

Orthoses
A careful practitioner must continuously think of precautions, such as
checking for pressure areas. Precautions for making a wrist
immobilization orthosis include the following:

• Be aware of and make adjustments for potential pressure

points on the radial styloid, on the ulnar styloid, at the first
web space, and over the dorsal aspects of the metacarpals. The
thumb web space is a prime area for skin irritation because it
is so tender. Some people cannot tolerate plastic in the first
web space. The thermoplastic material must be cut back and
replaced with soft strapping. Others can tolerate the plastic if
it is rolled and extremely thin. 65 Instruct the person to
monitor the skin for reddened areas and to communicate
immediately about any irritation that occurs.
 FIG. 7.20 This thenar web space was not rolled enough to allow
full thumb excursion.

• Control edema before orthotic provision. For persons with

sustained edema, avoid using constricting wrist orthoses.
Instead, fabricate a wider forearm trough with wide strapping
material. 18 Dorsal orthoses are better for edematous hands.
21,40 Carefully monitor persons who have the potential for

edematous hands, and make necessary orthotic adjustments.

As discussed earlier, a “continuous strap” made from flexible
 fabric is a good strapping option to help manage edema.
• For persons with little subcutaneous tissue and thin skin,
carefully monitor the skin for pressure areas. Lining the
orthosis with padding may help, but several adjustments may
be necessary for a proper fit. Fabricating the orthosis over a
thick orthotic liner, QuickCast liner, or a piece of stockinette
can prevent skin irritation during orthotic fabrication.
• Make sure the orthosis provides adequate support for
functional activities.
Prefabricated Orthoses
Prefabricated or commercially available wrist orthoses are commonly
used in the treatment of CTS and RA. 26,72 A variety of prefabricated
wrist orthoses are available, as shown in Fig. 7.21.
As discussed, conservative management of CTS includes
positioning the wrist as close to neutral as possible to maximize the
space in the carpal tunnel. The supportive metal or thermoplastic stay
in most prefabricated wrist orthoses positions the wrist in extension.
Therefore, an adjustment must be made to position the wrist in the
desired neutral position. However, care must be taken when
adjustments are made to ensure that the orthosis adequately fits and
supports the hand.
Several options for prefabricated wrist orthoses are marketed for
CTS. Options for the work environment include padding to reduce
trauma from vibration, leather for added durability, and metal
internal pieces that act to position the wrist. Prefabricated wrist
immobilization orthoses are also effective for symptoms of CTS
during pregnancy. 24
Fabricating an orthosis for a person who has RA is most effective in
the early stages and incorporates positioning, immobilization, and the
assumed comfort of neutral warmth from a soft orthosis. The effects of
RA can result in decreased joint stability, leading to decreased grip
strength and the more obvious finger deformities. 26 When persons
with RA wear wrist orthoses, they help decrease pain during ADLs. 70
Prefabricated wrist orthoses marketed for persons with RA are
designed for easy application and to decrease ulnar deviation. Some
orthoses include correction or protection for finger joints as well as for
the wrist joint.
Therapists need to determine whether to fabricate a custom wrist
orthosis or to use a commercial prefabricated wrist orthosis. There are
many factors to consider with this decision, such as the impact of the
prefabricated or custom orthosis on hand function, pain reduction,
and degrees of immobilization that the orthosis provides. 22,55,73,74
Research helps therapists select the best orthosis for their clients.
Collier and Thomas 22 studied the degree of immobilization of a
custom volar wrist orthosis compared with three commercial
prefabricated wrist orthoses. They found that the custom wrist
orthosis allowed “significantly less palmar flexion and significantly
more dorsiflexion” than the commercial orthoses. Thus, custom
thermoplastic orthoses may block wrist motion better than
prefabricated orthoses, which are more flexible.
Other studies considered the effect of commercial prefabricated
orthoses on grip and dexterity, 17,70,73,74 work performance, 55 and
proximal musculature. 14 Continued research needs to be done to
analyze the efficacy of commercial orthoses, especially as newer ones
are developed. Furthermore, as Stern and colleagues 72 found, no
single type of wrist orthosis will be appropriate for all clients and that
satisfaction with a prefabricated orthosis is often associated with
therapeutic benefits, comfort, and utility. Therefore, it benefits
therapists to stock a variety of prefabricated orthosis options in the
clinic, 71 or therapists can provide information to clients so that they
can procure the right orthosis for themselves. Box 7.1 provides some
questions for therapists to contemplate when considering a
prefabricated wrist orthosis or custom-made wrist orthosis. This
information can also be used to educate clients to procure the right
prefabricated orthosis for themselves.
 FIG. 7.21 A, This wrist orthosis has D-ring straps and immobilizes the
MCPs (Rolyan® D-Ring Wrist Brace). B, This wrist orthosis has a
unique strapping system with laces (Sammons Preston Rolyan® Laced
Wrist Support). C, This lightweight orthosis can be used for carpal
tunnel and other repetitive injuries (Sammons Preston Exolite Wrist
Brace). D, The Rolyan® Workhard® D-Ring Wrist Brace is made of soft,
pliable leather with ¼” padding for improved work durability. (Courtesy
Performance Health, Warrenville, IL.)

BOX 7.1 Questions to Determine Use of Custom-

Made Versus Prefabricated Wrist Orthosis

• Is time a factor? (Consider providing prefabricated orthoses;

 although with experience a custom orthosis can be made in a
short time period.)
• Is cost a factor? (Consider costs with custom orthoses versus
prefabricated orthoses.)
• Is fit a factor? (Consider whether the prefabricated orthosis is
restricting too much motion, such as thumb opposition, or chafes
the hand. 77 Or consider whether it is really doing what it is
supposed to do, such as keeping the hand in neutral with carpal
tunnel syndrome (CTS). 77
• Is only wrist support required? (Consider either a custom or a
prefabricated orthosis.)
• Is restriction of motion a factor? (Consider a custom orthosis.)
• Does the person need the orthosis only for pain relief, such as
with arthritis? (Consider a prefabricated orthosis or a custom-
made orthosis with padding.)
• Is the person involved in sports? (Consider a soft prefabricated
orthosis to avert injury to other people. 10 )
• Is wrist and hand edema a factor? (Consider fabricating a custom
dorsal wrist orthosis, taking edema into consideration.)
• Is the weight of the orthosis a factor? (Consider custom
fabricating an orthosis out of lighter thermoplastic material
[1⁄16 inch] or a lightweight prefabricated orthosis.)
• What are the occupational demands of the person? (Consider a
custom-fabricated orthosis if heavy labor is part of the person’s
life or a prefabricated orthosis if demands are minimal. 38
Consider the material out of which the prefabricated orthosis is
fabricated. A prefabricated orthosis out of leather may provide
adequate durability, support, protection, and comfort for job
demands.)
• Has any research evidence on the orthoses being considered been
accessed?
Impact on Occupations
For people with the diagnoses discussed in this chapter, supporting
the wrist while allowing finger and thumb motions enables them to
continue their life occupations. For example, a person with CTS wears
a wrist orthosis to avoid extreme wrist positions when working and
doing other occupations. A person with arthritis obtains support and
pain relief from wearing a wrist orthosis while doing functional
activities. A person undergoing serial orthotic intervention after a
Colles fracture to decrease stiffness will eventually be able to better
perform meaningful occupations. Wrist orthoses can help many
people maintain or eventually improve their functional abilities.

a
Self-Quiz 7.1
For the following questions, circle either true (T) or false (F).

1. T F Wrist immobilization orthoses can be volar, dorsal, ulnar, or

circumferential.
2. T F A wrist immobilization orthosis usually decreases wrist pain
or inflammation, provides support, enhances digital function,
and prevents wrist deformity.
3. T F All prefabricated orthoses are made to correctly fit someone
who has carpal tunnel syndrome (CTS).
4. T F Some research suggests the value of early conservative
intervention with orthotic intervention.
5. T F After removal of a cast for a Colles fracture, if motion is
limited in the wrist, the therapist may consider serial orthotic
intervention.
6. T F The therapist must follow standard intervention protocols
exactly for any diagnosis that requires a wrist immobilization
orthotic application.
7. T F With a wrist immobilization orthosis, the therapist usually
 positions the wrist in extreme extension, which promotes
functional movement.
8. T F The hypothenar bar on a wrist immobilization orthosis helps
to position the hand in a neutral resting position by preventing
extreme ulnar deviation.
9. T F The therapist should position the volar wrist immobilization
orthosis distal to the distal palmar crease.
10. T F If a mistake is made during fabrication of a volar wrist
immobilization orthosis, in getting the correct wrist extension
the therapist should spot heat the wrist area to make an
adjustment.
11. T F People with CTS should be encouraged to perform strong
finger flexion while wearing their orthoses to allow for finger
mobility.

a
See Appendix A for the answer key.
Summary
As this chapter content reflects, appropriate wrist alignment is very
important to maintaining a functional hand. A well-fitted orthosis can
be a key element to assist with recovery from many conditions.
Therefore, therapists should be aware of diagnostic indications, types,
parts, and appropriate fabrication for wrist orthotic intervention. As
always in clinical practice, the therapist needs to apply clinical
reasoning, because each case is different. Finally, therapists should
consider the person’s occupations when providing a wrist orthosis.

Review Questions
1. What are three main indications for use of a wrist
immobilization orthosis?
2. When fabricating a wrist orthosis for a person with RA,
what are some of the common deformities that can
influence orthotic intervention?
3. When might a therapist consider serial orthotic
intervention with a wrist immobilization orthosis?
4. What are the goals of wrist orthotic intervention with a
Colles fracture?
5. What is the advantage of a volar wrist immobilization
orthosis?
6. What is a disadvantage of a dorsal wrist immobilization
orthosis?
7. What purpose does the hypothenar bar serve on a wrist
immobilization orthosis?
8. What are two positions that the therapist can use for
molding a static wrist orthosis, and what are the
advantages of each?
9. Which precautions are unique to static wrist
immobilization orthoses?
10. What are four questions that therapists could consider
when deciding on a prefabricated wrist orthosis versus a
custom-fabricated wrist orthosis?
11. What are some findings from the evidence that support
wrist orthotic intervention for CTS?
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Appendix 7.1 Case Studies
Case Study 7.1 a

Read the following scenario and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Angela is a homemaker who began experiencing carpal tunnel
syndrome (CTS) symptoms of numbness, grasp weakness, and
paresthesias over the distribution of the median nerve. Angela went to
her family physician, whose nurse provided her with a quick remedy.
Not being familiar with the correct wrist positioning for CTS, the
nurse placed a strip of thermoplastic material stretching down the
dorsal aspect of Angela’s forearm, wrist, and hand and wrapped it in
gauze. After a while Angela began to complain about the
thermoplastic strip feeling awkward during activities, such as using a
knife to cut meat, because it was not supporting the wrist. Eventually
Angela began to wake up in the middle of the night, noticing that her
hand was again numb. Angela returned to her family physician. This
time he referred her to a neurologist, who diagnosed her with CTS.
The neurologist provided a cortisone shot and referred her to
occupational therapy. The occupational therapist requested an order
for a custom orthosis. At that point, Angela had doubts about wearing
the orthosis. She asked for valid reasons for the custom orthosis
versus a prefabricated orthosis. She stated in frustration, “Why don’t I
just go ahead and have surgery!”

1. Provide two reasons that the thermoplastic strip was not the
best choice.
__________________________________________________________________
2. Describe the correct position for the custom orthosis that the
therapist should fabricate for Angela.
__________________________________________________________________
3. What would be the suggested wearing schedule?
__________________________________________________________________
 4. What precautions are important with orthotic wear?
__________________________________________________________________
5. How should the therapist address Angela’s concerns about
getting a custom orthosis and surgery? Include in the answer
how you might present the research evidence to Angela.
__________________________________________________________________
6. Explain two advantages of using a custom-made orthosis
compared to a prefabricated orthosis for CTS.
__________________________________________________________________

Case Study 7.2 a

Read the following scenario and use your clinical reasoning skills to answer
the questions based on information from this chapter.
Diane is a 52-year-old woman who was walking outside at dusk
with a friend. She came up to an intersection without seeing the curb,
and she fell with her right hand stretched out in front of her. She went
to the emergency department, and a closed reduction approach with
casting was used for her nondisplaced Colles fracture. After her cast
was removed the physician ordered therapy for edema and pain
control, range of motion (ROM), and fabrication of a wrist orthosis for
the right upper extremity.

1. Diane comes to therapy with her right wrist in 15 degrees

flexion. Her wrist can be passively extended to neutral.
Describe the orthotic position for her right hand and the
rationale for the position.
__________________________________________________________________
2. As Diane’s ROM improves, how should the therapist revise the
position of the orthosis?
__________________________________________________________________
3. At what point should the therapist discontinue wrist orthotic
intervention?
__________________________________________________________________
Appendix 7.2 Laboratory Exercises
Laboratory Exercise 7.1
1. Practice making a wrist immobilization orthotic pattern on
another person. Use the detailed instructions provided to draw
the pattern.
2. Using the outline for the left and right hand, draw a wrist
immobilization pattern without the detailed instructions.
Laboratory Exercise 7.2 a
Orthosis A

1. What problems can you identify regarding this orthosis?

2. What problems may arise from continual orthotic wear?
Orthosis B
You are supervising a student in clinical practice. You ask the student
to practice making a wrist immobilization orthosis before actually
fabricating an orthosis on a person. Orthosis B is a picture of the
student’s orthosis.

1. What problems should you address with the student regarding

the orthosis?
Orthosis C
Orthosis C was made for a 54-year-old woman working as a school
bus driver. The person works full-time and has wrist extensor
tendinopathy.

1. What problems can you identify regarding this orthosis?

2. What problems may arise from continual orthotic wear?
Laboratory Exercise 7.3
Practice fabricating a wrist immobilization orthosis on a partner.
Before starting, determine the correct position for your partner’s hand.
Measure the angle of wrist extension with a goniometer to ensure a
correct position. After fitting your orthosis and making all
adjustments, use Form 7.1 as a self-evaluation of the wrist
immobilization orthosis, and use Grading Sheet 7.1 as a classroom
grading sheet.

Laboratory Exercise 7.4 a

The following picture is a volar-based wrist immobilization orthosis.
Identify the parts of the orthosis that are marked.
1. ______________________________________________
2. _______________________________________________
3. _______________________________________________
Appendix 7.3 Form and Grading Sheet
Form 7.1 Wrist Immobilization Orthosis
Grading Sheet 7.1 Wrist Immobilization
Orthosis
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
Thumb Immobilization Orthoses
Helene L. Lohman

CHAPTER OBJECTIVES
1. Discuss important functional and anatomical considerations for
orthotic intervention of the thumb.
2. Explain appropriate thumb and wrist positions for thumb
immobilization orthoses.
3. Identify the three components of a thumb immobilization orthosis.
4. Describe the reasons for supporting the joints of the thumb.
5. Discuss the diagnostic indications for a thumb immobilization
orthosis.
6. Discuss the process of pattern making and orthotic fabrication for
a thumb immobilization orthosis.
7. Describe elements of a proper fit of a thumb immobilization
orthosis.
8. Explain general and specific patient safety precautions for a
thumb immobilization orthosis.
9. Use clinical reasoning to evaluate fit problems of a thumb
immobilization orthosis.
10. Use clinical reasoning to evaluate a fabricated thumb
immobilization orthosis.
11. Apply knowledge about thumb immobilization orthotic
intervention to a case study.
12. Recognize the importance of evidence-based practice with
thumb immobilization orthotic provision.
 13. Describe the appropriate use of prefabricated thumb orthoses.

KEY TERMS
de Quervain tenosynovitis
hypertonicity
osteoarthritis (OA)
rheumatoid arthritis (RA)
scaphoid fracture
ulnar collateral ligament (UCL) injury (skier’s thumb or
gamekeeper’s thumb)

On a winter vacation, Jill fell while snow skiing down a steep slope. She
attempted to brace herself with an outstretched hand and an abducted
thumb. Jill’s thumb bent backward upon hitting the ground. After being
helped down the slope, Jill was seen by a local orthopedic physician who
diagnosed her with skier’s thumb. The physician referred Jill to a local
occupational therapy clinic where she was fitted for a hand-based thumb
orthosis. The physician suggested that she follow up with additional
physician monitoring and therapy once she returned to her home state.

Frequently prescribed for the thumb is a custom or prefabricated

immobilization orthosis. The purpose of a thumb orthosis is to
immobilize, protect, rest, and position one or all the thumb
carpometacarpal (CMC), metacarpophalangeal (MCP), and
interphalangeal (IP) joints while allowing the other digits to be free. A
commonly recommended orthosis for the thumb is the thumb palmar
abduction immobilization orthosis. 2 Other names for this orthosis are
the thumb spica orthosis, the short or long opponens orthosis, the CMC-
MCP immobilization orthosis, 71 or the thumb gauntlet orthosis.
Thumb immobilization orthoses can be divided into two broad
categories: (1) forearm based and (2) hand based. Forearm-based
thumb orthoses stabilize the wrist and the thumb. Stabilizing and
supporting the thumb and wrist is beneficial for a painful wrist.
Hand-based thumb orthoses provide stabilization for the thumb while
allowing for wrist mobility. Forearm-based or hand-based thumb
immobilization orthoses are often used to manage different conditions
that affect the thumb’s CMC, MCP, or IP joints.
Thumb conditions that may require a forearm-based orthosis
include but are not limited to de Quervain tenosynovitis, rheumatoid
arthritis (RA), osteoarthritis (OA), scaphoid fracture, and
hypertonicity. For example, for people who have de Quervain
tenosynovitis, a forearm-based thumb orthosis provides rest, support,
and protection of the tendons that course along the radial side of the
wrist into the thumb joints. The therapist may also apply a forearm-
based thumb immobilization orthosis postoperatively for control of
motion in persons with RA after a joint arthrodesis or replacement. A
thumb immobilization orthosis can position the thumb before surgery.
26
 FIG. 8.1 Thumb orthosis for hypertonicity (Rolyan® Thump Loop).
Courtesy Performance Health, Warrenville, IL

Thumb conditions that may require a hand-based orthosis include

but are not limited to traumatic thumb MCP joint injuries, such as
sprains, MCP or IP joint dislocations, median nerve injury, and MCP
ligament injuries, including the ulnar collateral ligament (UCL)
(known as skier’s/gamekeeper’s thumb) and the radial collateral
ligament (RCL).With the resulting muscle imbalance from a median
nerve injury, the therapist may apply a hand-based thumb
immobilization orthosis to keep the thumb web space adequately
open. For hypertonicity, a thumb orthosis—sometimes called a figure-
eight thumb wrap or thumb loop orthosis (Fig. 8.1)—facilitates hand use
by decreasing the palm-in-thumb posture or palmar adduction that is
often associated with this condition. Therefore, because the thumb
orthosis is so commonly prescribed, it is important that therapists
become familiar with its application and fabrication.
Functional and Anatomical
Considerations for Orthotic
Intervention of the Thumb
The thumb is essential for hand functions because of its overall
importance to grip, pinch, and fine manipulation. The thumb’s
exceptional mobility results from the unique shape of its saddle joint
(the CMC joint), the arrangement of its ligaments, and its intrinsic
musculature. 6 , 15 , 65 The thumb provides stability for grip, pinch, and
mobility because it opposes the fingers for fine manipulations. 68
Sensory input to the tip of the thumb is important for functional grasp
and pinch.
A thorough understanding of the anatomy and functional
movements of the thumb is necessary before the therapist attempts to
fabricate a thumb orthosis. The most crucial aspect of the thumb
immobilization orthotic design is the position of the CMC joint. 68
Positioning of the thumb in a thumb post (see Fig. 8.5) allows for
palmar abduction and some opposition, which are critical motions for
functional prehension. See Chapter 4 for a review of the anatomy and
functional movements of the thumb.
Features of the Thumb Immobilization
Orthosis
The thumb immobilization orthosis prevents motion of one, two, or all
of the thumb joints. 24 The orthosis has numerous design variations.
Designs include volar (Fig. 8.2), dorsal (Fig. 8.3), or radial gutter (Fig.
8.4) depending on the person’s condition and purpose of the orthosis.
The orthosis may be hand based or wrist based, depending on the
person’s diagnosis, the anatomical structures involved, and the
associated pain at the wrist. If the wrist is included, the wrist position
varies according to the diagnosis. For example, with de Quervain
tenosynovitis, the wrist is commonly positioned in 15 degrees of
extension to take the pressure off the abductor pollicis longus and
extensor pollicis brevis tendons. 10
The orthotic components fabricated in the final product vary
according to the thumb joints that are included. The orthotic design is
based on the therapeutic goals for the person. The therapist must have
a good understanding of the purpose and the fabrication process of
the various orthotic components. Central to most thumb
immobilization orthoses are three components: (1) the opponens bar,
(2) the C bar, and (3) the thumb post (Fig. 8.5). 24 The opponens bar
and C bar position the thumb, usually in some degree of palmar
abduction. The thumb post, which is an extension of the C bar,
immobilizes the MCP only or both the MCP and IP joints.
The position of the thumb in an orthosis varies from palmar
abduction to radial abduction, depending on the person’s diagnosis.
With some conditions, such as arthritis, the therapist facilitates
prehension by stabilizing the thumb CMC joint in palmar abduction
and opposition. Certain diagnostic protocols, such as those for
extensor pollicis longus (EPL) repairs, tendon transfers for thumb
extension, and extensor tenolysis of the thumb, require the thumb to
be in an extended and radial abducted position. 11 The thumb
immobilization orthosis may do one of the following:
 • Stabilize only the CMC joint
• Include the CMC and MCP joints
• Encompass all three joints (i.e., CMC, MCP, and IP)

The physician’s order may specify which thumb joints to

immobilize in the orthosis. In some situations, the therapist may be
responsible for determining which joints the orthosis should stabilize.
The therapist uses diagnostic protocols, strong knowledge of
anatomy, and an assessment of the person’s pain to make this
decision. Certain diagnostic protocols (such as those for thumb
replantations, tendon transfers, and tendon repairs) often require the
inclusion of the IP joint in the orthosis. 61 Overall the therapist
fabricates an orthosis that is the most supportive and least restrictive
in movement.
Diagnostic Indications
Therapists fabricate thumb immobilization orthoses in general and
specialized hand therapy practices. Specific diagnostic conditions that
require a thumb immobilization orthosis include, but are not limited
to:

FIG. 8.2 A volar thumb immobilization orthosis.

FIG. 8.3 A dorsal thumb immobilization orthosis.
FIG. 8.4 A radial gutter thumb immobilization orthosis.
 FIG. 8.5 The three components of a thumb immobilization orthosis.
The opponens bar in conjunction with a C bar and a thumb post.

• Capsular tightness of the MCP and IP joints after trauma a

• Congenital adduction deformity of the thumb
• de Quervain tenosynovitis
• Distal radius fractures a
• EPL repairs a
• Extrinsic flexor or extensor muscle contracture a
• Flexor pollicis longus (FPL) repair a
• Hypertonicity
• Median nerve injuries
• MCP joint dislocations
• OA
• Posttraumatic adduction contracture a
• RA
• RCL or UCL strains
• Repair of MCP joint collateral ligaments a
• Scaphoid fractures a
• Stable fractures of the proximal phalanx of the first metacarpal
a

• Tendon transfers a

Intervention for many of these conditions may require the expertise

of experienced hand therapists. In clinical practice, therapists
commonly treat persons who have de Quervain tenosynovitis, RA,
OA, fractures, and ligament injuries. The orthoses for these conditions
will be specifically discussed in this chapter. (Table 8.1 contains
guidelines for these hand conditions.) The novice therapist should
remember that physicians and experienced therapists may have their
own guidelines for positioning and orthotic-wearing schedules. The
therapist should also be aware that thumb palmar abduction may be
uncomfortable for some persons. Therefore, the thumb may be
positioned midway between radial and palmar abduction.

Orthotic Intervention for de Quervain

Tenosynovitis
De Quervain tenosynovitis, which results from repetitive thumb
motions and wrist ulnar deviation, is a form of tenosynovitis affecting
the abductor pollicis longus (APL) and the extensor pollicis brevis
(EPB) in the first dorsal compartment. People whose occupations
involve repetitive wrist deviation and thumb motions (such as the
home construction tasks of painting, scraping, wall papering, and
hammering) are prone to this condition. 31 Any repetitive life activity
that aggravates the wrist and thumb, such as typing on a computer,
may lead to this condition. De Quervain tenosynovitis is the most
commonly diagnosed wrist tendonitis in athletes, 51 such as golfers. 39
People present with pain over the radial styloid, edema in the first
dorsal compartment, and positive results from the Finkelstein test
(Fig. 8.6). The Finkelstein test (also called the Eichhoff test) involves
instructing the individual to clench the thumb in a fist and passively
deviating the wrist in the ulnar direction, 4 with a positive test
resulting in pain during the motion (see Fig. 8.6).
During the acute phase of de Quervain tenosynovitis, conservative
therapeutic management involves immobilization of the thumb and
wrist for symptom control 32 to rest the involved tendons. 32 This
orthosis is classified by the American Society of Hand Therapists
(ASHT) as a wrist extension, thumb CMC palmar abduction, and
MCP flexion immobilization orthosis. 3 The orthosis may cover the
volar or dorsal forearm or the radial aspect of the forearm and hand.
The therapist positions the wrist in 15 degrees of extension, neutral
wrist deviation, the thumb midway between palmar and radial
abduction (40 to 45 degrees), and the thumb MCP joint in neutral. 10,20
Usually the IP joint is free for functional activities; however, the IP
joint is included in the orthosis if the person is overusing the thumb or
fights the orthosis, causing even more pain. Other recommendations
exist for positioning. For example, Ilyas and colleagues 32 recommend
conservative intervention by positioning the thumb in 30 degrees of
abduction and 30 degrees of MCP flexion. Ultimately the position
chosen for the thumb is the one that best relieves the person’s
symptoms.

TABLE 8.1

Conditions That May Require a Thumb Immobilization Orthosis

CMC, Carpometacarpal; MCP, metacarpophalangeal; RCL, radial collateral ligament; ROM,
range of motion; UCL, ulnar collateral ligament.

Radial gutter or forearm-based thumb orthoses are worn during the

night and as needed in the day during function to avoid pain and rest
the tendons. The orthosis is removed for occupations that are pain-
free during the day to help remodel and nourish collagen formation. 20
A prefabricated orthosis is recommended after the person’s pain
subsides 36,72 for work and sports activities, 2 or if the person does not
want to wear a custom orthosis. 7 The study by Menendez and
colleagues (N = 85) compared full-time wear of a thumb orthosis for
de Quervain tenosynovitis to as-needed wear. 43 The investigators
found that there were no statistically significant differences in patient-
reported outcomes with measures for disability, grip strength, pain,
and treatment satisfaction between the group that wore the orthosis
full time as compared to the group that wore the orthosis as needed.
The investigators found that psychological factors such as depression
and anxiety correlated with disability scores on the Disabilities of the
Arm, Shoulder and Hand (DASH) questionnaire.
 Most intervention for de Quervain tenosynovitis is done
conservatively. However, if symptoms are not resolved, then surgery
may be indicated. Postsurgical management of de Quervain
tenosynovitis involves orthotic intervention, usually for 7 to 10 days.
51

Research Evidence for de Quervain Tenosynovitis

Few studies have considered the efficacy of thumb orthotic
intervention for de Quervain tenosynovitis, and results are variable
(Table 8.2). Most studies consider medical intervention approaches,
such as nonsteroidal antiinflammatory drugs (NSAIDs) or
corticosteroid injections, compared with conservative measures, such
as orthoses. Two articles discuss systematic reviews of medical
treatment options as compared to hand therapy. Cavaleri and
colleagues 12 completed a systematic review with meta-analyses of six
studies to compare corticosteroid injections with hand therapy. They
considered orthoses and corticosteroid injections along with other
approaches (e.g., acupuncture and general hand therapy). The
investigators found that hand therapy and corticosteroid injections
improved pain and function, but the combined intervention of
orthoses and corticosteroid injections was most effective.
 FIG. 8.6 The Finkelstein test is used to assess the presence of de
Quervain tenosynovitis.
(From Waldman SD. Atlas of pain management injection techniques.
Philadelphia: Saunders; 2000.)

Richie and Briner 53 reviewed the literature to evaluate the evidence

of treatment options for de Quervain tenosynovitis. They considered
seven descriptive studies (N = 459 wrists) comparing effective
treatments without control groups. They found the highest success
rate for intervention of 83% for injection alone, followed by 61% for
injection and orthotic intervention together, 14% for orthotic
intervention alone, and 9% for rest or NSAIDs. 53 The authors
concluded that the combination of injection and orthotic intervention
resulted in a higher percentage of treatment failure (39%) compared
with treatment failure of solely providing injections (17%). These
authors did not discuss the limitations of the reviewed studies.
A recent quasi-experimental study completed by Nemati and
colleagues 46 considered a new modified mobilization type of orthosis
for de Quervain tenosynovitis. The investigators compared two types
of orthotic intervention with two groups of subjects (N = 24). One
group wore a modified forearm-based thumb orthosis that allowed
for dynamic wrist flexion and extension with a hinge component—
thus blocking wrist deviation. The other group wore a traditional
static forearm-based orthosis. The investigators developed the
modified dynamic orthosis to allow for wrist flexion and extension as
muscles for those motions are not involved with wrist radial and
ulnar deviation, which would aggravate de Quervain tenosynovitis.
After evaluation for pinch strength, pain, and function, the
investigators found that both orthoses were equal. The investigators
did, however, find that the study participants were more satisfied
with the orthosis that allowed for wrist flexion and extension, as it
was more comfortable (Fig. 8.7). More research needs to be completed
to determine the efficacy of thumb orthotic intervention with de
Quervain tenosynovitis. Therapists should review these studies as
they can provide information about intervention efficacy.

Orthotic Intervention for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disease that often
affects the joints symmetrically through recurring synovitis and
tenosynovitis. The disease frequently presents in the thumb joints,
particularly the MCP and CMC joints. Orthotic intervention for RA
can reduce pain, slow deformity, and stabilize the thumb joints. 49 One
perspective with orthotic intervention is to consider three stages of the
disease. In each stage a different therapeutic goal is addressed even
though the therapist may apply the same thumb immobilization
orthosis.
The first stage involves an inflammatory process. The goal of
orthotic intervention at this stage is to rest the joints and reduce
inflammation. The person wears the thumb immobilization orthosis
continuously during periods of inflammation and periodically
thereafter for pain control as necessary. When the disease progresses
in the second stage, the hand requires mechanical support because the
joints are less stable and are painful with use. The person wears a
thumb immobilization orthosis for support while engaging in daily
activities and perhaps at night for pain relief. In the third stage, pain is
usually not a factor, but the joints may be grossly deformed and
unstable. In lieu of surgical stabilization a thumb immobilization
orthosis may provide support to increase function during certain
activities. At this stage, orthotic intervention is rarely helpful for the
person at night, unless to help manage pain. 17 Another intervention
approach is to provide the person who has arthritis with a rigid
orthosis and a soft orthosis along with education for the benefits and
activity uses of each type. 56

TABLE 8.2

Evidence-Based Practice About Thumb Orthotic Intervention

RCT, Randomized controlled trial; TMC OA, trapeziometacarpal osteoarthritis.

Contributed by Whitney Henderson.

Two common thumb deformities resulting from the arthritic

process are boutonnière deformity (type I, MCP joint flexion and IP
joint extension) and swan neck deformity (type 3, MCP extension or
hyperextension and IP flexion). 15,45 Boutonnière deformity is believed
to be the most common type of thumb deformity and is identified by
MCP joint flexion and IP joint in hyperextension. 5 During the
beginning stages of boutonnière deformity a circumferential
Neoprene orthosis may be provided to support the MCP joint with the
IP joint free to move. 15
A swan neck deformity is identified by flexion of the IP joint and
hyperextension of the MCP joint of the thumb. For early stages of
swan neck deformity, a small custom-fitted dorsal thermoplastic
orthosis over the MCP joint prevents MCP hyperextension. 15 Later
dorsal and radial subluxation at the CMC joint causes CMC joint
adduction, MCP hyperextension, and IP flexion. 15 For this deformity
Colditz 15 suggests fabricating a hand-based thumb immobilization
orthosis that blocks MCP hyperextension (Fig. 8.8). With RA, laxity of
the UCL at the IP and MCP joint can develop. Fig. 8.9 shows a
functional orthosis, which can be used with RA or OA for lateral
instability of the thumb IP joint. Prefabricated options are also
available for both boutonnière and swan neck deformities.

FIG. 8.7 This orthosis for de Quervain tenosynovitis allows for wrist
flexion and extension, which increases client comfort, while still
protecting the aggravated tendons.
From Nemati, Z., Javanshir, M, A., Saeedi, H., et al. [2017]. The effect
of a new dynamic splint in pinch strength in de Quervain syndrome: a
comparative study. Disability and Rehabilitation: Assistive Technology,
12[5], 457–461.
 FIG. 8.8 This orthosis, which blocks metacarpophalangeal (MCP)
hyperextension, is applied for advanced swan neck deformity.
From Colditz, J. C. [2002]. Anatomic considerations for splinting the
thumb. In E. J. Mackin, A. D. Callahan, T. M. Skirven, et al. [Eds.],
Rehabilitation of the hand and upper extremity [5th ed., pp. 1858–
1874]. St. Louis: Mosby.

One approach to orthotic intervention for a hand with arthritis is to

immobilize the thumb in a forearm-based, thumb immobilization
orthosis with the wrist in 20 to 30 degrees of extension, the CMC joint
in 45 degrees of palmar abduction (if tolerated), and the MCP joint in
neutral. 61 This orthosis is classified by ASHT as a wrist extension,
thumb CMC palmar abduction, and MCP extension immobilization
orthosis. 3 Resting the hand in this position is extremely beneficial
during periods of inflammation or if the thumb is unstable at the
CMC joint. 38 Incorporating the wrist in a forearm-based thumb
orthosis is appropriate when the client’s wrist is painful or in the
presence of wrist arthritic involvement.

FIG. 8.9 This small orthosis can help a person with arthritis who has
lateral instability of the thumb interphalangeal (IP) joint. (From Colditz,
J. C. [2002]. Anatomic considerations for splinting the thumb. In E. J.
Mackin, A. D. Callahan, T. M. Skirven, et al. [Eds.], Rehabilitation of the
hand and upper extremity [5th ed., pp. 1858–1874]. St. Louis: Mosby.)

When fabricating an orthosis on a person who has RA, be aware

that the person may have fragile skin. Monitor all areas for potential
skin breakdown, including the ulnar head, Lister tubercle, the radial
styloid along the radial border, the CMC joint of the thumb, and the
scaphoid and pisiform bones on the volar surface of the wrist. 21
Padding the orthosis for comfort to prevent skin irritation may be
necessary.
 The selected orthotic material should be easily adjustable to
accommodate changes in swelling and repositioning as the disease
progresses. Asking persons about their swelling patterns is important
because orthoses fabricated during the day must allow enough room
for nocturnal swelling. Thermoplastic material less than 1⁄8 -inch thick
is best for small hand orthoses. Orthoses fabricated from heavier
thermoplastic material have the potential to irritate other joints. 41
Therapists should carefully evaluate all hand orthoses for potential
stress on other joints and instruct persons to wear the orthoses at
night, periodically during the day, and during stressful daily
activities. However, therapists should always tailor any orthotic-
wearing regimen to each person’s therapeutic needs.

Orthoses for Carpometacarpal Osteoarthritis

CMC joint arthritis can occur with OA or RA. CMC joint arthritis from
OA is a common thumb condition, affecting 20% of men and women
over age 40. 41,58,72 Pain from OA occurs at the base of the thumb or
the saddle-shaped CMC joint—these joints facilitate thumb
opposition. Pain at the CMC joint interferes with the person’s ability
to engage in normal functional activities because the CMC joint is the
most critical joint of the thumb for function. 13,47 Precipitating factors
include hypermobility, anatomical predisposition, repetitive grasping,
pinching, use of vibratory tools, being postmenopausal, and having a
family history of the condition. 41,49,58
CMC arthritis occurs with the trapeziometacarpal joint (basal joint)
and sometimes the scaphotrapezial joint. Both joints contribute to the
mobility of the thumb. 49 Over time the dorsal aspect of the CMC joint
is stressed by repetitive pinching and the strong muscle pull of the
adductor pollicis and the short intrinsic thumb muscles. All together,
these forces may cause the first CMC joint to sublux dorsally and
radially. This subluxation typically results in the first metacarpal
losing extension and becoming adducted. The MCP joint
hyperextends to accommodate grasp. 17,41,56
Orthoses are common interventions for conservative management
of CMC arthritis to improve function 64 and are recommended by the
American College of Rheumatology. 30 Orthoses help people with
CMC arthritis manage pain, preserve their first web space, protect
their joints, and provide stability for the intrinsic weakness of the
capsular structures. 23 During the early stages of CMC arthritis,
orthoses position the hand to prevent the thumb adduction deformity
of the metacarpal head and the “dorsoradial subluxation of the
metacarpal base on the trapezium.” 49 Orthoses stabilize the thumb so
that people can perform occupations. 49 Static orthoses are
recommended for hypermobile or unstable joints, but not for fixed
joints. 47
Many orthotic options exist for people who have CMC OA. Orthotic
options range from forearm orthoses (volar, radial gutter, or dorsal
with the CMC and MCP joints included) to hand-based orthoses (with
the CMC and MCP joints included, or only the CMC joint included).
From a survey study of therapy practice with CMC arthritis,
investigators found that therapists reported the most common
application for CMC OA of hand-based orthoses followed by forearm
orthoses. 48 Many custom-design options exist. One custom-fabricated
orthotic option for CMC OA designed by Colditz 15 is a hand-based
orthosis that allows for free motion of the thumb MCP joint and
stabilizes the CMC joint to manage pain (Fig. 8.10). The wrist is not
included in the orthotic design to allow for functional wrist motions
(Fig. 8.11). Therapists should fabricate this hand-based orthosis solely
for hands that have “a healthy MCP joint” because the MCP joint may
sustain additional flexion pressure due to the controlled flexion
position of the CMC joint. 42 Therapists must be attentive to wear on
the MCP joint. 47 Colditz suggests an initial full-time wear of 2 to 3
weeks with removal for hygiene. Afterward the orthosis should be
worn during painful functional activities. 16 Another option designed
by Cantero-Tellez et al. 11a offers support of the CMC and MCP thumb
joints with a minimum amount of thermoplastic material on the dorsal
surface. This design can be used for other diagnoses, such as thumb
ligament injuries (Fig. 8.12). Melvin 41 suggests fabricating a dorsal
hand-based thumb immobilization orthosis (thumb CMC palmar
abduction immobilization orthosis [Fig. 8.13]), 2 with the primary
therapeutic goal of restricting the mobility of the thumb joints to
decrease pain and inflammation. The dorsal orthosis stabilizes the
CMC and MCP joints in the maximal amount of palmar abduction
that is comfortable for the person and allows for a functional pinch.
Orthotic intervention of both joints in a thumb post stabilizes the
CMC joint in abduction so that the base of the MCP is stabilized. With
the orthosis on, the person should continue to perform complete
functional tasks, such as writing, comfortably. This thumb
immobilization orthosis may be fabricated from thin 1⁄16-inch or 3⁄32 -
inch) conforming thermoplastic material for a person with thin skin.
 FIG. 8.10 An orthosis for rheumatoid arthritis (RA) or osteoarthritis
that stabilizes only the carpometacarpal (CMC) joint. (From Colditz, J.
C. [2002]. Anatomic considerations for splinting the thumb. In E. J.
Mackin, A. D. Callahan, T. M. Skirven, et al. [Eds.], Rehabilitation of the
hand and upper extremity [5th ed., pp. 1858–1874]. St. Louis: Mosby.)

FIG. 8.11 A pattern for a thumb carpometacarpal (CMC)

immobilization orthosis. (From Colditz, J. C. [2000]. The biomechanics
of a thumb carpometacarpal immobilization splint: Design and fitting.
Journal of Hand Therapy, 13[3], 228–235.)
 Another consideration with any selected design for CMC arthritis is
that the thumb is generally positioned in palmar abduction. 47 Based
on cadaver research, people with a hypermobile MCP joint who are
positioned with the thumb in 30 degrees of MCP flexion may
experience reduced pressure on the palmar part of the
trapeziometacarpal joint, an area prone to deterioration. 44 Poole and
Pellegrini 50 recommend that the thumb be positioned in palmar
abduction and 30 degrees MCP flexion. They postulate that the 30
degrees of flexion benefits the position of the trapeziometacarpal joint,
allowing increased mobility for people in the earlier stages of the
disease (stages I and II).
Because so many options exist for orthoses for CMC arthritis,
therapists consider research evidence with design selection. Findings
from systematic reviews of research evidence show that no one
orthotic approach was better than another. 1,23 However, a finding
from a scoping review of 14 publications was that, although the
effectiveness of different orthoses still needs to be studied further,
some evidence supports the use of a short hand-based design for pain
reduction and improvement of function. 62 Furthermore, findings
from another systematic review were that custom and prefabricated
orthoses equally reduced pain. The investigators suggest that orthotic
choice may depend on needs, such as a thermoplastic orthosis for
harder work and a soft orthosis for activities of daily living (ADLs)
and sleep. 1 Overall these reviews provide evidence that application of
orthoses for CMC arthritis decreases pain and improves function.
23,33,35,62,63
Prefabricated orthoses are also a consideration for CMC OA.
However, some prefabricated orthoses should be used with caution,
because positioning the thumb in abduction within the orthosis can
increase MCP joint extension, which can worsen a possible deformity.
7 With a study of current therapy practice, the most frequently applied

prefabricated orthoses for CMC OA were hand-based followed by

forearm-based and thumb-based soft goods orthoses. 49 In a
comparison study of a prefabricated thumb orthosis and a hybrid
thumb orthosis made from thermoplastic and Neoprene material, the
hybrid orthosis reduced pain to a statistically significant degree. 58 In
another study considering custom as compared to prefabricated
thumb orthoses, both types of orthoses were found to improve
function and grip strength. The custom orthosis decreased pain more.
5 Hamann and colleagues 29 (N = 18 subjects with stage II and III CMC
22 ) are the first researchers to consider the stabilization efficiency and

function of prefabricated orthoses for CMC OA. Specifically, they

studied four orthoses: BSN medical, Push Metagrip (PUSH) orthosis,
Sporlastic orthosis (SPOR), and the Medi (MEDI) orthosis. The
investigators found that the MEDI and the BSN orthoses provided the
greatest amount of stabilization and motion restriction of the MCP
joint. The PUSH provided the least amount of stabilization of the MCP
joint. These findings may be based on the design of the orthoses
studied as the MEDI and BSN included the MCP joint and the PUSH
included solely the CMC joint. The SPOR, however, included both the
CMC and MCP joints and had higher range of motion (ROM) and less
stability in both joints. The PUSH orthosis stabilized only the CMC
joint and allowed for the most functional movement that involved
grasp/pinch. The MEDI orthosis stabilized the MCP and CMC joints
and allowed for the least functional movements. Clients have different
needs for stability and functionality. Applying results from such
research can assist with clinical decision making. Grenier and
colleagues completed a retrospective study (N = 48) of three orthoses
considering functional pinch strength. 28 One of the three orthoses
studied was the prefabricated Neoprene Comfort Cool orthosis. The
other two thumb orthoses were the custom forearm radially based
thumb spica orthosis immobilizing the CMC and MCP joints (similar
to Fig. 8.4) and the Colditz design immobilizing the CMC joint (shown
in Fig. 8.10). The research findings reported only the Colditz and
Comfort Cool orthoses outcomes, as sample size was too small for the
forearm thumb spica orthosis. The investigators found that wearing
the custom Colditz design and the prefabricated Comfort Cool design
resulted in an improvement in pinch strength with no statistical
difference between the two orthoses. The investigators suggest that
larger-scale research is needed to study the effectiveness of orthoses
for CMC arthritis in relationship to their impact on function.
However, therapists might consider findings from this study when
choosing between fabricating a custom orthosis or providing a
reasonably priced prefabricated orthosis.
 FIG. 8.12 This orthosis for carpometacarpal (CMC) arthritis supports
the CMC and metacarpophalangeal (MCP) thumb joints with minimum
thermoplastic material on the dorsal surface.
(A-C Courtesy Debby Schwartz, OTD, OTR/L, CHT.)

FIG. 8.13 A dorsal hand-based thumb immobilization orthosis (thumb

carpometacarpal [CMC] palmar abduction immobilization orthosis).

Given the variety of orthotic options available, therapists must

critically analyze which orthosis to provide (forearm based, hand
based, dorsal or volar) and which thumb joints to immobilize (CMC or
CMC and MCP). Critical thinking considerations include presence of
pain, need for stability, work, and functional demands. Therapists
consider findings from research of various designs. Ultimately
orthotic provision must to be appropriate for the client’s needs. 1,23,67
A client-centered approach may be most appropriate. Shankland and
colleagues 57 (N = 60) studied application of a client-centered approach
for intervention with people who presented with thumb CMC OA.
Based on the provision of the Canadian Occupational Performance
Measure (COPM), the investigators focused intervention on the
participants’ self-identified needs. The investigators found that a
client-centered approach addressing pain with orthotic provision and
other approaches along with meaningful activities resulted in
improvement in all study measures (COPM, DASH questionnaire,
total active range of motion [TAROM], lateral pinch strength, and the
visual analog scale for pain). It is important to note that the study did
not use a control group.
Finally, therapists might consider the type of orthosis for CMC OA
provided based on nighttime or day wear. With a study protocol
examining the impact of occupational therapy intervention with CMC
OA, Kjeken and colleagues 34 selected the prefabricated Push Brace
orthosis for daytime usage as it allows for good mobility and a
custom-made thermoplastic hand-based orthosis to help support the
thumb joints to avert subluxation and adduction for nighttime usage.

Orthoses for Carpometacarpal Joint

Rheumatoid Arthritis
Some persons with RA who present with CMC joint involvement
benefit from a hand-based thumb immobilization orthosis (thumb
CMC palmar abduction immobilization orthosis), 2 as shown in Fig.
8.13. 16,41 If tolerated, position the thumb in enough palmar abduction
for functional activities. With a hand-based thumb immobilization
orthosis, if the IP joint is painful and inflamed, incorporate the IP joint
into the orthosis. However, putting any material (especially plastic)
over the thumb pad virtually eliminates thumb and hand function.
The person wears this orthosis constantly for a minimum of 2 to 3
weeks with removal for hygiene and exercise. The wearing schedule is
adjusted according to the person’s pain and inflammation levels.
Researchers found that for people who have RA and CMC arthritis an
orthosis did not improve grip strength and that they required higher
muscle loads with or without an orthosis to equalize the same muscle
strength of healthy adults. 14 Therefore therapists need to consider
carefully the purpose of a CMC orthosis when providing it to
someone with RA.
On the other hand, some therapists stabilize the thumb CMC joint
alone with a short hand-based orthosis that is properly molded and
positioned (see Figs. 8.10 and 8.11). This orthosis works effectively on
people who have CMC joint subluxation resulting in adduction of the
first MCP joint and anyone with CMC arthritis who can tolerate
wearing a rigid orthosis. This orthosis can also be used for CMC OA.
15,16
Often when a physician refers a person who has RA for orthotic
intervention, deformities have already developed. If the therapist
attempts to place the person’s joints in the ideal position of 40 to 45
degrees of palmar abduction, excessive stress on the joints may result.
The therapist should always fabricate an orthosis for a hand affected
by arthritis in a position of comfort. 16

Orthoses for Ulnar Collateral Ligament Injury

A common thumb condition resulting in injury to the ulnar collateral
ligament (UCL) at the MCP joint of the thumb is known as skier’s
thumb (acute injury) or gamekeeper’s thumb (chronic injury). 20,29
Gamekeeper’s thumb was the original name of the injury because
gamekeepers stressed this joint when they killed birds by twisting
their necks. 15
The UCL helps stabilize the thumb by resisting radial stresses across
the MCP joint. 69 The UCL can be injured if the thumb is forcibly
abducted or hyperextended. This can occur when falling with an
outstretched hand and abducted thumb, such as during skiing. 69 It
can also occur during incidences in basketball, gymnastics, rugby,
volleyball, hockey, and football. 24
Treatment protocols depend on the extent of ligamental tear. There
are protocols that involve immediate postoperative motion, and thus
duration of casting and orthotic fabrication postoperatively varies
widely. Injuries are classified by the physician as grade I, II, or III. 70
The following is one of many suggested orthotic intervention
protocols for each grade of injury. This orthotic intervention protocol
is accompanied by hand therapy. 70
Grade I injuries, or those involving microscopic tears with no loss of
ligament integrity, are positioned in a hand-based thumb
immobilization orthosis with the CMC joint of the thumb in
approximately 40 degrees of palmar abduction (or in the most
comfortable amount of palmar abduction). 10 Some therapists position
the thumb post for the hand-based orthosis so that the MCP joint is in
slight ulnar deviation to take the stress off the UCL.20 This orthosis is
also called a thumb MCP radial and ulnar deviation restriction orthosis. 2
The purpose of this orthosis is to provide rest and protection during
the healing phase. The person wears the orthosis continuously for 2 to
3 weeks with removal for hygiene purposes.
Grade II injuries involve a partial ligament tear, but the overall
integrity of the ligament remains intact. The orthotic intervention
protocol is the same as for grade I injuries, except that the thumb
immobilization orthosis is worn for a longer time period (up to 4 or 5
weeks).
Grade III injuries involve a completely torn ligament and usually
require surgery. A Stener lesion can occur in a high percentage of
grade III UCL injuries when the end of the UCL is caught under the
adductor policis muscle and is surgically repaired. 37 After the injury
is casted, the cast is replaced by a thumb immobilization orthosis with
the same protocol as described for grade I injuries. Typically, after
surgery for a ruptured UCL (grade III) the person is immobilized in
cast or a custom hand-based thumb orthosis. Rocchi and colleagues 55
developed and studied (N = 30) a modified hand-based orthosis that
protects the UCL but allows for early controlled MCP joint flexion and
extension motions. This orthosis has an open section on the palmar
and dorsal sides of the MCP joint along with double thermoplastic
reinforcement on the radial and ulnar sides of the MCP joint. The
investigators divided the study participants into two groups with the
control group wearing the standard hand-based thumb orthosis and
the study group wearing the modified hand-based orthosis.
Participants in the control group performed IP motions post surgery.
Participants in the study group performed IP and MCP exercises post
surgery frequently throughout the day. Although both groups
demonstrated decreased pain post surgery, the group with the
modified hand-based orthosis reported less pain on a visual analog
scale at 2 and 6 months postoperatively. However, at 12 months
postoperatively pain scores were equal between groups. Those
participants wearing the modified orthosis had better functional
scores, higher MCP ROM, fewer therapy sessions, and less lost time
from work. Both the control group and the study group had equal
MCP joint stability and pinch strength. The authors postulated that
the application of the modified hand-based orthosis along with early
controlled motions helps to restore function more quickly and
therapists might explore its use in practice.
A unique “hybrid” orthosis was designed for athletes with a UCL
injury who require orthotic intervention for protection during sports
activities. 25 This orthotic design is a custom-made circumferential
thermoplastic orthosis molded around the MCP joint and is held in
place by a fabricated Neoprene wrap. The advantage of this orthotic
design is that it provides MCP stability with the thermoplastic insert
and allows for movement of other joints because of the Neoprene
stretch. In addition, this orthosis helps control pain and allows for
activities involving grip and pinch (Fig. 8.14). Therapists could either
fabricate both parts of this orthosis or fabricate the circumferential
orthosis and purchase a prefabricated Neoprene thumb wrap. For
those who return to skiing soon after a UCL injury, researchers
suggest fabricating a small thermoplastic orthosis held in place with
tape inside a ski glove. 2 Finally, as with any therapeutic intervention,
success is dependent on many factors (such as carefully following
therapeutic protocols and good surgery techniques).
An RCL injury (or “golfer’s thumb”) is an injury that occurs less
commonly than UCL injury 9 and requires a hand-based thumb
immobilization orthosis. The orthosis is almost the same as for a UCL
injury in a hand-based orthosis with a conforming thumb positioned
in palmar abduction that protects the ligament. This orthosis is
intended to protect the RCL from ulnar stress and alleviate pressure to
the healing ligament. 60 The golfer who has injured a thumb and wants
to return to the sport may find it difficult to play in a rigid orthosis.
Rather than wearing a rigid orthosis during play, the person can be
weaned from the orthosis in the same time as required for a UCL
injury. The client learns how to wrap the thumb, which will be
necessary for at least 1-year post injury, 56 or purchases a soft
prefabricated orthosis.

FIG. 8.14 A protective orthosis for an ulnar collateral ligament (UCL)

injury that combines a custom-made circumferential thermoplastic
orthosis molded around the metacarpophalangeal (MCP) joint, which is
held in place by a fabricated Neoprene wrap.
From Ford, M., McKee, P., & Szilagyi, M. [2004]. A hybrid thermoplastic
and Neoprene thumb metacarpophalangeal joint orthosis. Journal of
Hand Therapy, 17[1], 64–68.

Orthotic Interventions for Scaphoid Fractures

Fracture of the scaphoid bone is the second most common wrist
fracture. 8 Similar to Colles fracture, scaphoid fractures usually occur
because of a fall on an outstretched hand with the wrist dorsiflexed
more than 90 degrees 27 and are a consequence of strong forces to the
wrist. 19 Scaphoid fractures occur with impact sports, such as
basketball, football, and soccer. 27,54,67 Clinically, persons who have a
scaphoid fracture present with painful wrist movements and
tenderness on palpation of the scaphoid in the anatomical snuffbox
between the EPL and the EPB. 8
Physicians cast the arm, and after the immobilization stage the hand
may be positioned in an orthosis. There are many variations of
orthotic options. One option is a volar forearm-based thumb
immobilization orthosis 18 or a dorsal/volar forearm thumb
immobilization orthosis. The thumb CMC joint is positioned in
palmar abduction, the MCP joint is in 0 to 10 degrees flexion, and the
wrist is in neutral.
Some clients (especially those in noncontact competitive sports)
may benefit from a combination dorsal/volar thumb orthosis for
added stability, protection, and pain and edema control (Fig. 8.15). 24
Therapists should educate clients that proximal scaphoid fractures
take longer to heal, sometimes up to months, because of a poor
vascular supply. 24,52 For people who play sports and have a healing
scaphoid fracture, a soft commercial thumb immobilization orthosis
may be used as a protective measure. 27
FIG. 8.15 This combination volar and dorsal orthosis adds stability to
the healing scaphoid fracture.
From Fess, E. E., Gettle, K. S., Philips, C. A. , et al. [2005]. Hand and
upper extremity splinting: Principles and methods [3rd ed.]. St. Louis:
Elsevier Mosby.
FIG. 8.16 A pattern option for either a volar or a dorsal thumb
immobilization orthosis.
Fabrication of a Thumb Immobilization
Orthosis
There are many approaches to fabrication of a thumb immobilization
orthosis. Fig. 8.16 shows a pattern that can be used for either a volar or
dorsal thumb immobilization orthosis. The radial design of the thumb
immobilization orthosis 2 provides support on the radial side of the
hand while stabilizing the thumb. This design allows some wrist
flexion and extension but limits deviation. 41 The therapist usually
places the thumb in a palmar abducted position so that the thumb pad
can contact the index pad. The therapist leaves the IP joint free for
functional movement but can adapt the orthotic pattern to include the
IP joint if more support becomes necessary. The thumb may be placed
in a position of comfort (i.e., out of the functional plane) if the client
does not tolerate the thumb placed in the functional position or when
the physician does not want the thumb to incur any stress.
 FIG. 8.17 A detailed pattern for a radial gutter thumb immobilization
orthosis.

Fig. 8.17 shows a detailed radial gutter thumb immobilization

pattern that excludes the IP joint. (See Fig. 8.4 for a photograph of the
completed orthotic product.)

1. Position the forearm and hand palm down on a piece of paper.

The fingers should be in a natural resting position and slightly
abducted; the wrist should be neutral with respect to
deviation. Draw an outline of the hand and forearm to the
elbow. As you gain experience with pattern drawing, you will
not need to draw the entire hand and forearm outline. The
experienced therapist can estimate the placement of key points
on the pattern.
2. While the person’s hand is on the paper, mark an A at the
radial styloid and a B at the ulnar styloid. Mark the second and
fifth metacarpal heads C and D, respectively. Mark the IP joint
of the thumb E, and mark the olecranon process of the elbow
F. Then remove the person’s hand from the paper pattern.
3. Place an X two-thirds the length of the forearm on each side.
Place another X on each side of the pattern approximately 1 to
1½ inches outside and parallel to the two X markings for the
appropriate width of the orthosis. Mark these two Xs H.
4. Draw an angled line connecting the second and fifth
metacarpal heads (C to D). Extend this line approximately 1 to
1½ inches to the ulnar side of the hand, and mark it I.
5. Connect C to E. Extend this line approximately ½ to 1 inch.
Mark the end of the line G.
FIG. 8.18 To ensure proper fit, place the paper pattern on the
person.
 6. Draw a line from G down the radial side of the forearm,
making sure the line follows the increasing size of the forearm.
To ensure that the orthosis is two-thirds the length of the
forearm, end the line at H.
7. Begin a line from I, and extend it down the ulnar side of the
forearm, making certain that the line follows the increasing
size of the forearm. End the line at H.
8. For the proximal edge of the orthosis, draw a straight line that
connects both H’s.
9. Make sure the orthotic pattern lines are rounded at G, I, and
the two H’s to prevent any injury or discomfort.
10. Cut out the pattern.
11. Place the pattern on the person (Fig. 8.18). Make certain the
orthosis’ edges end midforearm on the volar and dorsal
surfaces of the person’s hand and forearm. Check that the
orthosis is two-thirds the forearm length and one-half the
forearm circumference. Check the thumb position, and make
any necessary adjustments (e.g., additions, deletions) on the
pattern.
12. Carefully trace with a pencil the thumb immobilization pattern
on a sheet of thermoplastic material.
13. Heat the thermoplastic material.
14. Cut the pattern out of the thermoplastic material.
15. Reheat the material, mold the form onto the person’s hand,
and make necessary adjustments. Make sure the thumb is
correctly positioned as the material hardens by having the
person lightly touch the thumb tip to the pads of the index or
middle fingers. Another approach is to provide light pressure
over the plastic of the thumb MCP joint to align it in palmar
abduction (Figs. 8.19 and 8.20).
FIG. 8.19 Have the person lightly touch the thumb tip to the
pads of the index and middle fingers to position the thumb in
palmar abduction.
 FIG. 8.20 Although the actual movement comes from the
carpometacarpal (CMC) joint, provide light pressure on the
thumb metacarpophalangeal (MCP) joint to position the thumb
correctly in palmar abduction.

16. Add three 2-inch straps (one at the wrist joint, one toward the
proximal end of the forearm trough, and one across the dorsal
aspect of the hand) connecting the hypothenar bar to the
metacarpal bar.
Fabrication of a Dorsal Hand-Based
Thumb Immobilization Orthosis
Hand-based thumb immobilization orthoses can be fabricated for
people who have the following diagnoses: low median nerve injury,
UCL or RCL injury of the MCP joint, CMC arthritis, and the potential
for a first web space contracture. Each of these diagnoses may require
placement of the thumb post in a different degree of abduction, based
on protocols and comfort of the patient. With this orthosis the IP joint
is usually left free for functional movement, unless extreme pain is
present in the IP joint. However, if the IP joint is left free (especially
during rigorous activity), it too can become vulnerable to stresses.
This hand-based orthotic design is most appropriate for stabilizing the
MCP joint because the position of the CMC is irrelevant. Finally,
because this hand-based orthotic design incorporates the dorsal aspect
of the palm, the therapist may need to add padding because the dorsal
skin has a minimal subcutaneous layer and the boniness of the dorsal
palm can cause skin breakdown.
 FIG. 8.21 A detailed pattern for a hand-based thumb immobilization
orthosis.

Fig. 8.21 shows a detailed hand-based dorsal thumb immobilization

pattern. (See Fig. 8.13 for a photograph of the completed orthotic
product.)

1. Position the person’s forearm and hand palm down on a piece

of paper. Ensure that the client’s thumb is radially abducted.
The fingers should be in a natural resting position and slightly
 abducted. Draw an outline of the hand, including the wrist
and a couple of inches of the forearm.
2. While the person’s hand is on the paper, mark the IP joint of
the thumb on both sides, and label it A (radial side of thumb)
and B (ulnar side of the thumb), respectively. Then mark the
second and fifth metacarpal heads C and D, respectively. Mark
the wrist joint on the ulnar side of the hand E, and mark F on
the radial side of the wrist. Remove the hand from the pattern.
3. Start in the web space. Draw an angled line connecting the
marks of the second and fifth metacarpal heads (D to C). Then
connect C to B and B to A. Curve the line around and angle it
down to F. Connect F to E. Then extend the line out from E
approximately equal to the length of the pattern on the hand.
Go up vertically, curve the line around, and connect it to D.
Make sure that all edges on this pattern are rounded.
4. Cut out the pattern, check fit, and make any adjustments. Make
sure the pattern allows enough room for an adequately fitting
thumb post.
5. Position the person’s upper extremity with the elbow resting
on the table and the forearm in a neutral position.
6. Trace the pattern onto a sheet of thermoplastic material.
7. Heat the thermoplastic material.
8. Cut the pattern out of the thermoplastic material.
9. Measure the CMC joint with a small goniometer to make sure
it is in the correct position.
10. Reheat the thermoplastic material.
11. Mold the orthosis onto the person’s hand. First form the
thumb post around the thenar area. Make sure the thumb is
correctly positioned as the material hardens. Allowances are
made in the circumference of the thumb post to ensure that the
client can move the thumb. This is particularly important
when fabricating an orthosis from thermoplastic material that
shrinks or has memory. Roll the volar part of the thumb post
proximal to the thumb IP crease to allow adequate IP flexion.
Then form the orthosis across the dorsal side of the hand from
 the thumb (radial side) to the ulnar side. Curving around the
ulnar side, fit the thermoplastic material proximal to the distal
palmar crease on the volar side of the hand. There will be just
enough room between the thumb post and the end of the
orthosis on the ulnar side to add a strap across the palm. Make
sure the proximal end of the orthosis is flared to prevent skin
breakdown.
12. After the thermoplastic material has hardened, check that the
person can perform IP thumb flexion without impingement by
the thumb post and that he or she can perform all wrist
movements without interference by the proximal end of the
orthosis. Adjust as necessary.
13. Add one strap across the palm.

Orthotic Intervention Pattern for Volar

Forearm-Based Orthosis, Radial Gutter, and/or
a Dorsal Hand-Based Thumb Immobilization
Orthosis
This orthotic pattern is versatile because it can be used for the
fabrication of three different thumb orthoses (i.e., volar-, radial- and
dorsal-based) (Fig. 8.22). With a volar-based thumb immobilization
orthosis for a proper fit, ensure that the pattern is fitted proximal to
the distal palmar crease and follows the curves of the forearm. For a
hand-based thumb immobilization orthosis, the dotted line on the
pattern indicates the proximal end of the orthosis, which fits distal to
the wrist joint. With this hand-based thumb immobilization orthosis,
the section of the orthotic pattern that extends parallel to the ulnar
side of the hand may need to be lengthened to fit around to the
palmar (volar) side of the hand. For the radial gutter thumb
immobilization orthosis, fit the pattern midforearm. Review the
instructions earlier in the chapter for tips on general fabrication of
radial gutter and dorsal hand-based thumb immobilization orthoses.
For any of the three types of thumb orthoses, carefully check the
pattern on the client before cutting out the thermoplastic material. The
portion of the pattern that will cover the thenar eminence may need to
be enlarged to fit the person’s hand. In addition, to fit the thumb post
pull the section that has a star drawn on it over the first web space and
the section with a triangle on it around to the palmar (volar) aspect of
the hand where it meets the “star” section.
 FIG. 8.22 Pattern for a volar forearm-based orthosis, radial gutter
orthosis, and/or a dorsal hand-based thumb immobilization orthosis.
The dotted line on the radial side connecting the hand based piece to
the forearm can help with fit on a forearm-based orthosis.
Technical Tips for Proper Fit
1. Before molding the orthosis, place the person’s elbow on a
tabletop, positioned in 90 degrees of flexion and the forearm in
a neutral position. Position the thumb and wrist according to
diagnostic indications.
2. Monitor joint positions by measuring during and after orthotic
fabrication. Place the thumb in a palmar abduction position as
is comfortable for the person. The best way to position the
thumb in palmar abduction for fabrication of an orthosis is to
have the person lightly touch the thumb tip to the index or
middle finger pad. Note that some persons (for example, a
person who has RA) will find the thumb post more
comfortable in a position between radial and palmar
abduction.
3. Follow the natural curves of the longitudinal, distal, and
proximal arches. Ensure the orthosis completely covers the
thenar eminence. Be especially careful to check that the index
finger has full flexion because of its close proximity to the
opponens bar, C bar, and thumb post, and if necessary
carefully roll the area just proximal to the proximal palmar
crease.
4. With a volar forearm orthosis check that the distal end of the
orthosis is positioned just proximal to the distal palmar crease
and that it does not interfere with finger flexion. Also check
that the forearm part of the orthosis is one-half the
circumference of the forearm.
 FIG. 8.23 Overlap the extra thermoplastic material into the
thumb web space.

5. For a radial gutter orthosis check that the forearm trough is

correctly placed in midforearm (i.e., place a goniometer with
the axis at midwrist, one arm extending between the third and
fourth digits, and the other arm pointing toward the
midforearm).
6. When molding the thumb post, overlap the thermoplastic
material into the thumb web space (Fig. 8.23). Be certain the
thumb IP joint remains in extension during molding to
facilitate later orthotic application and removal. Be extremely
careful in adjusting with a heat gun on the thumb post, or the
result may be an inappropriate fit.
7. When applying thermoplastic material that shrinks during
cooling and because the thumb is circumferential in shape,
allowances must be made to ensure easy application and
removal of the orthosis. The orthosis must provide enough
support to the thumb in the thumb post. The thumb must not
move excessively. There are several options to address the
correct size of the thumb post. One is to have the person make
very small thumb circles as the plastic cools, because this
motion allows for some extra room. 56 Another option is to
gently flare the thumb post with a narrow pencil 40 or popsicle
stick. For people with larger thumb joints a paper towel can be
placed in between where the pieces overlap to keep the
thermoplastic material from adhering, so the orthosis is easier
to take off.
8. Before the orthosis is completely cool, remove the orthosis
from the thumb to ensure that the orthosis can be easily doffed
and donned.
9. A thumb post can be fabricated with overlapping material that
does not bond. This design method allows for adjustment to
expand or contract the thumb post with Velcro straps that
secure the post. 56
 FIG. 8.24 Roll the distal end of the thumb post to allow full
interphalangeal (IP) flexion.

10. For a thumb immobilization orthosis that allows IP mobility,

make sure the distal end of the thumb post on the volar
surface has been rolled to allow full IP flexion, yet remains
high enough for full support (Fig. 8.24). When fabricating the
thumb post, place the thermoplastic material slightly over the
IP joint, and while stabilizing the thumb MCP joint have the
person slowly flex the IP joint. Roll the distal end of the thumb
post on the volar side to allow for full IP excursion. This
technique results in a thumb post that is high enough for
adequate support while not interfering with IP mobility.
11. Check that the distal end of the thumb post is just proximal to
the IP joint and has not migrated lower. Make sure that the
orthosis does not interfere with functional hand movements.

Patient Safety Tips and Precautions for

Fabrication of Thumb Orthoses
The cautious therapist checks for areas of skin pressure over the distal
ulna, the superficial branch of the radial nerve at the radial styloid,
and the volar and dorsal surfaces of the thumb MCP joint. Specific
precautions for the molding of the orthosis include the following:

• If the thumb post extends too far distally on the volar surface
of the IP joint, the result is restriction of the IP joint flexion
and a likely area for skin irritation.
• Because of its proximity to the opponens bar, C bar, and
thumb post, the radial base of the first metacarpal and first
web space has a potential for skin irritation.
• With a radial gutter orthosis, monitor the orthosis for a
pressure area at the midline of the forearm on the volar and
dorsal surfaces. Pull the sides of the forearm trough apart if it
is too tight.
• Be careful to fabricate an orthosis that is supportive to the
 thumb’s joints and is not too constrictive. Providing enough
support allows the orthosis to meet therapeutic goals.
Constriction results in decreased circulation and possible skin
breakdown. Make allowances for edema when fabricating the
thumb post.
• If using a thermoplastic material that has memory properties,
be aware that the material shrinks when cooling Therefore the
thumb post opening must remain large enough for
comfortable application and removal of the orthosis. Refer to
technical tips for suggestions on fabricating the thumb post.
Impact on Occupations
Having a workable thumb for grasp and pinch is paramount for
functional activities. Research findings support the thumb’s functional
importance. Swigart and colleagues established that people with CMC
arthritis had decreased involvement in crafts and changed their
athletic involvement. 59a With gamekeeper’s thumb, lack of thenar
strength and adequate pinch can impact daily functional activities,
such as turning a key or opening a jar. 73
Even with the stability provided by an orthosis, some people may
find it more difficult to perform meaningful occupations. For example,
Weiss and colleagues 66 found in their study (N = 25) that with some
subjects the long thumb immobilization orthosis inhibited function
and was more than necessary to meet therapeutic goals. Therefore, the
goal of orthotic intervention is to improve function for meaningful
activities. It is intended that with the benefits of orthotic wear and a
therapeutic program the person will return to functional and
meaningful activities. 73
Prefabricated Orthoses
Deciding to provide a client with a prefabricated thumb orthosis
requires careful reflection. Therapists critically consider the condition
for which the orthosis is being provided, materials that the orthosis is
made from, the design of the orthosis, and comfort factors. Therapists
should remember that because prefabricated thumb orthoses are
made for a mass population, the thumb positioning is often in some
degree of radial abduction, which may or may not be the correct
position for the patient. Furthermore, therapists should review the
literature to determine whether a custom thumb orthosis is preferable
over a prefabricated thumb orthosis to treat a condition.

Conditions
Prefabricated thumb orthoses are manufactured for a variety of
conditions, including arthritis, thumb MCP collateral ligament
injuries, de Quervain tenosynovitis, and hypertonicity. Orthotic types
and positions for all these conditions have been discussed in this
chapter (see Table 8.1).

Materials
Therapists should be aware of the characteristics of the wide variety of
materials available for prefabricated thumb orthoses. Material
firmness varies from soft to rigid. Soft materials are often used with
thumb orthotic intervention because they can be easier to apply and
provide a more comfortable fit for a client with a painful and
edematous thumb IP joint than a rigid orthosis. Neoprene is a
commonly used soft material for prefabricated orthoses. It has the
advantage of providing hugging support with flexibility for function,
but it has the disadvantage of retaining moisture next to the skin,
increasing the possibility of skin breakdown. Another soft material
used in prefabricated orthoses is leather. Leather orthoses absorb
perspiration and are pliable; however, they often become odiferous
and soiled. Some orthoses are lined with moisture-wicking material or
are fabricated from perforated material to address this issue.
Examples of prefabricated orthoses made from rigid materials are
those fabricated out of thermoplastic, vinyl, or adjustable
polypropylene materials.
An awareness of the orthosis’ function, condition for which it is
being used, and the client’s occupational demands helps therapists
critically determine the degree of material firmness to use. A
prefabricated orthosis made from a rigid material might be very
appropriate for a client engaged in sports or heavier work activities, or
for any condition that requires a higher amount of support and
protection. Finally, people who are allergic to latex require orthoses
that are made from latex-free materials.

Design and Comfort

Like custom-fabricated thumb orthoses, prefabricated orthoses are
either hand based or forearm based. The hand-based thumb
immobilization designs provide support to the thumb joints through
the circumferential thumb post component, thermoplastic material, or
optional stays. The forearm-based immobilization designs derive
some of their support from a longer lever arm. Prefabricated forearm-
based orthoses contain many features that should be critically
considered for client usage. Examples of these features are adjustable
or additional straps and adjustable thumb stays to provide optimal
support and fit. Some designs for both the forearm- and hand-based
orthoses are hybrid designs. These orthoses usually have a softer
outer layer with removable and adjustable inserts made from
thermoplastic material to customize the fit.
Another consideration is the comfort of the prefabricated thumb
orthosis. Factors to think about are adjustability, temperature,
bulkiness, and padding of the possible orthotic selection. When
adjusting the orthosis, therapists should account for the number and
location of straps and types of strapping material to obtain an
appropriate fit. For example, with a long thumb orthosis the therapist
should consider whether the wrist straps provide adequate support.
Considering temperature, the type of thermoplastic material that is
used for the prefabricated orthosis is scrutinized as some materials are
more breathable than others. Thumb orthoses made from Neoprene or
other soft materials are usually more breathable than rigid
thermoplastic materials. A prefabricated orthosis made from a
breathable material might be a consideration for a person living or
working in a hot environment. A person with arthritis might prefer a
thumb orthosis that provides warmth. Padding may be an essential
consideration with a person who has a tendency toward skin
breakdown. Thumb immobilization orthoses may chafe the web
space, so the therapist must monitor for fit and consider padding in
that area. Some prefabricated thumb immobilization designs include
added features, such as a gel pad for scar control or leather for added
durability. Fig. 8.25 outlines prefabricated thumb orthotic options.
 FIG. 8.25 A, This Push MetaGrip orthosis provides support of the
carpometacarpal (CMC) joint to help with thumb osteoarthritis. It can be
adjusted for fit and can be cleaned in a washing machine. (Courtesy of
BraceLab.) B, The Actimove® Rhizo Forte provides support of the CMC
and metacarpophalangeal (MCP) joints of the thumb. It can be adjusted
for fit, and material is dirt and water repellent (©BSN medical, Inc.) C,
This Comfort Cool® Wrist and Thumb CMC Restriction Orthosis is
made from perforated Neoprene, which keeps the extremity cool. It has
additional strapping at the wrist to allow for extra support. D, The
Rolyan® Fabrifoam® Ultra CarpalGard™ offers semi-rigid support of the
CMC joint while allowing for adjustable compression. (Courtesy
Performance Health, Warrenville, IL.) E, The Sammons Preston
Universal Thumb Orthosis has interchangeable flexible and rigid stays
that provide the desired support of the thumb. (Courtesy Performance
Health, Warrenville, IL.) F, The Rolyan® TakeOff® Thumb Support
provides highly conformable, breathable, slip-resistant, and warm
support. (Courtesy Performance Health, Warrenville, IL.)G, This SIRIS
boutonnière helps position the IP joint.
Courtesy Silver Ring™ Splint Company.
Summary
Thumb orthotic intervention is commonly provided in clinical
practice. Applying a critical analysis approach helps to determine the
most optimal thumb orthotic intervention. It behooves therapists to be
aware of the variety of orthoses (whether custom fabricated or
prefabricated) to provide clients with orthoses that address specific
conditions and occupational needs.

Review Questions
1. What are the general reasons for provision of a thumb
immobilization orthosis?
2. What are three common conditions that require thumb
immobilization orthoses?
3. What are some clinical indications for including the thumb
IP joint in a thumb immobilization orthosis?
4. What is an appropriate wearing schedule for a person with
RA who wears a thumb immobilization orthosis?
5. What is the suggested position for a thumb orthosis for a
person who has CMC joint arthritis? What joints are
stabilized and why?
6. What does research evidence suggest about the application
of orthoses for CMC joint arthritis in relationship to pain
and functional outcomes?
7. Which type of thumb immobilization orthosis should a
therapist fabricate for a person who has de Quervain
tenosynovitis?
8. What does the research evidence for orthotic intervention
of de Quervain tenosynovitis indicate?
9. Which type of thumb immobilization orthosis should be
fabricated for an injury of the thumb UCL?
10. What is the orthotic-wearing schedule for each grade of a
UCL injury?

a
Self-Quiz 8.1
For the following questions, circle either true (T) or false (F).
1. T F One purpose of a thumb immobilization orthosis is to
protect the thumb.
2. T F Many studies have considered the efficacy of orthoses
for de Quervain tenosynovitis.
3. T F A therapist should apply a thumb immobilization
orthosis to a client only during the chronic phase of de
Quervain tenosynovitis.
4. T F Fabricating either a long forearm thumb
immobilization orthosis or a radial gutter thumb
immobilization orthosis is best for a person who has de
Quervain tenosynovitis.
5. T F Thermoplastic material more than 1/8-inch thick is best
used for an orthosis for a person who has RA because this
material adds more support.
6. T F If a person with RA has wrist pain, the therapist
includes the wrist in the thumb immobilization orthosis.
7. T F Orthotic intervention for grade I ulnar collateral thumb
 injuries may require that the person wear the orthosis
continuously for 2 to 3 weeks with removal only for
hygiene.
8. T F The main purpose of orthotic intervention for an ulnar
collateral thumb injury is to keep the web space open.
9. T F Fracture of the scaphoid bone requires orthotic
intervention in a hand-based thumb immobilization
orthosis.

a
See Appendix A for the answer key.
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Appendix 8.1 Case Studies
Case Study 8.1 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Jack, a 10-year-old boy, was skiing with his family on vacation.
During one run on the bunny hill, he fell in a snow drift beside a tree
with an outstretched right dominant hand and his thumb positioned
in abduction. His thumb became painful and edematous. The
physician diagnosed a partial tear of the ulnar collateral ligament
(UCL; grade II) and casted the forearm, wrist, and thumb. After the
cast is removed, a referral to therapy indicates the need for a thumb
orthosis.

1. What type of orthosis should be selected? How should the

thumb be positioned?
____________________________________________________________________
2. What is the purpose of the orthosis?
____________________________________________________________________
3. List three patient precautions to be aware of when creating this
thumb immobilization orthosis.
____________________________________________________________________
4. What considerations should be made due to the patient’s age?
____________________________________________________________________
5. What is the suggested wearing schedule?
____________________________________________________________________
6. Before the 4- to 5-week healing period is over, Jack’s physician
releases him to resume skiing. Jack is looking forward to skiing
again. Jack’s physician ordered the fabrication of an orthosis to
wear while skiing. What type of orthosis might the therapist
fabricate?
____________________________________________________________________
Case Study 8.2 a
Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Margaret, a 58-year-old woman employed as a librarian, went to her
physician complaining of thumb pain at the carpometacarpal (CMC)
joint. She experiences pain while completing her activities of daily
living (ADLs). This pain had occurred for less than 1 year. She was
particularly concerned that the pain was being exacerbated by her job
demands of manipulating, lifting, and carrying books. At home she
was having difficulty with many of her ADLs and was concerned
about not being able to knit or cross-stitch. Clinical examination
revealed no additional pain or symptoms in the wrist, fingers, or other
joints of the thumb. Margaret was diagnosed with osteoarthritis of the
CMC joint. Her physician ordered therapy and fabrication of a thumb
orthosis. The order was not specific and did not state which joints
should be stabilized in the orthosis. No orthotic design was
mentioned.

1. What type of orthosis might the therapist fabricate? Which

thumb joints should be stabilized?
_____________________________________________________________________
2. What is the purpose of the orthosis?
_____________________________________________________________________
3. What is the suggested wearing schedule?
_____________________________________________________________________
4. What factors must be considered when determining whether to
provide a custom-made or a prefabricated orthosis?
_____________________________________________________________________
5. Margaret discontinued therapy, and 3 years later her
symptoms worsened due to continuing her hobby of
needlework and her work and home demands. She presented
with pain in her wrist and the thumb metacarpophalangeal
(MCP) joint due to progression of the osteoarthritis. Describe
an orthosis that the therapist might consider fabricating.
____________________________________________________________________
6. What position should the therapist place the thumb in the
thumb post?
____________________________________________________________________
Appendix 8.2 Laboratory Exercises
Laboratory Exercise 8.1 a

These components are in various types of thumb immobilization

orthoses. They are also part of other orthoses, such as the wrist cock-
up and resting hand orthosis. Label the orthotic components shown in
the following figure.
 1.
__________________________________________________________________
2.
__________________________________________________________________
3.
__________________________________________________________________

Laboratory Exercise 8.2

1. Practice making a pattern for a radial gutter thumb
immobilization orthosis on another person. Use the detailed
instructions on the previous pages to draw the pattern. Make
necessary adjustments to the pattern after cutting it out.
2. Practice drawing a pattern for a radial gutter thumb
immobilization orthosis on the following outlines of the hands
without using detailed instructions. Label the landmarks.
Laboratory Exercise 8.3 a
The following illustration shows a thumb immobilization orthosis for
a 35-year-old woman working as an administrative assistant
(secretary). She has a long history of rheumatoid arthritis (RA). Her
physician ordered a thumb immobilization orthosis after she
complained of thumb metacarpophalangeal (MCP) joint pain and
inflammation. Keeping in mind the diagnostic protocols for thumb
immobilization orthotic intervention, identify two problems with the
illustrated orthosis.
1. List two problems with this orthosis.
a.
_________________________________________________________
b.
_________________________________________________________
2. What problems might result from continual orthotic wear?
 ____________________________________________________________

Laboratory Exercise 8.4

On a partner, practice fabricating a radial gutter or a volar forearm-
based thumb immobilization orthosis that does not immobilize the
thumb interphalangeal (IP) joint. Before starting, use a goniometer to
ensure that the wrist is in 15 degrees of extension, the
carpometacarpal (CMC) joint of the thumb is in 45 degrees of palmar
abduction, and the MCP joint of the thumb is in 5 to 10 degrees of
flexion. Check the finished product to ensure that full finger flexion
and thumb IP flexion are possible after you fit the orthosis, and make
all adjustments. Use Form 8.1 as a check-off sheet for a self-evaluation
of the thumb immobilization orthosis. Use Grading Sheet 8.1 as a
classroom grading sheet.
Appendix 8.3 Form and Grading Sheet
Form 8.1 Thumb Immobilization Orthosis
Grading Sheet 8.1 Thumb Immobilization
Orthosis
a Condition may require consultation with an experienced hand
therapist.
b See Appendix A for the answer key.
b See Appendix A for the answer key.
b See Appendix A for the answer key
b See Appendix A for the answer key.
Hand Immobilization Orthoses
Brenda M. Coppard

CHAPTER OBJECTIVES
1. List diagnoses that benefit from resting hand orthoses (hand
immobilization orthoses).
2. Describe the functional or midjoint position of the wrist, thumb,
and digits.
3. Describe the antideformity or intrinsic plus position of the wrist,
thumb, and digits.
4. List the purposes of a resting hand orthosis (hand immobilization
orthosis).
5. Identify the components of a resting hand orthosis (hand
immobilization orthosis).
6. Explain the precautions to consider when fabricating a resting
hand orthosis (hand immobilization orthosis).
7. Determine a resting hand (hand immobilization) orthotic-wearing
schedule for different diagnostic indications.
8. Describe orthotic cleaning techniques that address infection
control.
9. Apply knowledge about the application of the resting hand
orthosis (hand immobilization orthosis) to a case study.
10. Use clinical judgment to evaluate a fabricated resting hand
orthosis (hand immobilization orthosis).
KEY TERMS
antideformity position
complex regional pain syndrome (CRPS)
Dupuytren contracture
functional position

Ruth is a 53-year-old woman who has rheumatoid arthritis. Recently she

experienced an exacerbation of her condition. She found it difficult to
manage her job as a flight attendant, household, and activities of daily
living due to pain and stiffness. Upon a referral to the therapy clinic,
Ruth was asked if she had worn any orthoses in the past to rest her
hands during periods of exacerbation.

Hand orthoses is a broad category of orthotic provision. This

chapter overviews the most common types of hand immobilization
orthoses for general practitioners. Commercial and customized hand
immobilization orthoses are described. The purpose, component parts,
and positions used for hand immobilization orthoses are described for
common conditions such as rheumatoid arthritis (RA), hand burns,
Dupuytren disease, and complex regional pain syndrome (CRPS).
Physicians commonly order resting hand orthoses, also known as
hand immobilization orthoses, 1 resting hand orthoses, or resting pan
orthoses. A resting hand orthosis is a static orthosis that immobilizes
the fingers and wrist. The thumb may or may not be immobilized by
the orthosis. Therapists fabricate custom resting hand orthoses or
purchase them commercially. Some of the commercially available
resting hand orthoses are prefabricated, preformed, and ready to
wear. Table 9.1 outlines prefabricated orthoses for the wrist and hand.
Others are available as precut resting hand orthotic kits that include
the precut thermoplastic material and strapping mechanism. Each of
these orthoses has advantages and disadvantages.
Preformed Hand Orthoses
Therapists order preformed commercial orthoses according to hand
size (i.e., small, medium, large, and extra large) for the right or left
hand. An advantage of premade orthoses is their quick application
(usually only straps require adjusting). There is an advantage to
ordering a preformed resting hand orthosis made from perforated
material. The preformed orthosis has perforations only in the body of
the orthosis. The edges are smooth because there are no perforations
near the edges of the orthosis. However, if the perforated preformed
or precut orthosis must be trimmed through the perforations, a rough
edge may result. Perforations at the edges of orthoses are undesirable
because of the discomfort they often create. Rough edges should be
padded, smoothed, or flared.

TABLE 9.1

Examples of Wrist/Hand Orthoses

 A disadvantage of the commercial orthosis is a less-than-ideal fit for
each person. With preformed orthoses the therapist has little control
over joint position and the particular therapeutic angles, which may
be different from the angles already incorporated into the orthotic
design. The orthoses must be ordered for application on the right or
left extremity, and the appropriate size needs to be factored. Unless
there is accessible inventory on site, this often requires two sizes to be
ordered to ensure appropriate fit, thus leading to additional cost and
time delays.
Precut Orthotic Kits
A resting hand orthotic kit typically contains strapping materials and
precut thermoplastic material in the shape of a resting hand orthosis.
Kits are available according to hand size (i.e., small, medium, large,
and extra large). An advantage of using a kit is the time the therapist
saves by the elimination of pattern making and cutting of
thermoplastic material. Similar to premolded orthoses, precuts from
perforated materials contain perforations in only the body of the
orthosis. Precuts are interchangeable for right or left extremity
application. The therapist has control over joint positioning. A
disadvantage is that the pattern is not customized to the person.
Therefore the precut orthosis may require many adjustments to obtain
a proper fit.
Customized Orthoses
A therapist can customize a resting hand orthosis by making a pattern
and fabricating the orthosis from thermoplastic material. The
advantage is an exact fit for the person, which increases the orthosis’
support and comfort. The therapist also has control over joint
positioning. Furthermore, if a hand changes in shape (i.e., swelling,
reduction), a therapist is skilled in modifying the existing orthosis
without incurring additional cost for a replacement. A disadvantage is
that customization may require more of the therapist’s time to
complete the orthosis and may be costlier. In addition, when a resting
hand orthosis pattern is cut out of perforated thermoplastic material,
it is difficult to obtain smooth edges because of the likelihood of
needing to cut through the perforations (which causes a rough edge).
Commercially available products, such as Rolyan Aquaplast Ultra
Thin Edging Material, can be applied over the rough edges to create a
smooth-edged reinforcement on orthoses fabricated from Aquaplast
materials. 47
Therapists must make informed decisions about whether they will
fabricate or purchase an orthosis. Many products are advertised to
save time and to be effective, but few studies compare orthotic
materials when used by therapists with the same level of experience.
24 Lau 24 compared the fabrication of a resting hand orthosis with use

of a precut orthosis; he compared the QuickCast (fiberglass material)

with Ezeform thermoplastic material. The study employed second-
year occupational therapy students as orthotic makers and first-year
occupational therapy students as their clients.
The clients responded to a questionnaire addressing comfort,
weight, and aesthetics. The orthotic makers also responded to a
questionnaire asking about measuring fit, edges, strap application,
aesthetics, safety, and ease of positioning. The analysis of timed trials
revealed no significant difference in time required for fabricating the
precut QuickCast and the Ezeform thermoplastic material. The
thermoplastic material was rated safer than the fiberglass material.
Because of the small sample, these results should be cautiously
interpreted, and further studies are warranted.
Purpose of the Resting Hand Orthosis
The resting hand orthosis has three purposes: to immobilize, to
position in functional alignment, and to retard further deformity. 28,59
When inflammation and pain are present in the hand, the joints and
surrounding structures become swollen and result in improper hand
alignment. Rest through immobilization reduces symptoms. The
therapist may provide an orthosis for a person with arthritis who has
early signs of ulnar drift by placing the hand in a comfortable neutral
position with the joints in midposition. The resting hand orthosis may
retard further deformity for some persons. Joints that are receptive to
proper positioning may allow for optimal maintenance of range of
motion (ROM). 59
Components of the Resting Hand
Orthosis
The therapist must know the orthosis’ components to make
adjustments for a correct fit. Four main components constitute the
resting hand orthosis: the forearm trough, the pan, the thumb trough,
and the C bar (Fig. 9.5). 16
Forearm troughs can be volar or dorsal based. The volar-based
forearm trough at the proximal portion of the orthosis supports the
weight of the forearm. Dorsally based forearm troughs are located on
the dorsum of the forearm. The therapist applies biomechanical
principles to make the trough approximately two-thirds the length of
the forearm to distribute pressure of the hand and to allow elbow
flexion when appropriate. The width is one-half the circumference of
the forearm. The proximal end of the trough is flared or rolled to
avoid a pressure area.
When a great amount of forearm support is desired, a volar-based
forearm trough is the best design (Fig. 9.6). When the volar surface of
the forearm must be avoided because of sutures, sores, rashes, or
intravenous needles, a dorsally based forearm trough design is
frequently used (Fig. 9.7). Dorsally based troughs are a beneficial
design for applying a resting hand orthosis to a person with
hypertonicity. The forearm trough is used as a lever to extend the
wrist in addition to extending the fingers.
The pan of the orthosis supports the fingers and the palm. The
therapist conforms the pan to the arches of the hand, thus helping to
maintain such hand functions as grasping and cupping motions. The
pan should be wide enough to house the width of the index, middle,
ring, and little fingers when they are in a slightly abducted position.
The sides of the pan should be curved so that they measure
approximately ½ inch in height. The curved sides add strength to the
pan and ensure that the fingers do not slide radially or ulnarly off the
sides of the pan. However, if the pan’s edges are too high, the
positioning strap bridges over the fingers and fails to anchor them
properly.

FIG. 9.5 The components of a resting hand orthosis are the forearm
trough, pan, thumb trough, and C bar.
 FIG. 9.6 Volar-based resting hand orthosis. A, Side view. B, Volar
view.

The thumb trough supports the thumb and should extend

approximately ½ inch beyond the end of the thumb. This extension
allows the entire thumb to rest in the trough. The width and depth of
the thumb trough should be one-half the circumference of the thumb,
which typically should be in a palmar abducted position. The
therapist should attempt to position the carpometacarpal (CMC) joint
in 40 to 45 degrees of palmar abduction 52 and extend the thumb’s
interphalangeal (IP) and metacarpal joints.
The C bar keeps the web space of the thumb positioned in palmar
abduction. If the web space tightens, it inhibits cylindrical grasp and
prevents the thumb from fully opposing the other digits. From the
radial side of the orthosis, the thumb, the web space, and the digits
should resemble a C (see Fig. 9.6).
Resting Hand Orthosis Positions
Generally, two types of positioning are accomplished by a resting
hand orthosis: a functional (midjoint) position and an antideformity
(intrinsic plus) position. Diagnostic indication determines the general
position used.

FIG. 9.7 Dorsally based resting hand orthosis. A, Dorsal view. B,

Volar view.

Functional Position
To relieve stress on the wrist and hand joints, the resting hand
orthosis positions the hand in a functional or midjoint position (Fig.
9.8). “The exact specifications of the functional position of the hand in
a resting hand orthosis and the recommended joint positions vary.” 24
One functional position that we suggest places the wrist in 20 to 30
degrees of extension, the thumb in 45 degrees of abduction (midway
between palmar and radial abduction), the metacarpophalangeal
(MCP) joints in 35 to 45 degrees of flexion, and all proximal
interphalangeal (PIP) and distal interphalangeal (DIP) joints in slight
flexion.

Antideformity Position
The antideformity (also known as protected or safe) position is often
used to place the hand in such a fashion as to maintain a
tension/distraction of anatomical structures to avoid contracture and
promote function. The antideformity position places the wrist in 15 to
20 degrees of extension, the thumb midway between radial and
palmar abduction, the thumb IP joint in full extension, the MCPs at 50
to 80 degrees of flexion, and the PIPs and DIPs in full extension (Fig.
9.9). 55
Diagnostic Indications
Several diagnostic categories may warrant the provision of a resting
hand orthosis. Persons who require resting hand orthoses commonly
have arthritis 2,12,37,39 ; postoperative Dupuytren contracture
release13,41; burn injuries to the hand 44 , tendinitis, hemiplegic hand 40
; acquired brain injury 7 ; hypertonic hand and wrist 33 ; and
tenosynovitis. 43 Table 9.2 lists evidence associated with hand
orthoses related to a variety of diagnostic conditions.

FIG. 9.8 A resting hand orthosis with the hand in a functional

(midjoint) position.
 FIG. 9.9 A resting hand orthosis with the hand in an antideformity
(intrinsic plus) position.

The resting hand orthosis maintains the hand in a functional or

antideformity position, preserves a balance between extrinsic and
intrinsic muscles, and provides localized rest to the tissues of the
fingers, thumb, and wrist. 52 Although hand immobilization orthoses
are commonly used, a paucity of literature exists on their efficacy.
Thus it is a ripe area for future research. Therapists should consider
the resting hand orthosis as a legitimate intervention for appropriate
conditions despite the lack of evidence.

TABLE 9.2

Evidence-Based Practice Related to Wrist Hand Orthoses

AROM, Active range of motion; MCP, metacarpophalangeal; PROM, passive range of motion;
RA, rheumatoid arthritis; ROM, range of motion.
Rheumatoid Arthritis
Therapists often provide resting hand orthoses for people with RA
during periods of acute inflammation and pain that require support
and immobilization 3,34,59 for wear when their hands are not needed
for activities. 25 The biomechanical rationale for orthotic intervention
of acutely inflamed joints is to reduce pain by relieving stress and
muscle spasms. However, it may not additionally prevent deformity.
3,14
Typical joint placement in an orthosis for a person with RA is to
position the wrist in 10 degrees of extension, the thumb in palmar
abduction, the MCP joints in 35 to 45 degrees of flexion, and all the
PIP and DIP joints in slight flexion. 35 For a person who has severe
deformities or exacerbations from arthritis, the resting hand orthosis
may also position the wrist at neutral or slight extension and 5 to 10
degrees of ulnar deviation. 17,29 The thumb may be positioned midway
between radial and palmar abduction to increase comfort. These joint
angles are ideal. Therapists use clinical judgment to determine what
joint angles are positions of comfort for orthotic intervention.
Note that wrist extension varies from the typical 30 degrees of
extension. When the wrist is in slight extension, the carpal tunnel is
open—as opposed to being narrowed, with 30 degrees of extension. 35
Finger spacers may be used in the pan to provide comfort and to
prevent finger slippage in the orthosis. 35 Finger spacers should not be
used to passively correct ulnar deformity because of the risk for
pressure areas. 35 In addition, once the orthosis is removed, there is no
evidence that orthotic wear alters the deformity. However, it may
prevent further deformity.

Acute Rheumatoid Arthritis

In persons who have acute RA the use of orthoses for purposes of rest
during pain and inflammation is controversial. 12,34 Periods of rest (3
weeks or less) seem to be beneficial, but longer periods may cause loss
of motion. 37 Persons with acute exacerbations wear orthoses full-time
except for short periods of gentle ROM exercise and hygiene. 38 Biese 3
recommends that persons wear orthoses at night and part-time during
the day. In addition, persons may find it beneficial to wear orthoses at
night for several weeks after the acute inflammation subsides. 4

Chronic Rheumatoid Arthritis

When the therapist provides an orthosis for a joint with chronic RA,
the rationale is often based on biomechanical factors. “Theoretically,
by realigning and redistributing the damaging internal and external
forces acting on the joint, the orthosis may help to prevent
deformity…or improve joint function and functional use of the
extremity.” 14 Therapists who provide orthoses to persons with
chronic RA should be aware that prolonged use of a resting hand
orthosis may also be harmful. 14 Studies on animals indicate that
immobilization leads to decreased bone mass and strength,
degeneration of cartilage, increase in joint capsule adhesions,
weakness in tendon and ligament strength, and muscle atrophy. 14
In addition to orthotic intervention, persons with RA benefit from a
combination of management of inflammation, education in joint
protection, muscle strengthening, ROM maintenance, and pain
reduction. 14,27,38 Persons in late stages of RA who have skeletal
collapse and deformity may benefit from the support of an orthosis
during activities and at nighttime. 3,5 For example, a wrist or thumb
orthosis might benefit the person during daytime activities and a
resting hand orthosis for nighttime.
Compliance of persons with RA in wearing resting hand orthoses
has been estimated at approximately 50%. 15 The degree to which a
person’s compliance with an orthotic-wearing schedule affects the
disease outcome is unknown. However, research indicates that some
persons with RA who wore their orthoses only at times of symptom
exacerbation did not demonstrate negative outcomes in relation to
ROM or deformities. 15
Wearing schedules for resting hand orthoses vary depending on the
diagnostic condition, orthotic purpose, and physician order (Table
9.3). Persons with RA often wear resting hand orthoses at night. A
person who has RA may also wear a resting hand orthosis during the
day for additional rest but should remove the orthosis at least once
each day for hygiene and appropriate exercises. A person who has
bilateral hand orthoses may choose to wear alternate orthoses each
night.

Hand Burns
Burn care requires a team approach. 48 Occupational and physical
therapists provide the orthotic and exercise interventions. 48 Despite
the hands accounting for a small percentage of total body surface,
they can have devastating effects on function. 55 Not all persons who
sustain hand burns require an orthosis. Orthotic provision depends on
burn depth degree as well as the person’s tolerance for orthoses and
overall therapy. 11 Initial evaluations are typically conducted in the
first 48 to 72 hours after admission to a burn unit and/or hospital. 58
The timing of orthotic intervention for burns is important. Due to the
contractile nature of scar tissue, the question to consider is if
prophylactic orthotic intervention is necessary. 58 Literature suggests
that the majority of therapists initiate orthotic intervention within the
first 24 hours for burned hands and wrists. 58 Often the first orthotic
intervention is provided within operating rooms.
Therapists do not position the person in the functional position after
a hand burn. Instead, the therapist places the hand in the intrinsic plus
or antideformity position 44 (see Fig. 9.9). The literature cites 43
orthoses to position the dorsally burned hand joints. 43 Despite the
wide range of orthotic designs that exist for dorsal hand burns, it is
common practice to use the antideformity position for acute hand
burns. 43,58
Positioning varies, depending on the surface of the hand that is
burned. In general, the goal of providing an orthosis in the
antideformity position is to prevent deformity by keeping structures
whose length allows motion from shortening. These structures are the
collateral ligaments of the MCPs, the volar plates of the IPs, and the
wrist capsule and ligaments. The dorsal skin of the hand maintains its
length in the antideformity position. The thumb web space is also
vulnerable to remodeling in a shortened form in the presence of
inflammation and if tension of the structure is absent.

TABLE 9.3

Conditions That Require a Resting Hand Orthosis

ADLs, Activities of daily living; DIP, distal interphalangeal; MCP, metacarpophalangeal; PIP,
proximal interphalangeal; ROM, range of motion.
a Diagnosis may require additional types of orthotic intervention.

Experts in hand rehabilitation suggest the antideformity position for

a palmar or circumferential burn places the wrist in 15 to 30 degrees of
extension and 0 degrees (i.e., neutral) for a dorsal hand burn. For
dorsal and volar burns the therapist should flex the MCPs into 50 to
80 degrees, fully extend the PIP joints and DIP joints, and place the
thumb midway between radial and palmar abduction. 11,55 After a
burn injury the thumb web space is at risk for developing an
adduction contracture. 53 Therefore the position of choice for the
thumb is midway between radial and palmar abduction, if tolerated.
In cases in which the thumb index web space is contracted, a Z-plasty
surgery may be performed 48 (Fig. 9.10). These joint angles are ideal.
Some persons with burns may not initially tolerate these joint
positions, and the hand should never be forced into the perfect
intrinsic plus position. 11 When tolerable, the resting hand orthosis for
the person who has hand burns can be adjusted more closely to the
ideal position. As healing occurs, the orthosis is modified to maintain
the palmar arches of the hand. 49 Stages of burn recovery should be
considered with orthotic intervention. The phases of recovery are
emergent, acute, skin grafting, and rehabilitation.
 FIG. 9.10 A, B, Z-plasty to lengthen contracted web space.
From Simpson, R. L. [2011]. Management of burns of the upper
extremity. In T. M. Skirven, A. L. Osterman, & J. M. Fedorczyk, et al.
[Eds.], Rehabilitation of the hand and upper extremity [6th ed., p. 312].
St. Louis: Mosby.

Emergent Phase
The emergent phase is the first 24 to 72 postburn hours. 55 From 8 to
12 hours after the burn, dorsal edema occurs and encourages wrist
flexion, MCP joint hyperextension, and IP joint flexion. 10,55 Edema
peaks up to 36 hours after the burn injury and begins to dissipate after
1 or 2 days. Usually the edema is resolved by 7 to 10 days after injury;
however, destruction of the dorsal veins or lymphatic vessels may
result in chronic edema. 55 Static orthosis intervention is initiated
during the emergent phase to support the hand and maintain the
length of vulnerable structures. 10 Positioning to counteract the forces
of edema includes placing the wrist in 15 to 20 degrees of extension,
the MCP joints in 70 to 90 degrees of flexion, and the PIP and DIP
joints in full extension with the thumb positioned midway between
palmar and radial abduction and with the IP joint slightly flexed. 55
Positioning is important during the emergent phase. 55 Elevation of
the extremity above the heart level can result in decreased arterial
supply to the hand. 55 Additionally, excessive weight bearing on the
olecranon of elbow should be avoided to prevent undue stress on the
ulnar nerve. A foam wedge in which the forearm can rest assists in
controlling edema to the hand (Fig. 9.11).
 FIG. 9.11 Foam wedge to position for edema management.
From Tufaro, P. A., & Bondoc, S. L. [2011]. Therapist’s management of
the burned hand. In T. M. Skirven, A. L. Osterman, & J. M. Fedorczyk,
et al. [Eds.], Rehabilitation of the hand and upper extremity [6th ed., p.
320]. St. Louis: Mosby.

Children may sustain hand burns for many reasons, such as from a
from fire, steam via vaporizers. 26 contact with a treadmill, 36 and
glass-fronted fireplaces. 54 For children with dorsal hand burns,
during the emergent phase the MCP joints may not need to be flexed
as far as 60 to 70 degrees. For children under the age of 3 years,
therapists may not need to provide an orthosis, unless it is determined
that the wrist requires support. 9 Young children who have burned
hands may not need orthoses because the bulky dressings applied to
the burned hand may provide adequate support. If a child is age 3
years or older, orthotic intervention should be considered.
For any clients with hand burns a prefabricated resting hand
orthosis in an antideformity position can be applied if a therapist
cannot immediately construct a custom-made orthosis. 10
Prefabricated orthoses may be appropriate for superficial burns with
edema for the first 3 to 5 days. For full-thickness burns with excessive
edema, custom-made orthoses are necessary. 10,55 An orthosis applied
in the first 72 hours after a burn may not fit the person 2 hours after
application because of the significant edema that usually follows a
burn injury.
The therapist closely monitors the person to make necessary
adjustments to the orthosis. When fabricating a custom orthosis for a
person with excessive edema, a therapist avoids forcing wrist and
hand joints into the ideal position and risking ischemia from damaged
capillaries. 10 With edema reduction, serial orthotic intervention may
be necessary as digit, wrist, and hand ROM is gained toward the ideal
position. Serial resting hand orthoses for persons with burns should
conform to the person, rather than conforming persons to the
orthoses. 10
Persons with hand burns have bandages covering burn sites. “As
layers of bandage around the hand increase, accommodation for the
increased bandage thickness must be accounted for in the [orthotic]
design, if it is to fit correctly.” 42 To correct for bandage thickness the
orthosis’ bend corresponding to MCP flexion in the pan is formed
more proximally. 42 Thus if commercially available orthoses are used
initially, due to therapist time constraints, the forearm troughs will
likely need to be pried open to increase their width to accommodate
the hand’s edema and bandage thickness. 55 For persons who are
conscious, bandage changes and orthotic changes can be painful.
Consider offering distractions to the person such as watching
television or engaging with virtual reality and gaming devices. 55
The initial orthotic provision for a person with hand burns is
applied with gauze rather than straps. The gauze reduces the risk of
compromising circulation. Soiled gauze is discarded during donning
and doffing the orthosis. New gauze is applied for purposes of
infection control. Orthoses on adults are removed for exercise,
hygiene, and appropriate functional tasks. For children, orthoses are
removed for exercise, hygiene, and play activities. 10

Acute Phase
The acute phase begins after the emergent phase and lasts until
wound closure. 10 Once edema begins to decrease, serial adjustments
are made to the orthosis. Therefore it is advantageous to use
thermoplastic material with memory properties. During the acute
phase, therapists monitor the direction of deforming forces and adjust
the existing orthosis or design an additional orthosis to “orient the
collagen being deposited during the early stages of wound healing as
well as maintain joint alignment.” 9
Healing wounds are also monitored, and the orthoses are evaluated
for fit and for correct donning and doffing. As ROM is improved, the
orthotic-wearing schedule is decreased during the day to provide time
for activities that require hand use. If the person is unwilling or
uncooperative in participating in self-care and supervised activities,
the orthosis is worn continuously to prevent contractures. It is
important for persons to wear orthoses at nighttime.

Skin Graft Phase

Before a skin graft, it is crucial to obtain full ROM. After the skin graft
the site needs to be immobilized for 3 to 5 days postoperatively. 10,55
Usually an antideformity position resting hand orthosis is
appropriate. The orthosis is often applied in the operating room or
bedside to ensure immobilization of the graft.

Rehabilitation Phase
The rehabilitation phase occurs after wound closure or graft
adherence until scar maturation. 10 The intervention goal for orthotic
provision at this stage is to prevent contracture. Contractures from
volar burns are wrist flexion, MP and IP flexion, and thumb
adduction. Contractures from dorsal burns are wrist extension or
flexion, MP and IP extension, and thumb adduction. 11 Throughout
the person’s rehabilitation after a burn, orthoses are donned over an
extremity covered with a pressure garment. Orthoses may be used in
conjunction with materials that manage scar formation, including
silicone gel sheeting or elastomer/elastomer putty inserts. During the
rehabilitation phase, static (immobilization) and dynamic
(mobilization) orthotic intervention may be needed. Plaster or
synthetic material casting may also be considered. 9

FIG. 9.12 Dupuytren contracture of the palm and little finger. Note the
nodules and cord.
From Hurst L. [2011]. Dupuytren’s disease: surgical management. In T.
M. Skirven, A. L. Osterman, & J. M. Fedorczyk, et al. [Eds.],
Rehabilitation of the hand and upper extremity [6th ed., p. 267]. St.
Louis: Mosby.

Persons commonly wear resting hand orthoses during the healing

stages of burns. After wounds heal, persons may wear day orthoses
with pressure garments or elastomer molds to increase ROM and to
control scarring. In addition to daytime orthoses, it is important for
the person to wear a resting hand orthosis at night to maintain
maximum elongation of the healing skin and provide rest and
functional alignment.

Dupuytren Disease
Dupuytren disease is a benign fibromatosis characterized by the
formation of finger flexion contracture(s) with a thickened band of
palmar and digital fascia. 19,30 Palpable nodules first develop in the
distal palmar crease, usually in line with the finger(s). Slowly the
condition matures into a longitudinal cord that is readily
distinguishable from a tendon ( Fig. 9.12). 19,30 In addition, pain and
decreased ROM are the primary symptoms that often lead to impaired
functional performance. 21 Dupuytren contractures are common and
often severe in persons of Northern European origin. However, this
disorder is present in most ethnic groups. 30 Epilepsy, diabetes
mellitus, smoking, acquired immunodeficiency syndrome (AIDS),
vascular disorders, and alcoholism are associated with Dupuytren
contracture. 19,21,30,51 Persons with Dupuytren diathesis (a more
aggressive form of the disease) often are male and have a family
history of the disease, bilateral involvement, and lesions (e.g., plantar
fibromatosis), with onset usually younger than 50 years. 18
When a Dupuytren contracture is apparent, stretching or orthotic
intervention that positions joints in extension does not delay the
progression of the contracture. 19,30 However, recent studies indicate
that injections of collagenase Clostridium histolyticum (CCH) are
effective and safe interventions to reduce Dupuytren disease nodules.
8,45,46 Some research shows that an injection of CCH reduces the

palmar nodule size and hardness. 8

FIG. 9.13 Four basic skin incision patterns for Dupuytren fasciectomy.
A, Zigzag. B, Littler-Brunner. C, Longitudinal. D, Transverse (open
palm technique).
From Hurst L. [2011]. Dupuytren’s disease: surgical management. In T.
 M. Skirven, A. L. Osterman, & J. M. Fedorczyk, et al. [Eds.],
Rehabilitation of the hand and upper extremity [6th ed., p. 273]. St.
Louis: Mosby.

Surgery is performed to release severe Dupuytren contractures.

Although surgery does not cure the disease, it is often indicated in the
presence of painful nodules; uncomfortable induration (hardness);
and MCP, PIP, or DIP joint contractures. 19,31 Surgical procedures to
treat Dupuytren disease include fasciotomy, regional fasciectomy, and
dermofasciectomy. 19,31,41 Fasciectomy options include open, closed,
needle, and enzymatic. 19 Four incision patterns are used for
Dupuytren fasciectomies (Fig. 9.13). The incision patterns include
zigzag plasty, Littler-Bruner, Z-plasty, and transverse incisions. Most
Dupuytren release surgeries are completed in an ambulatory or day
surgery setting. 19
Longitudinal follow-up studies report a recurrence after surgery is
100%. 32 Intermediate results of surgery may vary, depending on the
affected joint. 30 For example, the MCP joint has a single fascial cord
that is relatively easy to release. The PIP joint has four fascial cords
that are difficult to release. In addition, the soft tissue around the PIP
joint may contract and pull the joint into flexion, and components of
the extensor mechanism may adhere to surrounding structures. The
PIP joint of the little finger is the most difficult to correct. Flexion
contractures at the DIP joint are uncommon but are difficult to correct
for the same reasons as the PIP joint contracture. Contractures of the
web spaces may be present, limiting the motion of adjacent fingers.
Web space contractures may also result in poor hygiene between the
fingers.
 FIG. 9.14 Dorsal static protective orthosis for immediate wear post
fasciectomy. The design allows for flexion, but not
metacarpophalangeal (MCP) joint extension, in a controlled range
preventing neurovascular and wound tension. The person exercises
within the orthosis, strapping the interphalangeal (IP) joints to the
dorsal hood between exercise sessions.
From Evans, R. B. [2011]. Therapeutic management of Dupuytren’s
contracture. In T. M. Skirven, A. L. Osterman, & J. M. Fedorczyk, et al.
[Eds.], Rehabilitation of the hand and upper extremity [6th ed.]. St.
Louis: Mosby.

Therapy and orthotic intervention begin 24 hours after surgery. 13

Postoperative orthotic intervention may include the fabrication of a
dorsal static protective orthosis (Fig. 9.14). 13 The dorsal static
protective orthosis positions the wrist at neutral, the MCP joints at 35
to 45 degrees of flexion, and the IP joints in relaxed extension. 13 Note
that the digits receiving surgery release are the only digits included in
the orthosis. The thumb is positioned in mild abduction if the first
web space was a surgical site. Some therapists and physicians prefer a
resting hand orthosis post Dupuytren release; the wrist is placed in a
neutral or slightly flexed position. The MCP, PIP, and DIP joints are
positioned in full extension. If the thumb is involved, it is
incorporated into the orthosis. However, the uninvolved thumb
usually does not need to be immobilized in the orthosis. Therefore the
orthosis will not have a thumb trough component (Fig. 9.15). The
thumb may be incorporated into the orthosis, particularly when the
adjacent index finger has been released from a contracture. Note that
the dorsal static protective orthosis is a no-tension approach to
orthotic intervention. The protective orthosis is worn for 3 weeks.
Daytime wear is discontinued. Then a volar hand-based extension
orthosis (Fig. 9.16) with straps positioned over the MCP and PIP joints
to maintain or improve extension is provided, and the person wears
this orthosis during nighttime. 13
Traditionally after a surgical release of a Dupuytren contracture, the
person wears the initial orthosis continuously during both day and
night with removal for hygiene and exercise. The orthosis is worn
until the wounds completely heal. Orthoses are worn longer in the
presence of a PIP contracture release. As the risk of losing ROM
dissipates, the person may be weaned from orthotic use. Researchers
reported that “no differences were observed in self-reported upper
limb disability or active ROM between a group of patients who were
all routinely splinted after surgery and a group of patients receiving
hand therapy and only splinted if and when contractures occurred.
Given the added expense of therapists’ time, thermoplastic materials
and the potential inconvenience to patients having to wear a device,
the routine additional of night-time splinting for all patients after
fasciectomy or dermofasciectomy is not recommended except where
extension deficits occur” 20 (p. 136). Finally, orthoses other than a
resting hand orthosis, such as volar or dorsal hand-based orthosis, for
people with less extensive surgical procedures may be appropriate. 39
FIG. 9.15 A pattern for a resting hand orthosis after surgical release
of Dupuytren contracture. Note that the thumb is not incorporated into
the orthotic design.
 FIG. 9.16 A, Dynamic extension orthosis can be used during the day
during weeks 2–4 for more difficult cases. B, A volar hand-based
extension orthosis with straps over the metacarpophalangeal (MCP)
and proximal interphalangeal (PIP) joints is used to maintain or improve
 extension.
From Evans, R. B. [2011]. Therapeutic management of Dupuytren’s
contracture. In T. M. Skirven, A. L. Osterman, & J. M. Fedorczyk, et al.
[Eds.], Rehabilitation of the hand and upper extremity [6th ed.]. St.
Louis: Mosby.

Therapists working with persons who undergo a Dupuytren release

must be aware of possible complications. Complications include
excessive inflammation, wound infection, abnormal scar formation,
joint contractures, stiffness, pain, and CRPS. 13,41 Occasionally in
severe cases with complications, mobilization orthoses can be used
when MCP and PIP joint extension are unsatisfactory and when
multiple digit static orthoses are difficult for the person to don
independently. 13

Complex Regional Pain Syndrome (Reflex

Sympathetic Dystrophy)
Complex regional pain syndrome (CRPS) is a term that describes
posttraumatic pain that manifests by “inappropriate automatic
activity and impaired extremity function.” 22 Typical symptoms
include the following 22 :

• Pain: Out of proportional intensity to the injury, often

described as throbbing, burning, cutting, searing, and
shooting
• Skin color changes: Blotchy, purple, pale, or red
• Skin temperature changes: Warmer or cooler compared with
contralateral side
• Skin texture changes: Thin, shiny, and sometimes excessively
sweaty
• Swelling and stiffness
• Decreased ability to move the affected body part

There are two types of CRPS. CRPS type I is usually triggered by

tissue injury. The term applies to all persons with the symptoms listed
previously but with no underlying peripheral nerve injury. CRPS type
II is associated with the symptoms in the presence of a peripheral
nerve injury.
The goal of rehabilitation for persons with CRPS is to eliminate one
of the three etiological factors: pain, diathesis, and abnormal
sympathetic reflex. 23,57 This is accomplished by minimizing ROM and
strength losses, managing edema, and providing pain management so
that the therapist can maximize function and provide activities of
daily living (ADLs) and instrumental activities of daily living (IADLs)
training for independence. The physician may be able to intervene
with medications and nerve blocks.
As part of a comprehensive therapy regimen for CRPS, a resting
hand orthosis may initially provide rest to the hand, reduce pain, and
relieve muscle spasm. 23,57 Orthotic intervention during the presence
of CRPS should be of a low force that does not exacerbate the pain or
irritate the tissues. 56 Walsh and Muntzer 56 recommend that the
resting hand orthosis position for the person be in 20 degrees of wrist
extension, palmar abduction of the thumb, 70 degrees of MCP joint
flexion, and 0 to 10 degrees of PIP joint extension. This is an ideal
position, which persons with CRPS may not tolerate. Above all,
therapists working with persons who have CRPS should avoid
causing pain. Therefore the hand should be positioned in a position of
comfort. Orthoses other than a resting hand orthosis may also be
appropriate for this diagnostic population. (See Chapter 7 for a
discussion of wrist orthotic intervention for CRPS.)
Resting hand orthoses provided to persons with CRPS are initially
to be worn at all times with removal for therapy, hygiene, and (if
possible) ADLs. As pain reduction and motion improvement occur,
the amount of time that the person wears the orthosis is decreased.

Hand Crush Injury

To provide an orthosis for a crushed hand, position the wrist in 0 to 30
degrees of extension, the MCPs in 60 to 80 degrees of flexion, the PIPs
and DIPs in full extension, and the thumb in palmar abduction and
extension. 6 Placing a crushed hand into this position provides rest to
the injured tissue and decreases pain, edema, and inflammation. 50

Other Conditions
Resting hand orthoses are appropriate “for protecting tendons, joints,
capsular and ligamentous structures.” 25 These diagnoses usually
require the expertise of experienced therapists and may warrant
different orthoses for daytime wear and resting hand orthoses for
nighttime use.
Therapists sometimes provide resting hand orthoses for persons
who have increased tone or spasticity following a stroke or traumatic
brain injury and who are at risk for developing contractures. 7,28 (See
Chapter 15 for more information on orthotic intervention for a person
who has an extremity with increased tone or spasticity.) Table 9.3 lists
common hand conditions that may require a resting hand orthosis
and includes information regarding suggested hand positioning and
orthotic-wearing schedules. Beginning therapists should remember
that these are general guidelines, and physicians and experienced
therapists may have their own specific protocols for orthotic
positioning and wearing.
Fabrication of a Resting Hand Orthosis
Beginning orthotic makers may learn to fabricate orthotic patterns by
following detailed written instructions, by looking at pictures of
orthotic patterns, or by looking at a ready-made sample. As beginners
gain more experience, they will easily draw orthotic patterns without
having to follow detailed instructions or pictures. Steps for fabricating
a resting hand orthosis can be found in the following procedure. The
therapist must also be sure to teach the wearer or caregiver to clean
the orthosis when open wounds with exudate are present (Box 9.1).
Precautions for a Resting Hand
Orthosis
The therapist should take precautions when applying an orthosis to a
person. If the diagnosis permits, the therapist should instruct the
person to remove the orthosis for a ROM schedule to prevent stiffness
and control edema.

• The therapist monitors the person for pressure areas from the
orthosis. With burns and other conditions resulting in open
wounds, the therapist adjusts the orthosis frequently as
bandage bulk changes.

B O X 9 . 1 C l e a n i n g Te c h n i q u e s f o r O r t h o s e s t o C o n t r o l
Infection
During Orthotic Fabrication
1. After cutting a pattern from the thermoplastic
material, reimmerse the plastic in hot water.
2. Remove and spray with quaternary ammonia
cleaning solution.
3. Place the orthosis between two clean cloths to
maintain heat and reduce the microorganism
contamination from handling the material.
4. Use gloves when molding the orthosis to the person.
Latex gloves are recommended. Vinyl gloves adhere
to the plastic.
Donning an Orthosis in the Operating Room
Follow steps 1 through 4.
Clean the orthosis after the fit evaluation is completed,
and place in a clean cloth during transportation.
Transport the orthosis only when the person receiving
the orthosis is in the operating room.
Keep the orthosis in the clean cloth until it is needed in
 the operating room. The orthosis in the cloth should
be kept off sterile surfaces in the operating room.
When the person leaves the operating room, all
orthoses should be taken with him or her to the
appropriate recovery room.
Data from Wright, M. P., Taddonio, T. E., Prasad, J. K., et al. The microbiology and
cleaning of thermoplastic splints in burn care. Journal of Burn Care & Rehabilitation,
10(1), 79–83, 1989.

• To prevent infection the therapist teaches the person or

caregiver to clean the orthosis when open wounds with
exudate are present. After removing the orthosis, the person
or caregiver cleans it with warm soapy water, hydrogen
peroxide, or rubbing alcohol and dries it with a clean cloth
(see Box 9.1). Rubbing alcohol may be the most effective for
removing skin cells, perspiration, dirt, and exudate.
• For a resting hand orthosis for a person in an intensive care
unit (ICU), supplies and tools must be kept as sterile as
possible. Careful planning about supply needs before going
into the unit helps prevent repetitious trips. Enlist the help of
a second person, aide, or therapist to assist with the orthotic
process. The therapist working in a sterile environment
follows the facility’s protocol on universal precautions and
body substance procedures. Prepackaged sterilized equipment
can be used for orthotic provision. Alternatively, any
equipment that can withstand the heat from an autoclave can
be used.
• Depending on facility regulations, various actions may be
taken to ensure optimal wear and care of an orthosis. The
therapist considers the appropriate posting of the wearing
schedule in the person’s room. This precaution is especially
helpful when others are involved in applying and removing
the orthosis. A photograph of the person wearing the orthosis
posted in the room or in the person’s care plan in the chart
may help with correct orthotic application. The therapist
informs nursing staff members of the wearing schedule and
 care instruction.
• After providing an orthosis to a person in the ICU, the
therapist follows up at least once after the orthosis’
application regarding the fit and the person’s tolerance of the
orthosis. Orthoses on persons with burns require frequent
adjustments. As the person recovers, the orthotic design may
change several times.
• A person who has RA may benefit from an orthosis made from
thinner thermoplastic (less than ⅛ inch). The thinner material
reduces the weight over affected joints. 29

Procedure for Fabrication of a Resting

Hand Orthosis
The first step in the fabrication of a resting hand orthosis is drawing a
pattern similar to that shown in Fig. 9.17A .

1. Place the person’s hand flat and palm down, with the fingers
slightly abducted for a functional position or adducted for an
intrinsic plus position. Trace the outline of the upper extremity
from one side of the elbow to the other.
2. While the person’s hand is on the piece of paper, mark the
following areas: (1) the radial styloid A and the ulnar styloid B,
(2) the CMC joint of the thumb C, (3) the apex of the thumb
web space D, (4) the web space between the second and third
digits E, and (5) the olecranon process of the elbow F.
3. Remove the person’s hand from the piece of paper. Draw a line
across, indicating two-thirds of the length of the forearm. Then
label this line G. After doing this, extend line G approximately
1 to 1½ inches beyond each side of the outline of the arm. Then
mark an H approximately 1 inch from the outline to the radial
side of A. Mark an I approximately 1 inch from the outline to
the ulnar side of B.
4. Draw a dotted vertical line from the web space of the second
 and third digits (E) proximally down the palm approximately 3
inches. Draw a dotted horizontal line from the bottom of the
thumb web space (D) toward the ulnar side of the hand until
the line intersects the dotted vertical line. Mark a J at the
intersection of these two dotted lines. Mark an N
approximately 1 inch from the outline to the radial side of D.
5. Draw a solid vertical line from J toward the wrist. Then curve
this line so that it meets C on the pattern (see Fig. 9.17A). This
part of the pattern is known as the thumb trough. After reaching
C, curve the line upward until it reaches halfway between N
and D.
6. Mark a K approximately 1 inch to the radial side of the index
finger’s PIP joint. Mark an L 1 inch from the top of the outline
of the middle finger. Mark an M approximately 1 inch to the
ulnar side of the little finger’s PIP joint.
7. Draw the line that ends to the side of N through K, and extend
the line upward and around the corner through L. From L,
round the corner to connect the line with M, and then pass it
through I. Continue drawing the line, and connect it with the
end of G. Connect the radial end of G to pass through H. From
H, extend the line toward C. Curve the line so that it connects
to C (see Fig. 9.17A).
8. Cut out the pattern. Cut the solid lines of the thumb trough also.
Do not cut the dotted lines.
9. Place the pattern on the person in the appropriate joint
placement. Check the length of the pan, thumb trough, and
forearm trough. Assess the fit of the C bar by forming the paper
towel in the thumb web space. Make necessary adjustments
(e.g., additions, deletions) on the pattern.
10. With a pencil, trace the pattern onto the sheet of thermoplastic
material.
11. Heat the thermoplastic material.
12. Cut the pattern out of the thermoplastic material, and reheat it.
Before placing the material on the person, think about the
strategy that you will employ during the molding process.
 13. Instruct the person to rest the elbow on the table. The arm
should be vertical and the hand relaxed. Although some
thermoplastic materials in the vertical position may stretch
during the molding process, the vertical position allows the best
control of the wrist position. Mold the plastic form onto the
person’s hand and make necessary adjustments. Cold water or
vapocoolant spray can be used to hasten the cooling time.
However, this is not appropriate for persons with open wounds,
such as burns.
14. Add straps to the pan, the thumb trough, and the forearm
trough (see Fig. 9.17B). One pan strap is located across the PIP
joints; the other is just proximal to the MCP joints. The strap
across the thumb lies proximal to the IP joint. The forearm has
two straps: one courses across the wrist, and one is located
across the proximal forearm trough. (See also Laboratory
Exercise 9.1.)

Technical Tips for a Proper Fit

• For persons who have fleshier forearms, the pattern requires an
allowance of more than 1 inch on each side. To be accurate,
measure the circumference of the person’s forearm at several
locations and make the pattern corresponding to the location of
the measurements one-half of these measurements.
• Check the pattern carefully to determine fit, particularly the
length of the pan, thumb trough, and forearm trough and the
conformity of the C bar. Moistening the paper towel pattern or a
foil pattern allows detailed assessment of pattern fit.
• Select a thermoplastic material with strength or rigidity. Avoid
materials with excessive stretch characteristics. The orthotic
material must be strong enough to support the entire hand, wrist,
and forearm. A thermoplastic material with memory can be
reheated several times and is beneficial if the orthosis requires
serial adjustments. To make an orthosis more lightweight, select a
 thermoplastic material that is perforated or is thinner than 1⁄8
inch, especially to manage conditions such as RA.
• Make sure the orthosis supports the wrist area well. If the thumb
trough is cut beyond the radial styloid, the wrist support is
compromised.
• Measure the person’s joints with a goniometer when possible to
ensure a correct therapeutic position before applying the
thermoplastic material. Be cautious of positioning the wrist in too
much ulnar or radial deviation.
• When applying the straps, be sure the hand and forearm securely
fit into the orthosis. For maximal joint control, place straps across
the PIPs, thumb IP, palm, wrist, and proximal forearm.
Additional straps may be necessary, particularly for persons who
have hypertonicity. Consider using gauze or elastic bandages to
secure the orthosis when straps are not reasonable.
• Contour the orthotic pan to the hand to preserve the hand’s
arches. The pan should be wide enough to comfortably support
the width of the index, middle, ring, and little fingers.
• Make sure the C bar conforms to the thumb web space (see Fig.
9.17C). The therapist may find it helpful to stretch the edge of the
C bar and then conform it to the web space. Cut any extra
material from the C bar as necessary.
• Verify that the thumb trough is long enough and wide enough.
Stretch or trim the thumb trough as necessary.
• For fabrication of a dorsally based resting hand orthosis, the
pattern remains the same—with the addition of a slit cut at the
level of the MCP joints in the pan portion of the orthosis. The slit
begins and ends about 1 inch from the ulnar and radial sides of
the pan, as shown in Fig. 9.17D . When the orthosis is placed on
the person, the hand inserts through the slit in such a way that
the fingers rest on top of the pan portion and the forearm trough
rests on the dorsal surface of the forearm. The edges of the slit
require rolling or slight flaring away from the surface of the skin
to prevent pressure areas. In addition, the thumb trough is a
separate piece and must be attached to the pan and wrist portion
of the orthosis. Thus material with bonding or self-adherence
characteristics is important. (See also Laboratory Exercise 9.2.)
 FIG. 9.17 Fabrication of a resting hand orthosis. A, Detailed pattern.
B, Strap placement. C, C bar conformity to the thumb web space on a
resting hand orthosis. D, Pattern for a dorsal-based resting hand
orthosis.

Review Questions
1. What are four common diagnostic conditions in which a
therapist may provide a resting hand orthosis for
intervention?
2. In what position should the therapist place the wrist,
MCPs, and thumb for a functional resting hand orthosis?
3. For a person with RA who needs a resting hand orthosis,
how should the joints be positioned?
4. When might a therapist use a dorsally based resting hand
orthosis rather than a volar-based orthosis?
5. In what position should the therapist place the wrist,
MCPs, and thumb for an antideformity resting hand
orthosis?
6. What are the three purposes for using a resting hand
orthosis?
7. What are the four main components of a resting hand
orthosis?
8. Which equipment must be sterile to make a resting hand
orthosis in a burn unit?
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. ed 5. St. Louis: Mosby; 2002.
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Appendix 9.1 Case Studies
Case Study 9.1 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Juan, a 39-year-old man with bilateral dorsal hand burns, has just
been admitted to the intensive care unit (ICU). Juan has second- and
third-degree burns resulting from a torch exploding in his hands. He
is receiving intravenous pain medication and is not alert.
Approximately 14 hours have passed since his admission, and you
just received orders to fabricate bilateral hand orthoses.

1. Which type of orthosis is appropriate for dorsal hand burns?

a. Bilateral resting hand orthoses with the hand in a
functional (midjoint) position
b. Bilateral resting hand orthoses with the hand in an
antideformity (intrinsic plus) position
c. Bilateral wrist cock-up orthoses
2. What is the appropriate wrist position?
a. Neutral
b. 15 to 30 degrees of flexion
c. 15 to 30 degrees of extension
3. What is the appropriate metacarpophalangeal (MCP) position?
a. 50 to 80 degrees of extension
b. 50 to 80 degrees of flexion
c. Full extension
4. What is the appropriate thumb position?
a. Radial abduction
b. Palmar abduction
c. Midway between palmar and radial abduction
5. Which of the following statements is false regarding the
orthosis process for the previous scenario?
a. The supplies should be sterile.
 b. An extremely stretchable material is necessary to
fabricate the orthoses over the bandages.
c. The therapist should give an orthotic-wearing
schedule to the ICU nurse for inclusion in the
treatment plan.

Case Study 9.2 a

Read the following scenario, and use your clinical reasoning to answer the
questions based on information from this chapter and previous chapters.
Ken is a 45-year-old right-hand–dominant man with diabetes
mellitus and Dupuytren disease. He underwent an elective surgical
procedure to release proximal interphalangeal flexion contractures in
his right ring and little fingers. The physician used a Z-plasty open
palm technique. Ken returns from the surgical suite, and you receive
an order to “evaluate, treat, and provide orthosis.” Ken is an
accountant who is married with a 16-year-old son.

1. What diagnosis in Ken’s past medical history is associated with

Dupuytren disease?
2. What orthotic designs are appropriate for Ken’s condition?
3. What therapeutic position will be used in the orthotic design?
4. What wearing schedule will you give Ken?
5. You notice that Ken’s bandage bulk is considerable. How will
you design the orthosis to accommodate for bandage
thickness? What type of thermoplastic material properties will
you choose?
6. How frequently will Ken require therapy?
7. What support systems may Ken require for rehabilitation from
this surgery?
Appendix 9.2 Laboratory Exercises
Laboratory Exercise 9.1 Making a Hand
Orthosis Pattern
1. Practice making a resting hand orthosis pattern on another
person. Use the detailed instructions provided to draw the
pattern. Cut out the pattern, and make necessary adjustments.
2. Use the outline of the following hands to draw the resting hand
orthosis pattern without using the detailed instructions.
Laboratory Exercise 9.2 Identifying Problems
With Orthoses a
There are three persons who sustained burns on their hands. Their
wounds have healed, and they must wear orthoses at night to prevent
contractures. The therapist fabricated the following orthoses. Look at
each picture and identify the problem with each.

1. What is the problem with this orthosis? a

2. What is the problem with this orthosis?
3. What is the problem with this orthosis?
Laboratory Exercise 9.3 Fabricating a Hand
Orthosis
Practice fabricating a resting hand orthosis on a partner. Before
starting, determine the position in which you should place your
partner’s hand. Use a goniometer to measure the angles of wrist
extension, metacarpophalangeal (MCP) flexion, and thumb palmar
abduction to ensure a correct position. After fitting the orthosis and
making all adjustments, use Form 9.1 as a self-evaluation check-off
sheet. Use Grading Sheet 9.1 as a classroom grading sheet. (Grading
Sheet 9.1 may also be used as a self-evaluation sheet.)
Appendix 9.3 Form And Grading Sheet
Form 9.1 Resting Hand Orthosis
Grading Sheet 9.1 Resting Hand Orthosis
a See Appendix A for the answer key.
a See Appendix A for the answer key.
10
Elbow and Forearm
Immobilization Orthoses
Salvador Bondoc, and John Jackson

CHAPTER OBJECTIVES
1. Define anatomical and biomechanical considerations for orthotic
intervention of the elbow and forearm.
2. Discuss clinical/diagnostic indications for elbow and forearm
immobilization orthoses.
3. Identify the components of elbow immobilization orthoses.
4. Describe the fabrication process for an anterior and posterior
elbow orthosis.
5. Review the precautions for elbow and forearm immobilization
orthoses.
6. Use clinical reasoning to evaluate a problematic elbow or forearm
immobilization orthosis.
7. Use clinical reasoning to evaluate a fabricated elbow or forearm
immobilization orthosis.
8. Apply knowledge about the application of elbow or forearm
immobilization orthoses to a case study.

KEY TERMS
anterior elbow immobilization orthosis
anterior transposition
concomitant injury
cubital tunnel syndrome
distal humerus
elbow instability
Essex-Lopresti fracture
medial and lateral epicondyles
Monteggia fracture
olecranon process
open reduction internal fixation (ORIF)
posterior elbow immobilization orthosis
radial head
subcutaneous
submuscular
“terrible triad” injury
tendinosis
tennis elbow
valgus
varus

Devon was playing basketball in a recreation league and fell on his

outstretched hand. When he went to the emergency department, he was
diagnosed with a dislocation of the ulnohumeral joint. The physician
explained to Devon that the ulnohumeral joint played an important role
in stabilizing the elbow. He subsequently was immobilized in a cast.
After the cast was removed, Devon had difficulty reaching due to pain
and stiffness at the elbow. This difficulty limited his ability to do many
of his daily living activities, work, and play basketball. Devon’s provider
referred him for occupational therapy. During his first therapy session
the occupational therapist explained that stiffness of the elbow was a
common complication after an elbow cast removal. Both the therapist
and Devon collaborated on priority goals to help Devon regain his
motion, alleviate his pain, and most importantly resume his usual daily
life activities and return to work and playing basketball again.
Anatomical and Biomechanical
Considerations
The mechanical analog of the elbow joint is a simple hinge. Yet the
sagittal plane motion of flexion and extension is produced by two
articulations with different arthrokinematic properties: the
humeroulnar and the humeroradial joints. The humeroulnar
articulation consists of the trochlear notch of the proximal ulna and
the trochlea of the distal humerus. The humeroradial articulation is
formed by the fovea of the proximal radius and the capitellum of the
distal humerus. These joint structures share a singular capsule along
with the proximal radioulnar joint (PRUJ) and are highly congruent. 16
Although the PRUJ is anatomically linked to the humeroradial and
humeroulnar articulations, the motion produced is functionally
distinct. The PRUJ along with the distal radioulnar joint at the wrist
forms a singular longitudinal axis that affords pronation and
supination of the forearm. 15 With the high congruence of the joint
surfaces, any fracture or dislocation affecting the joint surfaces could
lead to loss of available range of motion in either or both extension-
flexion and supination-pronation. Furthermore, given the single-
capsule configuration of the elbow joint complex, prolonged
immobilization could further accentuate the loss or restriction in the
range of motion in all three elbow joints.
During range-of-motion assessment, normal elbow flexion produces
a soft end feel with the contact of the soft tissues and the volar
surfaces of the forearm and arm. Meanwhile, elbow extension
produces a hard end feel as the olecranon process of the ulna comes
into contact with the olecranon fossa of the distal humerus. The
forearm tends to deviate laterally when the forearm is supinated
during elbow extension. The valgus angulation of the elbow, also
known as the carrying angle, is 10 to 15 degrees from the longitudinal
axis of the humerus and is attributed to the distal expansion of the
medial aspect of the trochlea. 16,22 This valgus angle must be
considered when applying immobilization or mobilization orthoses to
the elbow in extension. In the absence of trauma or underlying
pathology, an elbow in excessive valgus position (typically observed
with prolonged weight bearing in elbow extension and forearm
supination) may lead to a disruption or laxity of the medial collateral
ligament.
Throughout the ranges of elbow flexion and extension, the medial
and lateral collateral ligament complexes also contribute to the
stability of the elbow joint. Elements of the medial collateral ligament
complex produce valgus (medial) restraint from maximum extension
to 120 degrees of flexion. 24 Meanwhile, the lateral (ulnar) collateral
ligament complex remains taut throughout the range of motion and is
further accentuated when the elbow undergoes varus stress. 20 Given
the contribution of the collateral ligament complex to elbow stability,
injury to either or both ligaments could also alter elbow alignment
and range of motion.
The volar surface of the elbow is filled with soft tissue and features
a transverse crease that, depending on a person’s muscle mass and
elbow joint complex laxity, may lie on a flat or concave surface when
the elbow is in full extension. This volar area is bordered by the biceps
brachii superiorly, the bellies of the brachioradialis, the common hand
extensors laterally, and the common hand flexors medially. The
landscape of the dorsal elbow surface is bony. When the elbow is in 90
degrees of flexion, the center points of the olecranon process and the
medial and lateral epicondyles form a triangular configuration. These
bony prominences are potential sources of irritation and must be
protected during orthotic fabrication and fitting.
Clinical Indications and Common
Diagnoses
Immobilization orthoses for the elbow and the forearm are commonly
constructed to protect and support healing structures following a
traumatic injury to the bones, muscles, ligaments, and related soft
tissues. These conditions are managed either conservatively or
surgically. Conservative management may involve manipulation or
closed reduction before immobilization and is often indicated for
simple fractures. Surgical interventions vary based on the client’s
presentation and goals, surgeon’s choice, and available resources. The
more common surgical fixation procedures involve open reduction
with internal fixation using plates and screws and/or wiring. Other
surgical procedures used for the elbow include hinged external
fixation, arthroplasty (joint replacement), and nerve transposition. In
cases of external fixations an additional elbow immobilization orthosis
may be unnecessary.
An elbow immobilization orthosis may be indicated to manage pain
and support unstable structures (e.g., arthritis), restrict motion and
provide rest (e.g., ulnar nerve entrapment), or to prevent loss of or to
improve motion (e.g., elbow stiffness and contractures) through
progressive application. Elbow orthoses for the purpose of
immobilization may be commercially prefabricated or custom made.
The appropriate choice of orthosis depends on the clinical indication
and the preferences of the surgeon, therapist, and client. Table 10.1
provides a summary and comparison of conditions for which an
elbow immobilization orthosis is indicated.

Elbow Fractures and Dislocation

Traumatic fractures of the elbow may occur to the distal humerus,
proximal ulna, proximal radius, or any combination. The incidence of
elbow fractures is almost evenly distributed to the aforementioned
structures with distal humerus and proximal radius being more
common. 14 Fractures are often complicated by concomitant injury to
surrounding soft tissues, blood vessels, or nerves. More complex
forms of elbow fractures involve the articular surfaces and may
include joint dislocations. However, joint dislocations may occur from
disruptions in soft tissue support without fractures. Complex elbow
injuries, if not properly treated, have a poor prognosis with recurrent
instability, stiffness, and pain. 12

Distal Humerus Fractures

Fractures to the distal humerus constitute approximately a third of all
elbow fractures. 14 Intra-articular fractures may occur to one or both
condyles because they articulate with the ulna or radius and result
from compression forces across the elbow. Extra-articular fractures are
typically supracondylar (above the condyles) or transcondylar (across
the condyles above the articular surfaces) in nature. These fractures
generally result from a fall on an outstretched hand. 10 Conservatively
treated simple, nondisplaced fractures or postsurgical elbow fixation
of more complex, unstable fractures are immobilized in a long arm
cast or posterior elbow orthosis. A posterior elbow orthosis (Fig. 10.1)
is designed to position the elbow at 90 degrees flexion and forearm in
neutral. The duration of orthotic use may depend on the speed of
bone and soft tissue healing. In many cases there is an overlap
between immobilization orthoses for healing and mobilization
orthoses to prevent or manage soft tissue tightness. Therapists must
collaborate with the client’s physician to ensure timeliness of
intervention.

Proximal Radius Fractures

Proximal radius fractures are the most common of all elbow fractures.
24 In one estimate, 14 at least a third of all elbow fractures occur in the

radial head and neck. These elbow fractures occur by axial loading on
a pronated forearm with the elbow in more than 20 degrees of flexion.
The severity of the fracture and the client’s contexts determine
intervention. Simple or minimally displaced radial head fractures with
no evidence of mechanical block are often treated with gentle active
mobilization early in the recovery period using a posterior elbow
immobilization orthosis (see Fig. 10.1). This orthosis positions the
elbow in 90 degrees of flexion and forearm in neutral for rest and
protection. Displaced radial fractures may be treated surgically
depending on the presence of mechanical block and the number of
fracture segments. 17 Surgeons may elect to use an open reduction
internal fixation (ORIF) technique or radial head replacement. In
either case, clients need to be immobilized with a cast or commercially
available brace immediately following the surgery. Immobilization
orthotic provision may continue following cast removal, depending
on the client’s condition (e.g., rate of healing, joint stability, presence
of concomitant collateral ligament injury) and the surgeon’s
preference. For clients with ORIFs the objective is to maintain the
stability of the radial fixation by immobilizing the elbow in greater
than 90 degrees flexion with the forearm in neutral or pronated
position (Fig. 10.2). As the client improves, the elbow angle may be
adjusted toward extension. For clients with radial head arthroplasties,
the choice of immobilization is largely dependent on the integrity of
the supportive ligaments and capsule. Some surgeons may opt for
commercially available adjustable hinged braces, such as the Bledsoe
brace (Fig. 10.3), or a therapist may fabricate a custom hinged elbow
device that may be adjusted or locked in the direction of both flexion
and extension.

TABLE 10.1

Conditions That Require an Elbow Immobilization Orthosis

FIG. 10.1 Posterior elbow orthosis with elbow in 90 degrees flexion.

FIG. 10.2 Posterior elbow orthosis with elbow in 120 degrees flexion.
 FIG. 10.3 Bledsoe brace.
Courtesy Bledsoe Brace Systems, Grand Prairie, Texas.

Proximal Ulnar Fractures

Most proximal ulnar fractures occur either at the olecranon or the
coronoid process. Olecranon fractures typically result from a direct
impact or from a hyperextension force. 3 Olecranon fractures are often
amenable to ORIF using a plate and screws or tension wiring. 6 Many
olecranon fractures involve the triceps either by rupture or avulsion.
Following acute management surgically or conservatively (closed
reduction), the elbow is braced or dorsally positioned in 30 to 45
degrees flexion to minimize the passive tension on the triceps.
Fractures of the coronoid process are more complex and associated
with significant instability. 13 (This topic is described later.)
Approaches to management are varied 2 and include a more
conservative cast immobilization or progressive hinged external
fixation for several weeks. In such cases the purpose of rehabilitative
orthotic provision shifts toward mobilization after cast removal due to
stiffness.

Forearm Fractures
Many complex elbow fractures affecting the proximal radius and ulna
result in disruption of the proximal and/or distal radioulnar joint(s).
Radial head fractures associated with disruption of the interosseous
membrane and dislocation of the distal radioulnar joint are also
termed Essex-Lopresti fractures. Proximal ulnar fractures along with
the dislocation of the radial head at the PRUJ are also known as
Monteggia fractures. The objective of managing these fractures is to
restore the joint articulation and kinematics for elbow and forearm
mobility. The initial aim of management is to stabilize the forearm by
restricting rotation. Restriction may be accomplished through bracing,
orthoses, or casting that extends throughout the upper limb proximal
to the elbow and distal to the wrist. Examples of the orthoses used to
immobilize the forearm and wrist and restrict the elbow include a
sugar tong orthosis (Fig. 10.4) and a Muenster orthosis. Both examples
enable some degree of elbow motion typically within the functional
range of 30 to 130 degrees of sagittal motion.
FIG. 10.4 Forearm immobilization orthosis, sugar tong type.
Elbow Dislocations
Dislocations of the elbow are common and may occur with or without
fractures. Dislocations without fractures are considered simple,
whereas dislocations with fractures (typically of avulsion type) are
considered complex. Nearly all elbow dislocations, simple and
complex, occur in posterior or posterolateral directions, 5 resulting in
joint instability. A common pattern of complex elbow instability
results from a dislocation of the ulnohumeral joint and injury to the
varus and valgus stabilizers of the elbow and the radial head. 11 This
injury occurs due to a forceful fall on an outstretched hand. If a
coronoid avulsion fracture is involved, the condition is termed a
“terrible triad” injury.
To prevent instability, simple dislocations are managed in one or
more of the following options: (1) cast immobilization, (2) surgical
repair of ruptured collateral ligaments, or (3) early mobilization
following a reduction or repair procedure. Clients who undergo an
early mobilization program with or without ligament repair require
supportive orthotic provision during periods of rest. Wolff and
Hotchkiss 23 described a conservative approach to managing a
postreduction elbow dislocation to prevent lateral instability using
active mobilization within limits of pain and orthotic provision. The
immobilization orthosis places the elbow in 100 to 120 degrees of
elbow flexion with the forearm in neutral to a fully pronated position.
An alternative is a commercially available hinged brace that stabilizes
the elbow while at rest and may be adjusted during exercise.

Biceps Rupture
Distal biceps tendon rupture is uncommon and occurs more
frequently to the long head branch within the shoulder. Such injury
occurs more often in middle-aged men. The typical mechanism of
injury is eccentric loading of the biceps while the elbow is in a flexed
position. 18 Conservative management is often indicated for partial
tears, using an elbow brace or immobilization orthosis. This orthosis
places the elbow in 90 degrees flexion with the forearm in neutral to
supination. Postoperative bracing or orthotic provision is indicated for
full tears with the forearm in supination. The supinated position is
necessary to minimize the mechanical impingement of the distal
biceps. Seiler and colleagues 21 observed that 85% of the PRUJ space is
occupied by the biceps tendon when the forearm is pronated. They
theorized that repetitive pronation contributes to the pathophysiology
of the distal biceps rupture through mechanical shearing and
hypovascularization. Whether the client’s elbow is conservatively or
surgically managed, the orthosis or brace is progressively adjusted
into extension as gentle exercises are introduced and upgraded over a
typical course of tendon healing of 4 to 8 weeks.

Triceps Repair
Conservative management for a triceps repair is often indicated for
partial tears using an elbow brace or immobilization orthosis. This
orthosis places the elbow in 90 degrees flexion with the forearm in
neutral. Postoperative bracing or orthotic provision is indicated for
full tears with the forearm in neutral. The supinated position is
necessary to minimize the mechanical impingement of the distal
biceps.

Cubital Tunnel Syndrome

Cubital tunnel syndrome is the second most common site of nerve
compression in the upper extremity. 1,19 Anatomically, the ulnar nerve
is susceptible to injury at the elbow secondary to its superficial
location situated between the medial epicondyle of the humerus and
the olecranon. Injury to the nerve may occur as a result of trauma or
prolonged or sustained motion that compresses the nerve over time. 7
Ulnar nerve entrapment following a trauma may arise immediately or
gradually due to tethering of the nerve as it courses through a region
that may be occupied by edema or adherent scar. Symptoms include
pain and paresthesias (numbness, tingling) in the fourth and fifth
digits of the hand. In advanced stages, weakness and atrophy of the
hypothenar muscles and thumb adductor may be seen (see Chapter
14).

FIG. 10.5 Anterior elbow orthosis with elbow in −30 degrees of

extension.
 FIG. 10.6 Pil-O-Splint.
Courtesy North Coast Medical, Gilroy, California.

Conservative management focuses on avoiding postures and

positions that aggravate the symptoms. Clients are instructed to avoid
repetitive or sustained elbow flexion. A nighttime anterior elbow
extension orthosis is fabricated with the elbow positioned in 30 to 45
degrees of flexion (Fig. 10.5). If the exposed cubital tunnel region
remains irritated, a posterior elbow orthosis with a “belly gutter” to
the posteromedial aspect of the elbow may be an option. There are
commercially available soft orthotic devices, such as the Pil-O-Splint
(North Coast Medical, Gilroy, CA) (Fig. 10.6) and the Comfort Cool
ulnar protector (North Coast Medical) (Fig. 10.7), that offer additional
alternatives if a thermoplastic orthotic device is not tolerated by the
client. In one cadaver study by Apfel and Sigafoos, 26 three types of
orthoses braces were all successful in preventing less than 90 degrees
of elbow flexion. These are the Pil-O-Splint, Hely and Weber cubital
brace, and a folded towel splint. In addition to the use of an effective
orthosis design, the management of cubital tunnel syndrome should
incorporate behavior modification on the part of the client, such as
minimizing excessive elbow flexion and weight bearing on a flexed
elbow to reduce pressure or traction on the ulnar nerve. Rigid night
orthotic wear and activity modification have been found to be a
successful treatment for cubital tunnel syndrome. 28
 FIG. 10.7 Comfort Cool ulnar protector. (Courtesy North Coast
Medical, Gilroy, California.)

Surgical Decompression of High Ulnar Nerve

Injury
If conservative management of cubital tunnel syndrome is not
successful or if compression of the ulnar nerve is too severe, causing
distal muscle wasting and intolerable sensory discomfort on the part
of the client, then surgery may be indicated. This surgical procedure
includes anterior transposition of the ulnar nerve. Two main methods
to accomplish this procedure include subcutaneous and submuscular
transposition. 25 The subcutaneous method includes moving the ulnar
nerve anteriorly medial to the median nerve and below subcutaneous
fascia in the forearm. A posterior long arm orthosis with the elbow in
70 to 90 degrees flexion and the forearm in neutral is indicated. The
submuscular method includes moving the ulnar nerve anteriorly and
placed in a muscular bed, most commonly the flexor-pronator muscle
origin. A posterior long arm orthosis with the elbow in 70 to 90
degrees flexion and the forearm in slight pronation is commonly used.

Elbow Stiffness
Stiffness is a common consequence of trauma to the elbow joint
complex whether managed conservatively or surgically. Elbow
stiffness may be a common consequence for clients with osteoarthritis.
Elbow stiffness may be classified as intrinsic or extrinsic. 4 Intrinsic
elbow stiffness may have intra-articular pathology, such as partial
arthrodesis or loss of cartilaginous lining (i.e., osteoarthritis), or may
be due to a loss of articular congruency from a less than accurate
reduction and fixation after a fracture or dislocation. End range-of-
motion assessment of intrinsic stiffness often yields a “bone-on-bone”
end feel. On the other hand, extrinsic elbow stiffness is a result of
contractures to the surrounding capsular, ligamentous, and adjacent
soft tissue structures, including skin, muscle, and tendon. Often the
elbow is held in midflexion post injury. As the body undergoes the
phases of healing (i.e., inflammatory response to repair and
remodeling), tenacious edema, scarring, pain, and immobilization all
contribute to the elbow’s propensity to develop contractures of the
soft tissues. To address this problem, early intervention is indicated
through the controlled active motion and orthotic provision or bracing
that provides low-load and prolonged stretch. 8
 FIG. 10.8 A serial static elbow extension orthosis.

There are two general approaches to orthotic provision that

incorporate low-load and prolonged stretch to address elbow stiffness:
(1) static progressive or serial static orthoses (Fig. 10.8) and (2)
dynamic orthoses. The mechanism behind static progressive or serial
static orthoses is stress relaxation (i.e., when the tissue is stretched, the
load needed to maintain the stretched state decreases and becomes
better tolerated). The mechanism behind dynamic orthotic provision is
creep, in which load is constantly applied to cause a change in the
viscoelastic properties of tissues. 4 In a systematic review by Veltman
and colleagues, 27 static progressive orthotic wear resulted in an
average change of 36 degrees among 160 patients, and dynamic
orthosis resulted in an average change of 37 degrees among 72
patients. Rehabilitative management using orthoses for elbow stiffness
is effective, but it is also time extensive and requires consistent client
follow-through with the orthotic-wearing schedule and home
program of range-of-motion and stretching exercises to be successful.
Although both orthotic approaches are well supported by evidence,
therapists should be attuned to the client’s preferences and ability to
follow up to better achieve wearing tolerance and adherence.
When there is substantial fibrosis and maturation of scars, extrinsic
contractures may be resistant to orthotic provision or bracing and may
require open or arthroscopic release. Intrinsic contractures may
respond only to rehabilitative management when anatomically
possible. To achieve full range of motion of the elbow, tissue release
and joint arthroplasty may be necessary. 4

Tennis Elbow
Tennis elbow, or lateral epicondylosis, is not only very prevalent with
tennis players (and athletes that compete in racquet sports) but also
with everyday people who perform repetitive wrist and gripping
hand movements. 29 It involves overuse of the forearm extensor
muscles causing strain or microtears to the common extensor muscles,
especially the extensor carpi radialis brevis. 29 As a result, clients
report tenderness and pain at the lateral epicondyle and/or at the
common extensor tendon area, especially when grasping objects.
Clients may also experience decreased grip strength and
posterolateral pain with resisted supination. If not diagnosed early
and treated appropriately with immobilization and activity
modification, the microtears may not sufficiently heal or could
worsen, leading to chronic scarring of the muscle tendon or
tendinosis.
 FIG. 10.9 Counterforce brace.
(From Rizzone, K., Gregory, A (2013). Using casts, splints and braces
in the emergency department. Clinical Pediatric Emergency, 14(4),
340-348.)

There are two common orthotic approaches for the acute treatment
of lateral epicondylitis: a wrist immobilization (cock-up) orthosis with
the wrist at 20 to 30 degrees extension (see Chapter 7) and a
counterforce brace (Fig. 10.9), both of which are readily available
commercially at supermarkets or pharmacies. Studies comparing both
orthoses yield conflicting results. One such study concluded that the
use of a counterforce brace or sleeve was more effective at reducing
pain with grip compared with a wrist orthosis. 29 Another study
involving 42 participants showed that the wrist immobilization was
better for pain relief compared with the forearm counterforce brace. 31
Both studies 29,31 did not examine long-term effects. This is critical
because lateral epicondylitis is known to be a recurrent condition.
One study reported a novel orthotic design that incorporated both
counterforce bracing and wrist immobilization, with restriction of
forearm supination by way of a spiral forearm-wrist design, and made
a positive impact on the symptoms of tennis elbow. 30 In this study the
new spiral orthosis was worn for a total of 4 weeks. 30 Although this
study had a small sample, subjects did show significant increase in
grip strength, functional use of the hand, and decrease in pain.

FIG. 10.10 Posterior elbow orthosis.

Features of Elbow and Forearm
Orthoses
Posterior Elbow Orthosis
A posterior elbow orthosis (Fig. 10.10) is a common orthotic choice for
many acute posttraumatic and postsurgical elbow conditions,
especially when positioning the elbow at 70 to 120 degrees flexion.
The orthosis is easy to wear and offers rest and protection to painful
and healing structures. Because of the prominent bony prominences
located at the posterior elbow, measures to avoid pressure or provide
pressure relief should be built into the orthotic design. Edema, a
common consequence of elbow injury and surgery, must also be
accommodated into the orthotic design and managed through
compression sleeves. Sleeves will keep the skin, which is covered by
the orthosis, dry.

Anterior Elbow Orthosis

An anterior elbow orthosis is indicated in situations where there is a
posterior wound that cannot tolerate posterior pressure or contact. If
positioning the elbow at less than 70 degrees of flexion, then an
anterior orthosis may be considered. An anterior elbow orthosis is also
used to prevent or correct elbow flexion contractures. Following a
contracture release of a stiff elbow, an anterior elbow orthosis is used
as a serial static orthosis to slowly gain extension of the elbow over
time by remolding the orthosis in increased extension at weekly
intervals. In addition, the anterior design is effective in blocking elbow
flexion, such as with ulnar nerve compression neuropathies.
For extension contractures of 35 to 30 degrees, an anterior elbow
extension orthosis is fabricated for use when the client is at rest (Fig.
10.11). As the position of comfort tends to be in flexion, it is
recommended to gradually increase the wearing schedule to allow the
client to get used to keeping the elbow in extension. During the
fabrication process the orthosis may be molded to create a small space
near the cubital fossa. During application the client may apply
additional stretch to the elbow by attempting to fully approximate the
cubital fossa against the orthosis. If needed, a design modification of
creating a cubital window may provide the client a visual guide (Fig.
10.12). As the client’s elbow extension increases, the anterior elbow
orthosis may be remolded to further provide static stretch until the
goal is attained.

FIG. 10.11 Anterior elbow immobilization orthosis.

 FIG. 10.12 Anterior elbow immobilization orthosis with a cubital
window.

Static Progressive Elbow Extension

For flexion contractures of greater than 35 degrees, a static progressive
elbow orthosis is either fabricated or provided. An effective design for
a static progressive elbow extension orthosis is a custom turnbuckle
orthosis (Fig. 10.13). 9 This orthosis features a long radial gutter
distally, an anterior arm trough proximally, a pair of hinges, and a
turnbuckle. The expandable adjustment of the turnbuckle rods affords
incremental stretch. It should be noted that fabrication of this static
progressive orthosis requires experience, expertise, and time. Simpler
alternatives to the turnbuckle orthosis are commercially available,
including the Mayo elbow universal brace (Fig. 10.14) and the JAS
elbow orthosis (Fig. 10.15). Both braces are adjustable to the desired
range and degree of stretch.
FIG. 10.13 Static progressive elbow orthosis with a turnbuckle.
 FIG. 10.14 Mayo elbow universal brace.
Courtesy Aircast, Summit, New Jersey.

Static Progressive Elbow Flexion

For flexion contracture that prevents a client from achieving greater
than 90 degrees of flexion, a custom static progressive elbow flexion
orthosis is indicated (Fig. 10.16). This orthosis is referred to as the
“come-along” orthosis. This orthosis features an ulnar gutter distally, a
dorsal arm trough proximally, a pair of hinges, and strapping with an
embedded series of D-rings. The straps with D-rings may be
progressively advanced to provide the requisite flexion stretch. The
therapist must assess the onset of ulnar nerve symptoms (e.g., report
of numbness and tingling along the ulnar side of the hand and medial
forearm) with prolonged elbow flexion. If such symptoms occur, the
therapist examines and addresses the potential cause, including scar
adhesions and edema that may restrict ulnar nerve gliding. An
alternative to the use of D-straps is bungee cords (Fig. 10.17).
However, with bungee cords the therapeutic mechanism changes
from static progressive stress relaxation to dynamic orthotic provision
creep (see Chapter 13).

FIG. 10.15 JAS elbow orthosis.

Courtesy Joint Active Systems, Effingham, Illinois.
 FIG. 10.16 Custom, static progressive elbow flexion orthosis, front (A)
and back (B).

For flexion contracture that prevents a client with minimal elbow

flexion motion (<90 degrees), a “holster-and-cuff” design is
recommended (Fig. 10.18). The main biomechanical difference
between this orthosis and the static progressive “come-along” orthosis
is the length of the proximal moment arm. In a class I lever where the
axis or fulcrum is in the middle of the effort and weight, the
mechanical advantage favors the effort with a longer moment arm
(Fig. 10.19). Again, the fabrication of these static progressive flexion
orthoses requires experience, expertise, and time.
When the limitations are multidirectional, it may be necessary to
fabricate multiple static orthoses for each limitation. The therapist
must exercise a depth of reasoning in prioritizing which movement
direction should be emphasized. Key considerations include the
client’s goals, severity of deficit, and response to active interventions,
such as exercises, manual therapy, and therapeutic activities. It must
be noted that for true physiological change to occur in the
contractured tissues, the client must adhere to the wear regimen.
Initially, clients are instructed to wear the orthosis for 2-hour intervals
for a total of 6 to 8 hours daily. At first only short intervals are
tolerated. The goal is to develop a tolerance for longer intervals.
Clients may also be instructed to adjust the tension to allow increased
motion as tolerated. When more than one orthosis is required, the
client may alternate the orthoses during the day or wear one during
the day and the other at night for sleeping. The orthotic regimen is
highly individualized and tailored to meet the specific needs and
limitations of each client. Off-the-shelf prefabricated static progressive
flexion/extension orthoses are currently available and are effective in
many cases. The shape of the client’s arm, the degree of joint stiffness,
and the firmness of joint end feel impact the fit and effectiveness of
commercial orthoses.
 FIG. 10.17 Progressive elbow flexion orthosis using bungee cords.

Forearm Restriction
Restriction of forearm rotation is needed due to shaft fractures of the
forearm or fracture-dislocation of the elbow or wrist. An orthosis that
is nearly circumferentially positioned to the distal humerus and
extending distally to include the wrist provides immobilization to the
forearm. Two common designs are a sugar tong (see Fig. 10.4) and the
Muenster-type orthosis. Both orthoses cover the length of the forearm
dorsally and volarly. Note that with these orthoses the wrist is
positioned in neutral or near neutral and restricted from sagittal plane
movement. The elbow is partially restricted in the sagittal plane.
Fabrication of a Posterior Elbow
Immobilization Orthosis
The initial step in the fabrication of an elbow immobilization orthosis
is the drawing of a pattern. Elbow orthotic patterns differ from hand
patterns in that measurements of the client’s arm, elbow, forearm,
wrist, and hand are taken and recorded. A pattern is drawn based on
the recorded measurements. Tools and materials required to fabricate
the orthosis include:

• Perforated 1⁄8- to 3⁄16-inch thermoplastic material with

moderate elasticity, conformability, and bonding
• 1⁄8-inch polycushion padding
• 1- to 2-inch strap
• 2- or 3-inch stockinette
• Tape measure
• Marker
• Scissors

FIG. 10.18 Holster and cuff design orthosis.

 FIG. 10.19 Static progressive “come-along” orthosis. A, Measurement
from distal palmar crease (DPC) to 2 cm distal to axillary fold. B,
Drawing line along noted anatomical points. C, Drawing a
perpendicular line at DPC. D, Measurements taken at anatomical
landmarks.

Procedure for Fabrication of a Posterior

Elbow Immobilization Orthosis
The following steps describe the fabrication process for a posterior
elbow immobilization orthosis in 90 degrees of flexion. The angle of
the orthosis is determined by the structures to be protected.
1. Create a pattern by taking the following steps:
a. Using a tape measure, measure the length of the upper
extremity from the distal palmar crease (DPC), along
the ulna and up to approximately 2 cm distal to the
axillary fold (see Fig. 10.19A). Take note of the points
corresponding to the DPC, ulnar styloid, olecranon
process, and proximal arm.
b. Draw a straight line on the paper using the length
determined earlier (see Fig. 10.19B). Mark the
anatomical points stated earlier along the straight line.
c. Measure two-thirds of the circumference of the hand
at the palmar crease (see Fig. 10.19C). Draw a
perpendicular line at the DPC point by the straight
line referenced in step 1b This straight line should
bisect the perpendicular line.
d. Repeat step 1c on the remaining measurement points:
around the wrist by the ulnar styloid, around the
elbow by the olecranon, and around the arm above the
biceps (see Fig. 10.19D).
e. Cut slits along the olecranon line approximately one-
third of the width on both sides.
2. Cut the paper pattern from the paper and measure it on the
client in the correct orthotic position. Make sure that the
pattern covers the correct length from the DPC to the proximal
arm. Ensure the correct girth at the anatomical points identified
in step 1a. Once the pattern is deemed satisfactory, trace it on
the thermoplastic material and cut the material (Fig. 10.20). If
the material is too rigid to be cut, the material may be lightly
heated to the point that it may be cut using a pair of scissors.
Repetitive heating of the material may cause a loss of rigidity or
durability.
3. Position the client for orthotic provision. The ideal position is
the client in supine with the shoulder and elbow in 90 degrees
of flexion (Fig. 10.21). This position takes advantage of gravity
to produce an easier and more precise drape of the
 thermoplastic material. Alternatively, the client may be lying
prone with the shoulder abducted in 90 degrees and the
forearm dangling over the edge of the plinth/bed.
4. Using disks cut out from polycushion, pad the following bony
prominences: olecranon, lateral and medial epicondyles, and
the ulnar head at the wrist (Fig. 10.22).
5. Cover the padding with a layer of stockinette to prevent it from
adhering to the thermoplastic material. If the client has fragile
or sensitive skin (e.g., allergic reaction to adhesives), an
additional stockinette may be applied before sticking the
polycushion pads on the bony prominences.
6. The material is heated according to the manufacturer’s
suggested duration. The material is removed and patted dry.
7. Carefully drape the material over the arm in the proper position
described in step 3. Allow the material to rest on the client’s
limb before smoothing (Fig. 10.23).
8. The overlap between the arm and forearm troughs is pinched
and smoothed first (Fig. 10.24). Then proceed with ensuring
proper drape on the rest of the limb segments. A common error
is for the client to extend the elbow slightly during the molding
process, causing loss of the flexion angle. Using the noninjured
hand, the client supports the limb by the wrist.
9. Once the material has cooled, the padding and stockinette are
removed.
10. The elbow seams are smoothed, the edges flared, and the spaces
for pressure relief over the bony prominences are further
deepened by gently pushing the material (Fig. 10.25).
11. An alternative padding using the same thickness may be
reinserted to the interior of the orthosis.
12. The fit is checked, and adjustments are made as needed.
13. Apply the following straps: proximal upper arm; distal upper
arm, proximal to the elbow; proximal forearm; wrist and
metacarpals (Fig. 10.26).
14. Reapply the orthosis, and recheck the fit (Fig. 10.27). If the
elbow needs further reinforcement, a small thermoplastic strip
 may be cut, heated, and applied along corner edges of the
elbow.
15. Educate the client in proper donning/doffing, skin checks and
precautions, wearing schedule, and care of the orthosis.

FIG. 10.20 Trace pattern and cut out.

FIG. 10.21 Supine position of client for orthotic provision.
FIG. 10.22 Padding bony prominences.
FIG. 10.23 Draping material over the arm.
Technical Tips for A Proper Fit
• Select a thermoplastic material that is rigid enough to support
the elbow yet conforms well to the arm and joint.
• Align the thermoplastic material along the arm. Make sure to
properly position the material before molding.

FIG. 10.24 Overlapping the arm and forearm troughs.

• An elastic wrap may be used to hold the material in place and

 free up the therapist’s hands to support the arm in the correct
position. Ensure that the pressure is even throughout the
troughs. When using materials that are highly moldable, a
wrap may leave unsightly imprints throughout the orthosis.
• Determine that the client has full range of motion of the
shoulder and the hand when wearing the orthosis by having
the client move in all planes.
• Ensure that the elbow, forearm, and/or wrist joints are in the
correct angle during the molding process by checking the joint
angles with a goniometer before the material cools.
• Make sure that the orthosis extends as proximal to the axilla as
possible, particularly on the lateral side. This position
provides adequate support and leverage to properly
immobilize the elbow. Make sure the medial side of the
proximal portion clears the axilla to prevent irritation.
• If a mistake occurs, it is better to remold the entire orthosis
rather than spot heat/fix one area.
• If the material is not rigid enough, reinforce the orthosis with a
material that has low memory. Make sure that when adding
reinforcements like struts or exoskeletons, the orthosis is
actually worn by the client.
• If the client is not adhering to the wear schedule, there is a
tendency for the orthosis to curl inward (reducing
circumferential opening).
• Use wide straps to properly secure the arm and the forearm in
the orthosis. Consider using a figure-eight strap for clients
with larger limb girth.
FIG. 10.25 Seams are smoothed (A), and ends are flared (B).
FIG. 10.26 A and B, Strap application.
Precautions for Elbow Immobilization
Orthoses
• Pad all bony prominences.
• Smooth or flare all edges. For a client with sensitive skin, add
moleskin or thin padding as needed. Linings must be
monitored for organic grime, dirt, and stains.
• Edema in the elbow is common after injury or surgery. Make
sure the client is scheduled for a follow-up visit within several
days to modify and adjust the orthosis to accommodate for
changes in edema.
• When applying an orthosis over an incision site that is not yet
fully closed, make sure to cover the site with nonstick
dressing. This protective dressing prevents moisture from
transferring to the site from the orthosis.
• Open, draining, or infected wounds should not be covered by
orthoses in order to allow for aeration and avoid pressure.
Alternative orthoses should be explored.

FIG. 10.27 Rechecking fit for needed reinforcement. A,

Applying reinforcement. B, Adhering reinforcement to orthosis.
 a
Self-Quiz 10.1
For the following questions, circle either true (T) or false (F).

1. T F Elbow immobilization orthoses can be posterior or anterior.

2. T F It is better that the wrist be left free in forearm
immobilization orthoses to allow for more functional motion.
3. T F Thinner and highly perforated material is preferable for
postsurgical elbow orthoses to provide comfort and cooling.
4. T F Following a proximal radius fracture, the elbow can be
immobilized in either a brace or posterior elbow orthosis.
5. T F Posterior elbow orthoses are preferred for increasing
extension.
6. T F The angle of elbow immobilization is dictated by the client’s
comfort.
7. T F Olecranon fractures are positioned in 90 degrees of flexion.
8. T F An anterior elbow orthosis is appropriate for preventing or
correcting elbow flexion contractures and for blocking elbow
flexion.
9. T F The best orthosis for an extension contracture of the elbow
of greater than 30 degrees is a serial static elbow extension
orthosis.
10. T F Generally, biceps tendon repairs are immobilized with the
elbow in complete extension.
11. T F Postoperative treatment of cubital tunnel includes
positioning the elbow in 30 to 45 degrees of flexion.

a
See Appendix A for the answer key.

Review Questions
1. What are the main indications for elbow immobilization
 orthoses?
2. What are the precautions for elbow orthotic provision?
3. When might a therapist consider serial orthotic provision
with an elbow immobilization orthosis?
4. What are the purposes of immobilization orthotic
provision of the elbow?
5. What are the advantages and disadvantages of a custom
orthosis over a commercial orthosis for the elbow?
6. What are the indications for anterior elbow orthotic
provision?
7. What are the optimal positions for molding a posterior
elbow orthosis?
References
1. Blackmore S. Therapist’s management of ulnar nerve
compression at the
elbow. In: Mackin E.J, Callahan A.D, Skirven T.M, et
al., eds. Rehabilitation of the hand and upper extremity
. ed 5. St. Louis: Mosby; 2000.
2. Budoff J.E. Coronoid fractures. J Hand Surg Am
. 2012;37(11):2418–2423.
3. Cabanela M.F, Morrey B.F. Fractures of the
olecranon. In: Morrey B.F, ed. The elbow and its
disorders . ed 3. Philadelphia: Saunders; 2000:365–379.
4. Charalambos CP, Morrey BF: Posttraumatic elbow
stiffness, J Bone Joint Surg 94A:1428–1437.
5. de Haan J, den Hartog D, Tuinebreijer W.E, et
al. Functional treatment versus plaster for simple
elbow dislocations. BMC Musc Dis . 2010;11:263–
270. .
6. Edwards S.G, Cohen M.S, Lattanza L.L, et
al. Surgeon perceptions and outcomes regarding
proximal ulna fixation: a multicenter experience. J
Should Elb Surg . 2012;12:1637–1643.
7. Fess E, Gettle K, Philips C, et al. Splinting for work,
sports and the performing
arts. In: Fess E, Gettle K, Philips C, et al., eds. Hand
and upper extremity splinting: principles and methods
. ed 3. St. Louis: Mosby; 2005:470–471.
8. Flowers K.R, LaStayo P. Effect of total end range time
on improving passive range of motion. J Hand Ther
. 1994;7(3):150–157.
 9. Gelinas J.J, Faber K.J, Patterson S.D, et al. The
effectiveness for turnbuckle splinting for elbow
contractures. J Bone Joint Surg Br . 2000;82(1):74–78.
10. Hoisington S.A, Murthy V.L. Forearm
fractures. In: Hoppenfeld S, Murthy V.L, eds.
Treatment and rehabilitation of fractures
. Philadelphia: Lippincott Williams and
Williams; 2000:169–190.
11. Hotchkiss R. Fractures and dislocations of the
elbow. In: Green D.P, ed. Rockwood and Green’s
fractures in adults . ed 4. Philadelphia: Lippincott-
Raven; 1996.
12. Liu H.H, Wu K, Chang C.H. Treatment of complex
elbow injuries with a postoperative custom-made
progressive stretching static elbow splint. J Orthop
Trauma . 2006;20(6):400–404.
13. McKee R.C, McKee M.D. Complex fractures of the
proximal ulna: the critical importance of the coronoid
fragment. Inst Course Lect . 2012;61:227–233.
14. Morrey B.F. Anatomy of the elbow
joint. In: Morrey B.F, ed. The elbow and its disorders
. ed 3. Philadelphia: Saunders; 2000:13–42.
15. Neumann DA: The elbow and forearm complex. In
Kisner C, Colby LA: Therapeutic exercise foundations
and techniques, ed 6, Philadelphia, FA Davis.
16. Oatis C.A. Kinesiology: the mechanics and
pathomechanics of human movement
. Philadelphia: Lippincott Williams and
Williams; 2004.
17. Pike J.M, Athwal G.S, Faber K.J, et al. Radial head
fractures—an update. J Hand Surg Am
 . 2009;34(3):557–565.
18. Quach T, Jazayeri R, Sherman O.H, et al. Distal biceps
tendon injuries—current treatment options. Bull
NYU Hosp Jt Dis . 2010;68(2):103–111.
19. Rayan G. Ulnar nerve compression. Hand Clinics
. 1992;8:325.
20. Ruch D.S, Papadonikolakis A. Elbow instability and
arthroscopy. In: Trumble T.E, Budoff J.E, Cornwall R, eds.
Hand, elbow and shoulder: core knowledge in orthopedics
. St. Louis: Mosby; 2004:510–521.
21. Seiler 3rd. J.G, Parker L.M, Chamberland P.D, et
al. The distal biceps tendon: two potential
mechanisms involved in its rupture: arterial supply
and mechanical impingement. J Shoulder Elbow Surg
. 1995;4(3):149–156.
22. Smith L.K, Weiss E.L, Lehmkuhl L.D. Brunnstrom’s
clinical kinesiology . ed 5. Philadelphia: FA
Davis; 1996.
23. Wolff A.L, Hotchkiss R.N. Lateral elbow instability:
nonoperative, operative, and postoperative
management. J Hand Ther . 2006;19(2):238–243.
24. Yoon A, Athwal G.S, Faber K.J, et al. Radial head
fractures. J Hand Surg Am . 2012;37(12):2626–2634.
25. Moscony A. Peripheral nerve
problems. In: Cooper C, ed. Fundamentals of hand
therapy . ed 2. St. Louis: Elsevier Mosby; 2014:299–
300.
26. Apfel E, Sigafoos G.T. Comparison of range-of-
motion constraints provided by splints used in the
treatment of cubital tunnel syndrome—a pilot study.
J Hand Ther . 2006;19(4):384–392.
27. Veltman E.S, Doornberg J.N, Eygendaal D, van den
Bekerom M.P.J. Static progressive versus dynamic
splinting for posttraumatic elbow stiffness: a
systematic review of 232 patients. Arch Orthop
Trauma Surg . 2015;135:613–617.
28.
Shah C.M, Calfee R.P, Gelberman R.H, Goldfarb C.A.
of rigid night splinting and activity modification in
the treatment of cubital tunnel syndrome. J Hand
Surg . 2013;38A:1125–1130.
29. Jafarian F.S, Demneh E.S, Tyson S.F. The immediate
effect of orthotic management on grip strength of
patients with lateral epicondylosis. J Orthop Sports
Phys Therapy . 2009;39(6):484–490.
30.
Najafi M, Arazpour M, Aminian G, Curran S, Madani S.P, Hutc
of a new hand-forearm splint on grip strength, pain,
and function in patients with tennis elbow. Prosthet
Orthot Int . 2016;40(3):363–368.
31.
Garg R, Adamson G.J, Dawson P.A, Shankwiler J.A, Pink M.M.
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. 2010;19(4):508–512.
Appendix 10.1 Case Studies
Case Study 10.1 a

Read the following scenario, and use your clinical reasoning skills to
answer the questions based on information in this chapter.
Laura is a 47-year-old attorney who slipped on the ice and fractured
and dislocated her left elbow. She was first treated at the local
emergency department, where the elbow was casted. One week later,
she underwent open reduction internal fixation (ORIF) to the radial
head, which repaired the ruptured lateral ligament of the elbow. Two
days post surgery she is referred for therapy (before discharge from
the hospital) for a posterior elbow orthosis in 110 to 120 degrees of
flexion. Laura lives alone and has two active dogs for pets.

1. Describe the appropriate orthosis for Laura. List all of the joints
to include in this orthosis.
2. How should the client be positioned for fabrication of this
orthosis?
3. Which bony prominences require extra protection in the
orthosis? How is this accomplished?
4. What wearing schedule should be provided to Laura?

Case Study 10.2

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information from this chapter.
Marissa is a 42-year-old office clerk who is referred for therapy with
a diagnosis of ulnar neuropathy of the left hand. She reports waking
up in the middle of the night with tingling sensation to the ulnar side
of the forearm and hand lasting for 10 to 15 minutes. There is no
atrophy of the intrinsic hand muscles of the left hand. There is a
significant difference in strength of grip and pinch between the two
hands. Further examination reveals a positive Tinel sign to the ulnar
nerve at the cubital tunnel region and positive symptoms of tingling
following 30 seconds of sustained elbow flexion.
Frank is a 55-year-old factory worker who underwent an ulnar
nerve anterior submuscular transposition surgery 10 days ago. The
patient has just had his sutures removed, and the surgeon has referred
Frank to occupational therapy services for evaluation and treatment
and fabrication of an elbow orthosis.
Bob is a 37-year-old taxicab driver who sustained a terrible triad
injury of the right elbow from a non–work-related car accident. He
underwent open reduction internal fixation (ORIF) of the distal
humerus, coronoid process, and proximal radius. A hinged external
fixator was applied for 11 to 12 weeks. He was referred to therapy to
improve his range of motion and facilitate return to work. He came to
therapy 2 weeks after external fixator removal without an orthosis or
brace. His elbow range of motion is currently 50/120. Bob performs his
self-care activities independently. His main concern is being able to
drive his taxi again.

1. What orthosis or brace is most appropriate for each client?

2. What wearing schedule and instructions should be provided to
each client?
Appendix 10.2 Laboratory Exercises
Laboratory Exercise 10.1 Making an Elbow
Shell Pattern
1. Practice making a posterior elbow shell pattern on another
person. Use the detailed instructions provided to take
measurements and draw the pattern.
2. Cut out the pattern, and check for proper fit.

Laboratory Exercise 10.2 Fabricating an Elbow

Orthosis
Practice fabricating an elbow immobilization orthosis on a partner.
Before starting, determine the correct position for the partner’s elbow.
Measure the angle of elbow flexion/extension with a goniometer to
ensure correct position. After fitting the orthosis and making
adjustments, use Form 10.1 as a self-evaluation of the elbow
immobilization orthosis, and use Grading Sheet 10.1 as a classroom
grading sheet.
Appendix 10.3 Form and Grading Sheet
Form 10.1 Elbow Immobilization Orthosis
Grading Sheet 10.1 Elbow Immobilization
Orthosis
a See Appendix A for the answer key.
11
Orthoses for the Shoulder
William P. Finley

CHAPTER OBJECTIVES
1. Review general shoulder anatomy and biomechanical
considerations for immobilization.
2. Identify shoulder immobilization orthoses, slings, and braces.
3. Discuss common shoulder diagnoses that require immobilization.
4. Review precautions for shoulder immobilization.
5. Apply biomechanical consideration for orthotic, sling, and brace
application.
6. Demonstrate clinical judgment in the provision of shoulder
immobilization devices.
7. Apply knowledge of shoulder immobilization devices to a case
study.
8. Fabricate a proximal humerus cap orthosis.

KEY TERMS
acromion
AMBRI
appendicular skeleton
axial skeleton
Bankart lesion
Bankart repair
clavicular facet
coracohumeral ligament
figure-eight orthosis
glenoid fossa
open reduction internal fixation (ORIF)
osteoporotic fracture
subluxation
superior labrum tear from anterior to posterior (SLAP)
transverse humeral ligament
TUBS

Mr. Smith was walking with his wife on a busy city street when he fell
onto the side of his arm. He was immediately rushed to the emergency
department and was diagnosed with a humeral fracture, and surgery
was recommended. Mr. Smith had recently retired and was experiencing
various other medical conditions that did not make him a strong surgical
candidate. As such, he decided to proceed with nonoperative
management. Mr. Smith was placed in a sling and sent to occupational
therapy for a proximal humerus cap orthosis and light passive range-of-
motion exercises.
Anatomical and Biomechanical
Considerations
The shoulder complex is unlike any other structure in the human
body. The shoulder is composed of four joints, which perform
coordinated intricate movement patterns within a large range of
motion (ROM) and with significant strength. The bony anatomy of the
shoulder consists of the sternum, clavicle, scapula, and humerus. The
four joints of the shoulder are the: sternoclavicular joint,
acromioclavicular (AC) joint, scapulothoracic joint, and the
glenohumeral joint (Fig. 11.1). 19
The sternoclavicular joint is technically the link between the axial
skeleton and appendicular skeleton and is composed of the medial
end of the clavicle, the clavicular facet of the sternum, and the
superior border of the cartilage of the first rib. The movements of this
small joint are elevation and depression, protraction and retraction,
and axial rotation. An articular disk and a dense amount of tissue
stabilize this joint, which makes direct injuries or dislocations rare, but
a lack of motion can result in a loss of end-range motions for shoulder
flexion and abduction. 16
The articulation between the lateral end of the clavicle and the
acromion of the scapula forms the AC joint. The small movements of
this joint are upward and downward rotation, horizontal plane
rotation, and sagittal plane rotation. This small joint is highly
predisposed to osteoarthritis and is at high risk of dislocation in the
athletic population. 12
The scapulothoracic joint is not considered a true joint as it is
formed between the anterior surface of the scapula and the posterior-
lateral wall of the thorax. Although it is technically not the link
between the axial and appendicular skeleton, it is the foundation of
force transmission and motion between the larger core muscles and
the upper extremity. The scapulothoracic joint relies on the
surrounding musculature for stabilization. The kinematics consist of
elevation and depression, protraction and retraction, and upward and
downward rotation. 19 Due to the large amount of muscular
involvement, scapula dyskinesis plays a major role in many shoulder
injuries and pain pathologies. 11

FIG. 11.1 Anatomy of the shoulder complex.

From Phelps, K., & Hassed, C. (2011). General practice: The
integrative approach. Sydney: Churchill Livingstone/Elsevier.

The final joint of the shoulder complex, the glenohumeral joint is

formed by the head of the humerus and the concavity of the glenoid
fossa. The basic anatomical motions of this dynamic joint include
abduction and adduction, flexion and extension, and internal and
external rotation. There are considerable accessory motions that occur
at this joint such as roll, spin, and slide. Due to the mobility of this
joint, tissue stabilization is of utmost importance. The glenohumeral
joint is stabilized by the capsular ligaments, coracohumeral ligament,
transverse humeral ligament, glenoid labrum, and the surrounding
musculature. 19 Due to demands placed on this mobile joint, it is
predisposed to dislocations, and the surrounding tissues are
vulnerable to various traumatic and nontraumatic injuries. 29
Immobilization of the shoulder is more problematic than other parts
of the body due to the possibility of adhesive capsulitis (frozen
shoulder syndrome) and scapular dyskinesis (alteration of the static
and/or dynamic positioning of the scapula), which significantly
interferes with the rehabilitation process. 20,21 When immobilizing the
shoulder, proper fit, positioning, wear time, and client education are
necessary components. Incorrect or prolonged immobilization has
long-term deleterious effects. 12 Therefore, when immobilizing the
shoulder, the therapist considers numerous variables to minimally
impact the client’s rehabilitation.
Common Diagnoses
There are several diagnoses that often require shoulder orthotic
intervention (Table 11.1). Diagnoses include proximal humeral
fractures, shoulder subluxation and instability syndrome, rotator cuff
(RTC) repairs, superior labrum anterior to posterior (SLAP) and
Bankart repairs, AC dislocations, clavicle fractures, and axilla
contractures.

Proximal Humerus Fractures

Proximal humeral fractures are a common orthopedic injury, typically
affecting the older adult population, and can have a significant impact
on all functional activities. The proximal humeral fracture is
universally referred to as an osteoporotic fracture and can lead to
extreme pain and high levels of deformity. Incidences vary from 105
to 342 per 100,000 persons per year. 2 Proximal humeral fractures vary
in severity and are graded as one-part, two-part, three-part, or four-
part. Generally one- and two-part proximal humeral fractures are
managed conservatively. Three- and four-part proximal humeral
fractures are managed surgically. 2 Current evidence on
immobilization and rehabilitation for one- and two-part fractures is
very positive with 77% to 88% of patients having good to excellent
results based on ROM). 10 In contrast, researchers report a significant
decrease in quality of life when comparing nonsurgical to surgical
management of three-part proximal humerus fractures. 23 Four-part
proximal humerus fractures will have fracture lines along the humeral
head, greater tuberosity, lesser tuberosity, and humeral shaft; three
out of four parts will be displaced with respect to the fourth; and
surgery is almost always indicated. 5
The severity of fracture plays a crucial role in determining the need
for surgical intervention, orthotic provision, and/or immobilization
time frame. Because a humeral fracture is a common injury in the
older adult, one must consider prior level of function and
comorbidities to develop an intervention. Regardless of intervention
the elder population requires some form of immobilization of the
shoulder complex. The recommended immobilization time frame can
range from 1 to 7 weeks, depending on severity of fracture. 5 The most
common immobilization for humeral fractures is a traditional sling
with the arm placed in adduction and internal rotation and/or a
proximal humerus cap orthosis (Figs. 11.2 and 11.3)

Shoulder Subluxation and Instability

Syndrome
Shoulder instability syndrome is another common orthopedic
condition that may or may not warrant immobilization. Many people
with mild to moderate instability syndrome function without pain or
disability. Instability syndrome becomes problematic when it leads to
subluxation(s). There are two main types of classification for shoulder
instability/subluxation: TUBS (Traumatic etiology, Unidirectional
instability, Bankart lesion, whereby Surgery is required) and AMBRI
(Atraumatic, Multidirectional instability, Bilateral, Rehabilitation,
Inferior capsule shift), whereby rehabilitation is the treatment of
choice. 3
A TUBS injury is likely to be traumatic in nature and often leads to a
Bankart repair requiring immobilization of up to 6 weeks. These
clients are positioned in varying degrees of abduction and varying
degrees of rotation. Recent studies recommend a neutral to externally
rotated position, compared with the more traditional internally
rotated position. 33
Clients with an AMBRI classification usually have a small or flat
glenoid fossa, capsular tissue migration, weak RTC muscles,
malpositioning of the humeral head, and/or neuromuscular and
proprioceptive deficits. Multiple factors such as mechanism of injury
and number of previous subluxations affect the decision for the
position and length of immobilization. Although recent studies
contradict the traditional adducted and internally rotated sling
position, the internally rotated position is the most frequently used
position to stabilize the shoulder (see Fig. 11.2). Generally for a first
dislocation incident the client is immobilized for a slightly longer
period, but usually not greater than 4 weeks. When dislocations are
recurrent for a client, a much shorter time spent in the traditional
adducted internally rotated sling position is recommended. These
clients may be in a sling for less than 1 week; this is recommended to
avoid further anterior capsule laxity and posterior capsule tightness.

TABLE 11.1

Evidenced-Based Practice About Shoulder Immobilization Orthoses

AROM, Active range of motion; DASH, Disabilities of the Arm, Shoulder, and Hand; ER,
external rotation; IR, internal rotation; QOL, quality of life; RCT, randomized controlled trial;
ROM, range of motion; SF-36, Short Form-36; UE, upper extremity; UEFI, Upper Extremity
Functional Index; VAS, visual analog scale.

Contributed by Andrea Coppola.

 FIG. 11.2 Traditional shoulder sling (adduction and internal rotation).
Courtesy of DJO, LLC.

Rotator Cuff Repairs

RTC pathology represents up to 70% of shoulder pain disorders, and
there are approximately 250,000 repairs performed annually, making
it one of the most common orthopedic procedures. 15,24 In the
nonathletic population, RTC repair is generally recommended for
those with medium, large, and massive/full-thickness RTC tears.
There is a surgical option for partial-thickness or small RTC tears, but
it is usually reserved for the young, overhead athlete. 1,11
Immobilization following RTC repair is necessary for 2 to 6 weeks
with varying levels of activity and rehabilitation in the acute phase.
Immobilization of the shoulder is multifactorial, but for RTC repairs
the major concern is the amount of tension being placed on the
surgically repaired tendon(s). Increased tension on the repaired RTC
is associated with a higher rate of repair failure. 7 Through cadaveric
studies, researchers report the optimal posture of the shoulder
following RTC repair is elevation of 21 to 45 degrees and external
rotation of 18 to 23 degrees. 17 Although there is limited evidence to
support an abducted and externally rotated position when using pain
and function as outcomes, this evidence supports the notion of
changing the traditional sling design. 7 Thus immobilization positions
have significant variation. 18
 FIG. 11.3 Sarmiento proximal humeral cap orthosis with cross-body
strap.
Courtesy of Brian Laney, OT, CHT.

Multiple studies compared various shoulder immobilization

positions following RTC repair. 4,7,17 Due to increased tension on the
superior and posterior RTC, the traditional internally rotated and
adducted position is not recommended for RTC repair. Currently
there is no agreement upon optimal position to immobilize the
shoulder following RTC repair. This is most likely due to significant
anatomical variations among clients. It is recommended to immobilize
clients with RTC repairs in slight abduction and in a neutral to a
slightly externally rotated position (Fig. 11.4). 4,7,17

Superior Labrum Tear From Anterior to

Posterior and Bankart Repairs
SLAP and Bankart lesions are not as prevalent as RTC disorders.
However, they account for 6% to 12% of those who seek medical
treatment for shoulder pain. They are more common in young males
who are overhead athletes, military personnel, and/or extreme
athletes. 22,25 SLAP and Bankart tears are generally managed
surgically, especially when the biceps tendon is involved. A
nonsurgical option for small, partial, or type I tears exists, but type II,
III, and IV need to be managed surgically as the labrum will not heal
on its own when separated from the glenoid. 30

FIG. 11.4 Breg braces, demonstrating various degrees of shoulder

abduction and external rotation.
Courtesy of Breg, Inc.

SLAP and Bankart repairs are required with extensive damage to

the labrum. Due to the poor vascularity of the glenoid labrum,
surgical intervention is usually indicated. These injuries are often the
result of multiple dislocations occurring over a long period of time or
one traumatic injury. Such injuries are commonly related to sports,
falls, and more traumatic events (e.g., motor vehicle or bicycle
accidents). 32
Immobilization following labrum repairs is recommended for 4 to 6
weeks with progressive rehabilitation. Positioning following SLAP
and Bankart repair varies. There is no universally accepted position
after these procedures. 28,35 As with RTC repairs, a shift was made
from the traditional adducted and internally rotated sling to a position
of abduction and external rotation (see Fig. 11.4). Although some
studies support the abducted and externally rotated position, it is not
universally accepted. 31

Acromioclavicular Dislocations and Clavicle

Fractures
Injuries to the AC joint and clavicle are a common problem in the
young athlete. Clavicular fractures account for 2.6% to 4% of all
fractures. 14,21,27 The AC joint is susceptible to dislocation during falls,
particularly with the arm in an adducted position. There is also risk of
injury to the AC joint and clavicle when falling on an outstretched
hand. The AC joint is often impacted by motor vehicle or bicycle
accidents and sports injuries. These injuries are managed surgically or
nonsurgically depending on the type of dislocation or grouping of
fractures.
Immobilization for an AC dislocation ranges from 4 to 8 weeks and
includes various devices. The most commonly used device is some
type of figure-eight shoulder immobilizer (Fig. 11.5). A figure-eight
immobilizer is necessary following an AC or clavicular injury due to
the superior migration of the proximal clavicle. The figure-eight
places the clavicle and/or AC joint in proper anatomical alignment to
allow tissue healing. The figure-eight device may be used in
combination with a traditional shoulder sling and/or a control strap
(Fig. 11.6). The distal control strap provides additional inferior
pressure and is commonly used with a more severe AC joint
dislocation. 13

FIG. 11.5 Figure-eight shoulder orthosis.

From Rizzone, K., Gregory, A (2013). Using casts, splints and braces
in the emergency department. Clinical Pediatric Emergency, 14(4),
340-348.

Nonsurgical treatment is generally preferred when treating AC and

clavicular injuries, but there is a lack of consistency in immobilization
techniques and protocols. Research indicates that 94% of US surgeons
preferred a simple sling, whereas 88% of German surgeons preferred
the figure-eight straps. 6,26 Systematic reviews investigating these
immobilization techniques are inconclusive, particularly for middle
third clavicular fractures. 14 Regardless of the exact immobilization
technique, proper anatomical alignment is the key to tissue healing
and preventing further deformity.

FIG. 11.6 Acromioclavicular (AC) separation strap.

Courtesy of DJO, LLC.
 FIG. 11.7 Example of an airplane orthosis.
From Alok Su Rahul Ranjan et al: Peripheral Nerve Injuries. In
Textbook of orthopedics, ed 1, 2018, Elsevier.

Axilla Contractures
Axillary contractures are extremely challenging and problematic in
the rehabilitation of upper extremity burns. Axillary contractures are
classified by the severity and tissue involvement. Regardless of the
classification, some type of orthotic provision is required to prevent
future contracture development and to increase functional shoulder
motion, particularly for abduction. 8,19
The airplane orthosis is most often used for the prevention of axilla
contractures. Airplane orthoses are available commercially as
prefabricated orthoses, or they can be fabricated by the clinician. The
purposes of the airplane orthosis are to increase the abduction angle
of the glenohumeral joint, increase tissue elasticity, and prevent
further contracture. 9 Construction and application vary significantly,
depending on the client’s goals. Clients generally need some form of
an airplane orthosis for 3 to 6 months following a contracture to the
axilla (Fig. 11.7). Custom airplane orthoses are challenging to
fabricate. Fabrication requires multiple materials/supplies. The
process requires the time of at least two clinicians. Therefore a
prefabricated airplane orthosis is generally recommended.
Due to the size of the airplane orthosis, adherence to the wearing
schedule tends to be a major concern. Clients report discomfort and
decreased function, particularly while navigating the community. 9
Poor adherence is detrimental to the recovery process, resulting in
further contracture development and the need for additional surgical
procedures. Many attempts to increase comfort of the airplane
orthosis have been made to improve adherence to the wearing
schedule. 9,34 Changes include lightweight prefabricated devices and
variations that allow for functional adjustments based on occupational
needs. The airplane orthosis is challenging for the client to put on/take
off and to comply with usage, particularly during community
reintegration. The clinician must (1) educate the client about the
importance of adherence and (2) must consider all activities of daily
living when designing the airplane orthosis.
Shoulder Orthoses
Proximal Humerus Cap Orthoses
A proximal humerus cap orthosis is indicated for fractures to the
proximal humeral shaft and/or post open reduction internal fixation
(ORIF) of a proximal to mid-humeral fracture. The purpose of the
proximal humeral cap orthosis is to provide circumferential
compression while allowing gravity to assist with bone alignment.
The orthosis also protects the fracture or injury site while the client
engages in occupations and/or navigates the community. This orthosis
allows full ROM of the elbow, forearm, and wrist; therefore the client
is instructed in distal upper extremity therapeutic exercises for
motion. By allowing distal ROM, the proximal humeral cap orthosis
increases functional use and decreases edema in the distal upper
extremity.
The proximal humerus cap orthosis continues to evolve as orthotic
material and prefabricated devices become stronger, lighter, and more
comfortable. Multiple vendors offer prefabricated proximal humerus
cap orthoses that require the clinician to measure the upper extremity
at various locations to determine the appropriate size. If fabricating a
custom proximal humerus cap orthosis, provide a compression sleeve
or garment to increase circumferential support. The clinician
determines whether a cross-chest strap is appropriate (Fig. 11.8; see
Fig. 11.3).
Airplane Orthoses
The airplane orthosis is often used in burn rehabilitation to prevent
axilla contractures. The client is positioned in abduction (see Fig. 11.7).
The airplane orthosis is generally a dynamic or static progressive
design, and the clinician continues to increase the abduction angle as
the client progresses throughout rehabilitation.
 FIG. 11.8 Humeral cap orthosis with cross-body strap.

Custom airplane orthoses are complex and time/labor intensive to

fabricate. Due to advancements in prefabrication design, measuring
and purchasing a prefabricated orthosis is recommended for most
clients. Multiple companies (e.g., Breg, Ability, Rehabmart) sell
airplane orthoses with various designs and features. The clinician may
need to make slight modifications to these products to increase
comfort.
Adduction and Internal Rotation Sling
The adduction and internal rotation sling, or standard upper
extremity sling, is the most often used shoulder immobilization device
(see Fig. 11.2). Slings place the client in shoulder adduction and
internal rotation with the forearm across the abdomen. Slings are
commercially available in multiple variations and sizing options.
Slings are indicated for postoperative clients and with nonoperative
management of subluxations, fractures, muscular tears, and
impingements. 12 Most clients are discharged from the emergency
department or a medical office with a standard over-the-shoulder
sling. Some designs offer additional support straps, such as a cross-
chest strap.
Purchasing prefabricated adduction and internal rotation slings is
recommended due to economic cost and ease of use. The clinician is
responsible for adjusting and fitting the sling properly to the client.
Fitting includes an appreciation of bilateral scapula and shoulder
positioning. The elbow should rest and be supported in the sling,
while providing a slight compression to the glenohumeral joint.
Excessive compression often leads to upper trapezius overactivation,
impingement, and/or scapula dyskinesis. 29 Appreciation of the
contralateral side is recommended as contralateral compensation often
leads to additional shoulder and postural problems. 13,29 When the
client is viewed within the sling, shoulders should align without
significant elevation and the scapulae should be flush against the
thorax with the inferior angles in alignment and equal distance to the
spine.
Abduction and/or External Rotation
Sling
The abduction and/or external rotation sling has been increasing in
popularity in recent years (see Fig. 11.4). Several studies defend the
use of the abducted and/or externally rotated position to improve
glenohumeral positioning and healing, with short-term and long-term
functional improvements. 4,7,35 This brace (sometimes referred to as a
gunslinger orthosis) supports the shoulder in various degrees of
abduction and/or external rotation. The abduction and/or external
rotation brace is indicated postoperatively with various shoulder
surgeries, particularly labral repairs. The abduction and/or external
rotation brace is much larger and more complex than the traditional
arm sling.
A commercial, prefabricated abduction and/or external rotation
orthosis is recommended due to the complex nature of design,
support, and strapping. These orthoses tend to be significantly more
expensive when compared with the traditional sling.
Shoulder Support Figure-Eightorthosis
The figure-eight orthosis, often referred to as the figure-eight brace or
strap, is indicated following a proximal or midclavicular fracture (see
Fig. 11.5). In the event of a distal clavicular fracture and/or AC joint
dislocation, the figure-eight orthosis is used with the addition of a
stability control strap to provide additional support to the distal
clavicle and AC joint (see Fig. 11.6 ). The figure-eight orthosis
supports the healing clavicle and/or AC joint in proper anatomical
alignment and prevents superior migration of the proximal clavicle.
The brace is used in nonoperative and postoperative management of
clavicular and AC joint injuries.
The figure-eight orthosis is another device in which a commercially
prefabricated brace is recommended. Various companies (e.g.,
BraceAbility, Ossur, Orthotic Shop) sell the figure-eight orthosis at
relatively low prices. Some braces are available in one size fits all,
whereas others require the clinician to measure the client for a proper
size. In general, every brace fits snugly, and the straps are large and
padded. When using the additional control strap, the client is
educated about proper tension as this strap is often more elastic and
results in an increased compressive force. The control strap should
provide enough compression to stabilize the distal clavicle and/or AC
joint, but shoulder alignment should remain equal to the contralateral
side.

Procedure For Fabrication of A Proximal

Humerus Cap Orthosis
1. Place the client in a compression sleeve (elastic tubular bandage)
with elbow supported on table in slight assisted abduction.
2. Design a pattern by taking the following measurements (Fig.
11.9):
a. Part 1
1. Use a tape measure to measure the distance from the
posterior AC joint to the superior lateral epicondyle.
Subtract approximately 2 inches when designing the
pattern.
2. Draw a vertical line on the paper using the length
determined in the previous measurement.
3. Measure the distance from the anterior to the posterior
axilla. Subtract approximately 2 inches when
designing the pattern.
4. Draw a line across the paper using the width
determined in the previous measurement. This will
form the superior aspect of the orthosis.
5. Measure the circumference of the superior biceps.
Divide by 2 when designing the pattern.
6. Draw a line across the paper inferior to the previous
line. This will be in the middle of the orthosis.
7. Measure the circumference of the inferior biceps.
Divide by 2 when designing the pattern.
8. Draw a line across the paper inferior to the previous
line. This will be located toward the inferior border of
the orthosis.
b. Part 2
1. Measure the distance from the axilla to the medial
epicondyle. Subtract approximately 2 to 4 inches when
designing the pattern.
2. Draw a vertical line using the length determined in the
previous measurement.
3. Measure the circumference of the superior biceps.
Divide by 2 when designing the pattern.
4. Draw a horizontal line using the measurement
determined in the previous measurement. This will be
the superior aspect of the orthosis.
5. Measure the circumference of the inferior biceps.
Divide by 2 when designing the pattern.
 6. Draw a horizontal line using the measurement
determined in the previous measurement. This will be
the inferior aspect of the orthosis.
3. Round off the edges, and create a slight dome superiorly.
4. Cut the pattern from the paper (Fig. 11.10).
5. Place the paper pattern on the client to approximate size/fit.
6. Transfer the design from the paper to lightweight ⅛-inch
perforated thermoplastic material (Fig. 11.11).
7. Heat the thermoplastic material for part 1. Ensure that the
material is safe for contact. Mold to the client using the
drapability of the material. Allow the material to cool, and then
remove from the client.
8. Heat the thermoplastic material for part 2. Ensure that the
material is safe for contact, and mold to the client using the
drapability of the material (Fig. 11.12).
9. Place part 1 and part 2 on the client (give a very small stretch to
the material before application). Approximate strap locations at
anterior and poster deltoid, superior biceps and triceps, and
inferior biceps and triceps (Fig. 11.13; see Fig. 11.12).
10. Rivet the posterior strap in place and anterior turnbuckle for the
cross-body strap.
a. Create a turnbuckle by folding approximately 4 inches
of strapping material around a 1-inch plastic buckle
(Fig. 11.14).
b. Using a riveter (Fig. 11.15), punch holes on the
overlapping strap and through the splinting material
(Fig. 11.16).
c. Remove the small circular material that the riveter
punched out of the strap and the splint material.
d. Place the flat end of the rivet on the inside of the splint,
and push the other end through the straps and
splinting material.
e. Use flat pliers to push the metal rivets together (Figs.
11.17 and 11.18).
11. Pad the metal surfaces of the rivets on the inside of the orthosis
 (Figs. 11.19 and 11.20).
12. Place hook on the corresponding surface of part 2 (see Fig. 11.8).
13. Adjust to the client. Ensure that the orthosis is snug with 1 inch
of space between part 1 and part 2.
14. Ensure full ROM at the elbow and that no irritation to the axilla
or the thorax is present.
15. Add padding to the inferior boarders if showing signs of
irritation.
16. Ask the client to practice putting on and taking off the orthosis,
while maintaining shoulder motion precautions.

Technical Tips for Proper Fit

• Use a compression garment.
• Give the material a slight stretch before applying it to the client.
This will allow the material to slightly recoil and then contour to
the client.
• Pad the metal surfaces of the rivets on the inside of the orthosis.
• Pad the inferior border of part 1 and part 2 if the client shows
signs of irritation.
• Prepare all material in advance of the client session. Have the
turnbuckles cut and ready to be riveted. Have the rivets set up,
and have the moleskins cut (Fig. 11.21). Have all the strapping
material and turnbuckles prepared (if not already completed).
• Use a table to place your client’s elbow in slight abduction and
elbow/forearm resting on the table while fabricating the orthosis.
This will support the humeral head in a slightly abducted
position during orthotic fabrication (see Fig. 11.12).

Precautions for the Shoulder Cap Orthosis

• Assess for signs of irritation on the shoulder and the thorax from
orthosis contact.
• If using an additional body strap, assess for irritation on the
contralateral side.
• Ensure that the client has full elbow ROM without making
contact with the orthosis, particularly for end-range elbow
flexion.
• Ensure that the client is aware of precautions and can follow
precautions while putting on/taking off the orthosis.
• Ensure that there is at least 1 inch of space between part 1 and
part 2 on both sides of the orthosis. This will allow the client to
tighten or loosen the orthosis to account for fluctuations in edema
without needing to create a second orthosis.
• Review tightening and loosening of the orthosis with the client to
ensure compliance.
FIG. 11.9 Design patterns for proximal humeral cap orthosis.
FIG. 11.10 Cut the pattern from the paper.
FIG. 11.11 Tracing patterns onto thermoplastic material.
FIG. 11.12 Mold to the client using the drapability of the material
(proximal humeral orthosis part 2).
FIG. 11.13 Proximal humeral cap orthosis part 1 and part 2 with
strapping.
FIG. 11.14 Turnbuckle.
FIG. 11.15 Riveter and rivets.
FIG. 11.16 Riveting holes to line up turnbuckle with hole in splinting
material.
FIG. 11.17 Pliers pushing in rivets.
FIG. 11.18 Rivet in place.
FIG. 11.19 Interior surface of rivet (side contacting client before
padding).
FIG. 11.20 Interior surface of rivet with padding over all metal.
FIG. 11.21 Riveter and set-up equipment.
 a
Self-Quiz 11.1
For the following questions, circle either true (T) or false (F).

1. T F The shoulder complex is composed of five joints.

2. T F The scapulothoracic joint is not considered a true joint.
3. T F Type I, II, III, and IV proximal humeral fractures will require
surgical intervention.
4. T F Following a shoulder subluxation, clients should be
immobilized for 4 weeks or less
5. T F The preferred immobilization position following a labral
repair is internal rotation and adduction.
6. T F Clinicians must be aware of frozen shoulder syndrome and
scapular dyskinesis when immobilizing the shoulder.
7. T F Compliance issues are highly prevalent with the airplane
orthosis due to its large size and decreased function while in
use.
8. T F The figure-eight orthosis should have thin ridged straps.
9. T F Use of an internal rotation/adduction sling should compress
the humeral head, resulting in shoulder hiking.
10. T F AC joint separations will require an additional support strap
when managed nonoperatively.

a
See Appendix A for the answer key.

Review Questions
1. What are the four joints that constitute the shoulder
complex?
2. What are the main indicators for shoulder immobilization
orthoses?
3. What are two possible deleterious effects of prolonged or
incorrect shoulder immobilization?
4. What are the advantages of providing a prefabricated
orthosis for shoulder immobilization?
5. What are the advantages of a custom orthosis for shoulder
immobilization?
6. What diagnoses require a humeral cap orthosis?
7. What shoulder position should a client be in following a
SLAP repair?
8. Approximately how long is a client immobilized following
a first incident of shoulder dislocation?
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Appendix 11.1 Case Study
Case Study 11.1 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Lauren is a 27-year-old woman who works at a marketing firm. She
has also been a dancer her whole life and currently competes in small
weekend dancing competitions. One week ago she felt her right
shoulder dislocate while practicing with her partner. As this has
happened to her at least five times in the past 10 years, she performed
a self-manual reduction and followed up with her doctor later in the
week. Her doctor is concerned that she has damaged her labrum.
Lauren would like to attempt occupational therapy (OT) and then
consider surgery later in the year.
She arrives at OT without an orthosis and reports fear of re-
dislocation with dance moves requiring any overhead or behind-back
motion. Besides the fear of a re-dislocation, she has mild discomfort.
She can complete all activities of daily living (ADLs) and instrumental
IADLs (IADLs) and work with modified independence. She has not
returned to dancing, but that is her goal for therapy.

1. What orthosis would be the most appropriate for Lauren?

2. What is the orthosis-wearing schedule for Lauren?
3. What are some of the concerns with this type of immobilization
orthosis?
4. What should Lauren be educated about regarding this
orthosis?
Appendix 11.2 Laboratory Exercise
Laboratory Exercise 11.1 Fabricating a
Custom Proximal Humerus Cap Orthosis
Practice fabricating a proximal humerus cap orthosis. Follow the
outlined guidelines that address positioning, materials required, and
measurements. After fabrication:

• ensure comfort,
• check for ability to put on/take off independently,
• evaluate elbow range of motion,
• evaluate client’s ability to perform pendulum exercises, and
• use Form 11.1 to perform a self-evaluation. Use Grading Sheet
11.1 as a classroom grading sheet.
Appendix 11.3 Form And Grading Sheet
Form 11.1
Grading Sheet 11.1
a See Appendix A for the answer key.
12
Orthotics for the Fingers
Kristin Valdes

CHAPTER OBJECTIVES
1. Explain the functional and anatomical considerations of orthotics
for the fingers.
2. Identify diagnostic indications for using finger orthoses.
3. Describe a mallet finger.
4. Describe a boutonnière deformity.
5. Describe a swan neck deformity.
6. Name three structures that provide support to the stability of the
proximal interphalangeal (PIP) joint.
7. Explain the purpose of buddy straps.
8. Apply clinical reasoning to evaluate finger orthoses in terms of
materials used, strapping type and placement, and fit.
9. Discuss the process of making a mallet orthosis, a gutter
orthosis, and a PIP hyperextension block orthosis, a three-point
PIP extension orthosis, a trigger finger orthosis, and a distal
interphalangeal stabilization orthosis.

KEY TERMS
boutonnière deformity
buddy straps
central slip
collateral ligaments
extensor lag
finger sprain
flexion contracture
fusiform swelling
lateral bands
mallet finger
oblique retinacular ligament (ORL)
osteoarthritis
swan neck deformity
terminal extensor tendon
transverse retinacular ligament
trigger finger
volar plate (VP)

Marge is a 74-year-old right-hand–dominant woman who retired from

her job. She likes to crochet and knit. She has pain and swelling of her
index and small finger distal interphalangeal (DIP) joints. Her
physician diagnosed her with osteoarthritis of the fingers and sent her to
occupational therapy for evaluation and treatment. At her initial
evaluation she reports night DIP joint pain interferes with her sleep. She
reports she does not understand why her physician sent her to therapy,
and she thinks she just needs to “live with the pain.” She was grateful to
learn that there is evidence to support that DIP orthoses relieve pain at
the DIP joints, and she is anxious to see if they will help.

Depending on the diagnosis, finger problems may require orthotics

that cross the hand and wrist, or they may be treated with orthotics
that are smaller. This chapter describes the smaller orthoses that are
finger-based, crossing the proximal interphalangeal (PIP) and/or distal
interphalangeal (DIP) joint, leaving the metacarpophalangeal (MCP)
joint free.
Functional and Anatomical
Considerations of Orthotics for the
Fingers
The PIP and DIP joints are hinge joints. These joints have collateral
ligaments on each side that provide joint stability and restraint
against deviation forces. The radial collateral ligament protects against
ulnar deviation forces, and the ulnar collateral ligament protects
against radial deviation forces. On the palmar (or volar) surface is the
volar plate (VP), which is a fibrocartilaginous structure that prevents
hyperextension. As the extensor mechanism of the digits crosses over
the PIP joint, it branches into three bands: the central slip and two
lateral bands. The central slip attaches to the middle phalanx, and the
lateral bands attach to the distal phalanx. The central slip crosses the
PIP joint dorsally and is part of the PIP joint dorsal capsule. It is
implicated in boutonnière deformities. The lateral bands, which are
contributions from the intrinsic muscles, and the transverse
retinacular ligament are additional structures that contribute to the
delicate balance of the extensor mechanism at the PIP joint. They are
implicated in boutonnière deformities and swan neck deformities. The
terminal extensor tendon attaches to the distal phalanx and is
implicated in mallet finger injuries.
For all finger injuries and postsurgical interventions, it is always
important to prioritize edema control to prevent fibrosis of the edema
and adherence between anatomical structures. Treatment for edema
can often be incorporated into the orthotics process. Examples of this
would be the use of self-adherent compressive wrap under the
orthosis, application of a finger compression sleeve, or using self-
adherent compressive wrap to secure the orthosis on the finger. For
diagnoses that require orthotic application 24 hours a day but permit
washing of the digit, it may be appropriate to fabricate one orthosis
for shower use and another one for the rest of the day. In general,
thinner low-temperature thermoplastic (LTT) (1⁄16 inch or thinner) is
typically used on digits because it is less bulky yet strong enough to
support or protect these relatively small body parts. On a stronger
person or a person with larger hands, 3⁄32-inch material may be better
to use than a 1⁄16-inch thickness. Choosing perforated versus
nonperforated thermoplastic material is partly a matter of personal
choice, but therapists should use caution with perforated materials
because the edges may be rougher, and there can be the possibility of
increased skin problems or irregular pressure, particularly if there is
edema. Another material available for use is Orficast Thermoplastic
Tape. It is a unique textile-like thermoformable taping material. It
offers extreme comfort for clients and is very easy to use. This knitted
hybrid fabric is ideal for all applications of finger and/or thumb
orthoses.
Because finger orthoses are so small, there is an increased
possibility of their being pulled off during sleep or during activity. It
may be necessary to tape them in place in addition to using Velcro
straps. The therapist or patient must be careful not to apply the tape
circumferentially so as not to cause a tourniquet effect. An alternative
solution is to use a long Velcro strap to anchor the orthosis around the
hand or wrist.
Diagnostic Indications
Commonly seen diagnoses that require finger orthoses are mallet
fingers, boutonnière deformities, swan neck deformities, trigger
finger, painful osteoarthritis (OA) of DIP joints, PIP flexion
contractures, and finger sprains. These diagnoses are discussed
separately in terms of orthotic indications with consideration of
wearing schedule and fabrication tips. Prefabricated orthotic options
will also be addressed.

Mallet Finger
A mallet finger presents as a digit with a droop of the DIP joint (Fig.
12.1). This posture often occurs because of axial loading with the DIP
extended or else by a flexion force to the fingertip. The terminal
tendon is either torn or avulsed with a piece of bone, causing a droop
of the DIP joint. A laceration of the finger can also disrupt the terminal
tendon.
With a mallet injury, the DIP joint can usually be passively
extended to neutral, but the client is not able to actively extend it. This
is called a DIP extensor lag. If the DIP joint cannot be passively
extended fully, this is called a DIP flexion contracture. It is unlikely
for the DIP joint to develop a flexion contracture early on, but this can
be seen in more long-standing cases.
 FIG. 12.1 Mallet finger deformity.
From American Society for Surgery of the Hand. [1983]. The hand:
Examination and diagnosis [2nd ed.]. Edinburgh, Scotland: Churchill
Livingstone.

Orthoses for Mallet Finger

The goal of orthotics for mallet finger is to prevent DIP flexion. Some
physicians prefer the DIP joint to be supported in slight
hyperextension to prevent extensor lag, whereas others prefer a
neutral DIP position. The therapist should clarify the requested
position of the DIP joint with the physician. If hyperextension is
desired, care must be taken not to excessively hyperextend the joint,
because this may compromise blood flow to the area. Either way, it is
important that the orthosis does not impede PIP flexion unless there
are specific associated issues, such as a secondary swan neck
deformity, that would justify limiting the PIP joint’s mobility. The PIP
joint may also need to be included in the orthosis if the involved digit
is very short and the length of the required device is not practical to
maintain the required contact with the digit.
The DIP joint should be supported 24/7 for approximately 6 to 8
weeks 12 to allow the terminal tendon to heal. The joint should not be
left unsupported or be allowed to flex for even a moment during this
6-week interval. It can be challenging to achieve this continuous DIP
support because there is also the need for skin care. Sometimes
providing two orthoses will improve adherence because the patient
can remove the wet orthosis used in the shower and replace it with a
dry orthosis that has already been “set up” for application. Practice
application of the device with the client so there is a thorough
understanding of techniques used to support the DIP joint while
performing skin hygiene and when applying and removing the
orthosis. The therapist may also consider casting the mallet finger.
Tocco et al. 10 used QuickCast to immobilize 30 mallet fingers for 6
weeks if the injury was less than 21 days old and 8 weeks for chronic
injuries. Tocco et al. 10 found that full-time immobilization of type I
mallet fingers using QuickCast was more effective than the traditional
approach of instructing the patient in home-based splint removal for
skin hygiene. Please refer to Chapter 19 for more information
regarding casting.

TABLE 12.1

Evidence-Based Practice About Silver Ring Orthoses

DIP, Distal interphalangeal; PIP, proximal interphalangeal.

After approximately 6 to 8 weeks of continual support and with

medical clearance, the client is weaned off the orthosis. The orthosis is
usually still worn at night for several weeks. At this time it is
important to watch for the development of a DIP extensor lag; if this is
noticed, resume use of the orthosis and consult the physician. Table
12.1 presents a study on the efficacy of using two-step orthosis
treatment for mallet finger.

Boutonnière Deformity
A boutonnière deformity is a finger that postures with PIP flexion
and DIP hyperextension (Fig. 12.2). A boutonnière deformity can
result from axial loading, tendon laceration, burns, or arthritis. The
central slip is disrupted, which leads to the imbalance of the extensor
mechanism as the lateral bands displace volarly. If not treated in a
timely manner, the PIP joint extensor lag may become a flexion
contracture. In addition, the DIP joint may lose flexion motion due to
tightness of the oblique retinacular ligament (ORL), also called the
ligament of Landsmeer.

Orthotics for Boutonnière Deformity

The goal of orthotics for boutonnière deformity is to maintain PIP joint
extension while keeping the MCP and DIP joints free for
approximately 6 to 8 weeks. If there is a PIP flexion contracture, a
prefabricated dynamic three-point extension orthosis might be used,
or a static orthosis can be adjusted serially with the goal of achieving
full passive PIP extension. There are various types of orthoses for
boutonnière deformity, including simple volar gutter orthoses or
DeRoyal LMB Dynamic Wire-Foam Spring Extension Assist. Fig. 12.3
demonstrates some common options of orthotics for the PIP joint in
extension while keeping the DIP joint free. In some cases, including
the DIP joint in the orthosis may be preferable because this will
increase the mechanical advantage. It is usually acceptable to do this if
the ORL is not tight.
 FIG. 12.2 Normal anatomy and anatomy of boutonnière deformity.
From Burke, S. L., Higgins, J., McClinton, M. A., et al. [2006]. Hand and
upper extremity rehabilitation: A practical guide [3rd ed.]. St. Louis, MO:
Churchill Livingstone.

Serial casting is also an option with this diagnosis (Fig. 12.4). This
technique when using plaster cast material requires training and
practice before being used on clients. Orficast Thermoplastic Tape is
easier to apply because the material is heated in water and simply
wrapped around the digit (Fig. 12.5). After 6 to 8 weeks of support
and with medical clearance, the client is weaned off the orthosis. At
this time, it is important to watch for loss of PIP extension. If this is
noted, adjust orthotic usage accordingly.

FIG. 12.3 Extension orthoses. A, Tube. B, Capener. C, Custom.

From Burke, S. L., Higgins, J., McClinton, M. A., et al. [2006]. Hand and
upper extremity rehabilitation: A practical guide [3rd ed.]. St. Louis, MO:
Churchill Livingstone.
 FIG. 12.4 Serial cast.
From Burke, S. L., Higgins, J., McClinton, M. A., et al. [2006]. Hand and
upper extremity rehabilitation: A practical guide [3rd ed.]. St. Louis, MO:
Churchill Livingstone.
FIG. 12.5 Serial orthosis fabricated from Orficast.
Courtesy Kristin Valdes.
 FIG. 12.6 Normal finger anatomy and anatomy of swan neck
deformity.
From Burke, S. L., Higgins, J., McClinton, M. A., et al. [2006]. Hand and
upper extremity rehabilitation: A practical guide [3rd ed.] St. Louis, MO:
Churchill Livingstone.

Swan Neck Deformity

A swan neck deformity is seen when the finger postures with PIP
hyperextension and DIP flexion (Fig. 12.6). The swan neck deformity
at the PIP and DIP is the opposite of the boutonnière deformity. It
may be possible to correct the PIP and DIP joints passively, or they
may be fixed in their deformity positions. There are multiple possible
causes of this deformity that may occur at the level of the MCP, the
PIP, or the DIP joints. As with a boutonnière deformity, the result is
an imbalance of the extensor mechanism, but with a swan neck
deformity the lateral bands displace dorsally. In addition to other
traumatic causes, it is not uncommon for people with rheumatoid
arthritis to demonstrate swan neck deformities.

Orthoses for Swan Neck Deformity

The goal of orthoses for swan neck deformity is to prevent PIP
hyperextension and to promote DIP extension while not restricting
PIP flexion. Three-point and silver ring orthoses are shown in (Fig.
12.7). These orthoses prevent PIP hyperextension but allow PIP
flexion. They can be either custom formed or prefabricated.

Trigger Finger
Flexor tendons normally glide easily through the sheath and under
pulleys. When a tendon becomes inflamed and swollen, its ability to
slide freely is limited, and the finger can lock when attempting to
extend the finger after making a fist. Bending the finger or thumb can
make it snap or pop. Rheumatoid arthritis, gout, and diabetes also can
contribute to the presence of trigger finger. The lifetime risk of
developing trigger finger is between 2% and 3% but increases to up to
10% in diabetics. 9
FIG. 12.7 Proximal interphalangeal hyperextension block (swan neck)
orthoses. A, Custom-ordered silver ring orthosis. B, Prefabricated
polypropylene Oval-8 orthosis. C, Custom low-temperature
thermoplastic orthosis.
From Burke, S. L., Higgins, J., McClinton, M. A., et al. [2006]. Hand and
upper extremity rehabilitation: A practical guide [3rd ed.]. St. Louis, MO:
Churchill Livingstone.
 FIG. 12.8 Proximal interphalangeal flexion–blocking orthosis for
trigger finger.
Courtesy Kristin Valdes.

Finger Orthosis for Trigger Finger

Valdes 11 reported successfully managing trigger finger using a finger-
based orthotic device (Fig. 12.8). The decision to use a single-digit
orthosis was based on the understanding that blocking PIP flexion
would restrict flexor tendon movement through the affected A1
pulley while leaving the palm unrestricted. A thumb-based orthosis
can immobilize the interphalangeal (IP) joint but keep the thumb tip
as free as possible for improved prehension and tactile discrimination.
The orthoses are custom fabricated using thermoplastic material.

Osteoarthritis of Distal Interphalangeal Joint

OA can be a common occurrence at the DIP joints, resulting in
deformity and pain. Deformity, either radial or ulnar deviation at the
joint, or loss of full extension (extension lag) is common. Functional
deficits and reduced quality of life are well documented in those with
DIP joint disease, particularly when associated with other hand joint
involvement. 7 Aesthetic concerns from hand OA also cause
considerable distress, and their presence correlates with reduced
health-related quality of life. 5

Orthoses for Osteoarthritis of Distal Interphalangeal

Joint
Two studies 6,13 examined the use of wearing a customized gutter DIP
orthosis and the effect on pain. The studies demonstrated that
wearing a customized DIP orthosis significantly reduces pain. The
device can also be fabricated from the Orficast tape and can be slipped
on and off easily by the patient. The Ikeda et al. 6 study demonstrated
a large effect size of 2.59 for the reduction of pain after wearing the
DIP orthosis. Watt et al. 13 found that short-term nighttime DIP joint
splinting is a safe, simple treatment modality that reduces DIP joint
pain and improves extension of the digit and does not appear to give
rise to noncompliance, increased stiffness, or joint restriction.

Proximal Interphalangeal Flexion Contracture

The PIP joint is the structure producing the largest range of motion in
the hand, 8 accounting for 85% of the grasping capabilities of the
fingers. PIP joint contractures are common finger injuries seen by
therapists following joint dislocation, subluxation, synovitis, ligament
damage, soft tissue injury, or prolonged edema of the hand.

Orthoses for Proximal Interphalangeal Flexion

Contracture
The reason for orthotic intervention varies but may include increasing
function, preventing deformity, correcting deformity, protecting
healing structures, restricting motion, and allowing for tissue growth
and remodeling. The LMB spring wire (DeRoyal Industries), Reverse
Knuckle Bender (Bunnell), Joint Jack (Joint Jack Company), Capener
splint (LifeTec Inc.), and the Dynasplint (Dynasplint Systems, Inc.) are
prefabricated mobilizing orthotics that aid in PIP extension. Custom
low-profile orthoses and serial casting are also options available to
therapists. Recent studies 2–4 that provided a wearing schedule of a
minimum of 6 hours of a Capener device for 8 to 17 weeks obtained
the greatest improvements in extension deficits of the PIP joint. The
mean extension gain was 21 degrees. The force of the orthosis should
be low enough that the client senses the tension but feels no pain.
Clients should be instructed to remove the device intermittently for
finger range of motion (ROM) exercises to prevent tissue injury.
Clients should be instructed to watch for swelling, cyanosis, or
tingling, which may indicate that too much force is being applied.

Finger Proximal Interphalangeal Sprains

Clients may ignore finger sprains, but they can be very painful and
functionally debilitating with potential for chronic swelling and
stiffness and a surprisingly long recovery time. Uninjured digits are at
risk of losing motion and function, which further complicates the
picture. Prompt treatment can favorably affect the client’s outcome
and expedite return to occupations impacted by the injury.

TABLE 12.2

Grades of Ligament Sprain Injuries

Grade Description Treatment
Mild No instability with AROM or Immobilize the joint in full extension if comfortable
grade PROM; macroscopic continuity and available; otherwise immobilize in a small
I with microscopic tears. The amount of flexion. When pain has subsided, begin
sprain ligament is intact, but individual AROM, and protect with buddy taping or buddy
fibers are damaged. strapping.
Grade II Abnormal laxity with stress; the Immobilize the joint in full extension for 2 to 4
sprain collateral ligament is disrupted. weeks. The physician may recommend early ROM,
AROM is stable, but passive but avoid any lateral stress.
testing reveals instability.
 Grade III Complete tear of the collateral Early surgical intervention is often recommended.
sprain ligament along with injury to the
dorsal capsule or the VP. The
finger has usually dislocated with
injury.
AROM, Active range of motion; PROM, passive range of motion; ROM, range of motion; VP,
volar plate.

PIP sprains are graded in terms of severity, from grade I to III. Table
12.2 describes these grades and identifies proper treatment. PIP joint
dislocations are also described in terms of the direction of joint
dislocation (e.g., dorsal, lateral, or volar). PIP joint sprains are
associated with fusiform swelling, which is fullness at the PIP that
tapers proximally and distally. Edema control is critical with this
diagnosis.

Orthoses for Finger Proximal Interphalangeal Sprains

The goal of orthoses for finger PIP sprains is to support the PIP joint
and promote healing and stability. Orthotic options for the injured PIP
joint with extension limitations are similar to those used for
boutonnière deformities. If there is a PIP flexion contracture, then a
dynamic or serial static PIP extension orthosis is used, or serial casting
may be considered. If there has been a VP injury, then a dorsal gutter
is fabricated to block approximately 20 to 30 degrees of PIP extension
while allowing PIP flexion (Fig. 12.9).
Buddy straps (Fig. 12.10) are used to promote motion and support
the injured digit. There are many different styles to choose from. An
offset buddy strap may be needed, especially for small finger injuries
due to the length discrepancy between the small and ring fingers.
The physician will indicate what arc of motion is safe, according to
the injury and joint stability. It is important not to apply lateral stress
to the injured tissues. For example, if the index finger has an injury to
the radial collateral ligament, avoid ulnar stress on it. Lateral pinch
would also be problematic in this instance. Sometimes it is necessary
to custom fabricate a PIP gutter that corrects lateral position as well.
Fig. 12.11 shows a digital orthosis that provides lateral support. A
silver ring orthosis can also be used to prevent lateral stress to the
joint without interfering with joint mobility.

FIG. 12.9 Dorsal gutter orthosis blocking approximately 20 to 30

degrees of proximal interphalangeal extension.
From Fess, E. E., Gettle, K., Philips, C., et al. [2005]. Hand and upper
extremity splinting: Principles and methods [3rd ed.]. St. Louis, MO:
Mosby.

PIP finger sprains are at risk for stiffness and are prone to
developing flexion contractures. For this reason, a night PIP extension
orthosis is often appropriate to use. But this type of injury may also
present problems achieving PIP/DIP flexion as well. In this instance,
orthoses can be provided along with exercises to gain flexion passive
range of motion (PROM). Examples of flexion orthoses are shown in
Fig. 12.12. The force applied by the device should be low enough that
the client senses the tension but feels no pain, and tissue tolerances
should be monitored carefully.
Precautions for Finger Orthotics
• Monitor skin for signs of maceration and/or pressure on both
the finger affected and adjacent fingers that contact with the
orthosis.
• Check orthotic edges and straps for signs of tightness.
• Provide written instructions, and practice with clients so that
they are following guidelines of orthotics care and use
correctly.
• If the orthosis is circumferential, circulation should be assessed
with pressure to the digit to assess capillary refill.
Occupation-Based Orthotics
Some finger orthoses may help with hand function by decreasing pain
and providing stability. However, many finger orthoses can certainly
interfere with daily hand use. Understandably, clients may be
tempted to remove their orthoses to participate in activities they
enjoy. To help prevent this from happening, therapists should
incorporate an occupation-based approach.

FIG. 12.10 A and B, Examples of buddy straps for proximal

interphalangeal collateral ligament injuries.
From Burke, S. L., Higgins, J., McClinton, M. A., et al. [2006]. Hand and
upper extremity rehabilitation: A practical guide [3rd ed.]. St. Louis, MO:
Churchill Livingstone.
 FIG. 12.11 Proximal interphalangeal extension orthosis with lateral
support.
From Fess, E. E., Gettle, K., Philips, C., et al. [2005]. Hand and upper
extremity splinting: Principles and methods [3rd ed.]. St. Louis, MO:
Mosby.

Examples of Occupation-Based Finger

Orthoses
An elderly retired man enjoyed woodworking but was unable to use
his woodworking tools comfortably due to arthritis-related pain and
instability of the index finger PIP joint. He expressed interest in a PIP
joint protective orthosis to help him use his tools. To determine the
best position of the PIP joint orthosis, he brought his tools to therapy
and demonstrated the finger position he needed. An orthosis was
made that provided support during this task.

a
Self-Quiz 12.1
For the following questions, circle either true (T) or false (F).
 1. T F PIP joints are hinge joints.
2. T F A mallet finger is represented by loss of extension at the PIP
joint.
3. T F An extensor lag occurs when there is loss of passive
extension at the joint.
4. T F Finger sprains of the PIP joints are always trivial injuries.
5. T F Buddy straps promote motion and support an injured digit.

a
See Appendix A for the answer key.

A client with a mallet injury came to the clinic with maceration

under the orthosis. He stated that he was wearing his orthosis in the
shower and keeping the wet orthosis on his finger all day. In addition
to reviewing skin care guidelines and practicing safe protected
donning and doffing of the orthosis, an additional orthosis was made
to use while showering. This allowed him to apply a dry orthosis after
his shower. With this solution, he could avoid further skin maceration.
Fabrication of A Dorsal-Volar Mallet
Orthosis
The dorsal-volar mallet orthosis is indicated for a mallet injury. Fig.
12.13A represents a detailed pattern that can be used for any finger.
Fig. 12.13B shows a completed orthosis. This orthosis has some
adjustability for fluctuations in edema, which can be advantageous.
Nonperforated 3⁄32-inch material works well for this orthosis. An
alternative orthotic design is a DIP gutter orthosis. Fig. 12.13C
represents a detailed pattern for this alternative orthosis.
 FIG. 12.12 A to D, Examples of proximal interphalangeal/distal
interphalangeal flexion orthoses.
From Fess, E. E., Gettle, K., Philips, C., et al. [2005]. Hand and upper
extremity splinting: Principles and methods [3rd ed.]. St. Louis, MO:
Mosby.

1. Mark the length of the finger from the PIP joint to the tip.
2. Mark the width of the finger.
3. Cut out the pattern, and round the four edges.
4. Trace the pattern on a sheet of thermoplastic material.
5. Warm the material slightly to make it easier to cut the pattern
out of the thermoplastic material.
 6. Heat the thermoplastic material.
7. Apply the material to the client’s finger, clearing the volar PIP
crease. Be gentle with the amount of hand pressure over the
dorsal DIP because this is usually quite tender.
8. Maintain the DIP in extension or slight hyperextension,
depending on the physician’s order.
9. Allow the material to cool completely before removing the
orthosis.
10. Ensure proper fit of the orthosis. The orthosis should stay in
place securely with a thin ½-inch Velcro strap.
11. Trim the edges as needed.
12. Smooth all edges completely.

Technical Tips for Proper Fit of Mallet

Orthoses
1. Finger orthoses may seem easy to make because they are small.
However, it may take extra time to fabricate them precisely.
Do not be surprised if you wind up needing extra time to
make and fine-tune these small orthoses.
2. Ordinary Velcro loop straps may feel bulky on small finger
orthoses. Thinner strap material that is ½-inch wide and less
bulky can be very effective for finger orthoses.
3. If an orthosis slips, consider using paper tape to apply the
device to the finger and self-adherent elastic wrap, rather than
Velcro strapping.

Safety Tips for Mallet Orthoses

1. Device must be removed by the patient and finger washed to
prevent skin maceration.
2. If the patient has a pin to repair a bony mallet finger, protect
the pin with a cap of material to prevent jarring of the pin.
 FIG. 12.13 A, Dorsal-volar mallet orthosis pattern. B, Completed
dorsal-volar mallet orthosis. C, Distal interphalangeal gutter orthosis
pattern.
Prefabricated Mallet Orthoses
If there has been surgery and the client has a percutaneous pin, the
orthosis must accommodate the pin. The DIP orthosis can be a volar
gutter orthosis, a dorsal-volar orthosis, or a stack orthosis. A
prefabricated AlumaFoam orthosis is sometimes used, but there may
be inconveniences and skin issues associated with the adhesive tape
that is used to secure it. Prefabricated or custom fabricated stack
orthoses need to be monitored for clearance at the dorsal distal edge,
because this is an area prone to tenderness and edema related to the
injury (Fig. 12.14).
 FIG. 12.14 Mallet orthoses. A, Custom thermoplastic. B, AlumaFoam.
C, Stack.
From Burke, S. L., Higgins, J., McClinton, M. A., et al. [2006]. Hand and
upper extremity rehabilitation: A practical guide [3rd ed.]. St. Louis, MO:
Churchill Livingstone.

Mallet Finger Impact on Occupation

Mallet injuries can result in awkward hand use and can also limit the
freedom of flexion of uninvolved digits. It is important to teach clients
to maintain active PIP motion of the involved digit and to use
compensatory skills, such as relying on uninjured fingertips for
sensory input.
Fabrication of A Proximal
Interphalangeal Gutter Orthosis
A PIP gutter orthosis is indicated for a PIP sprain injury. Fig. 12.15A
represents a detailed pattern that can be used for any finger. Fig.
12.15B shows a completed orthosis. Nonperforated 3⁄32-inch material
works well for this orthosis.

1. Mark the length of the finger from the web space to the DIP
joint.
2. Mark the width of the finger, adding approximately ¼ to ½
inch on each side, depending on the size of the digit.
3. Cut out the pattern, and round the four edges.
4. Trace the pattern on a sheet of thermoplastic material.
5. Warm the material slightly to make it easier to cut the pattern
out of the thermoplastic material.
6. Heat the thermoplastic material.
7. Position the client’s hand with the palm up to allow the
material to drape.
8. Apply the material to the client’s finger, clearing the MCP and
DIP creases and positioning the PIP joint in the desired
position. (This is typically the available passive extension.) Be
gentle with the amount of hand pressure used over the PIP
joint and over the sides of the joint.
 FIG. 12.15 A, Proximal interphalangeal gutter orthosis pattern
for fabrication. B, Completed orthosis.
From Clark, G. L. [1998]. Hand rehabilitation: A practical guide
[2nd ed.]. New York, NY: Churchill Livingstone.

9. Roll the edges of the orthosis as needed for comfort and

clearance of MCP and DIP joint motions.
10. Allow the material to cool completely before removing the
orthosis.
11. Ensure proper fit of the orthosis.
12. Trim the edges as needed.
13. Smooth all edges completely.

Technical Tips for Proper Fit of a Proximal

Interphalangeal Gutter Orthosis
1. Straps must fit closely enough to provide a secure fit. Consider
using one long Velcro strap that wraps around the digit two to
three times for better fit.
2. Modify the height of finger orthotic edges so that straps can
have contact with the skin. If the edges are too high, the straps
will not be effective.
3. If the goal is to achieve full PIP extension, consider placing a
strap directly over the PIP joint, but be careful to closely
monitor skin tolerance.

Safety Tip for Proximal Interphalangeal

Orthosis
1. Straps should not be too tight because this can cause edema.
FIG. 12.16 A, Prefabricated proximal interphalangeal (PIP) extension
orthosis that crosses the distal interphalangeal (DIP). B, Prefabricated
PIP extension orthosis with DIP free. (From Fess, E. E., Gettle, K.,
Philips, C., et al. [2005]. Hand and upper extremity splinting: Principles
and methods [3rd ed.]. St. Louis, MO: Mosby.)
Prefabricated Proximal Interphalangeal
Orthoses
Fig. 12.16 shows examples of prefabricated PIP extension orthoses.
Remember that prefabricated orthoses do not always fit well or
accommodate edema. Also, there can be problems with distribution of
pressure, skin tolerance, and excessive joint forces.

Impact of Proximal Interphalangeal Injuries on

Occupations
PIP joint injuries can limit the flexibility and function of the entire
hand. Reaching into the pocket or grasping a tool may be impeded.
Pain can interfere with the comfort of doing a simple but socially
significant task such as a handshake. Rings may no longer fit over the
injured joint. Early appropriate therapy can help restore these
functions to clients.
Fabrication of A Proximal
Interphalangeal Hyperextension Block
(Swan Neck Orthosis)
The PIP hyperextension block orthosis is indicated for a finger with a
flexible swan neck deformity. Fig. 12.17A represents a detailed pattern
that can be used for any finger. Fig. 12.17B shows a completed
orthosis. An alternate orthotic design involves wrapping a thin strip
or tube of thermoplastic material in a spiral fashion (see Fig. 12.17C).
 FIG. 12.17 A, Proximal interphalangeal (PIP) hyperextension block
orthosis pattern. B, Completed PIP hyperextension block orthosis. C,
Spiral design PIP hyperextension block orthosis.

A properly fitting orthosis effectively blocks the PIP in slight flexion

when the finger is actively extended and allows unrestricted active
PIP flexion. A thin (1⁄16 inch) nonperforated thermoplastic material
(such as Orfit or Aquaplast) works well for this orthosis. It is
especially important to minimize bulk if multiple fingers need
orthoses on the same hand. The orthoses must not get caught on each
other.

1. Mark the length of the finger from the web space to the DIP
joint.
2. Mark the width of the finger, adding approximately ¼ inch on
each side.
3. Cut out the pattern, and round the four edges.
4. Trace the pattern on a sheet of thermoplastic material.
5. Cut the pattern out of the thermoplastic material. Cutting thin
material does not require heating of the plastic first.
6. Mark location for holes, leaving an approximately ¼- to ½-inch
bar of material in the center of the orthosis.
7. Punch holes.
8. Apply a light amount of lotion to the finger to enable the
material to slide over the finger easily.
9. Heat the thermoplastic material.
10. Slightly stretch the holes so that they are just large enough to
slide the finger through. Be careful not to overstretch because
the orthosis will be too loose.
11. Slide the material over the finger, weaving the finger up
through the proximal hole and down through the distal hole.
12. Center the volar thermoplastic bar directly under the PIP joint,
and the dorsal distal and proximal ends of the orthosis over
the middle and proximal phalanges.
13. As the orthosis is formed on the finger, keep the PIP in slight
flexion (approximately 20 to 25 degrees).
 14. Roll the edges of the volar thermoplastic bar as needed to
allow unrestricted PIP flexion.
15. Fold the lateral sides of the orthosis volarly and contour the
material to the finger.
16. Allow the material to cool completely before removing the
orthosis.
17. Ensure proper fit of the orthosis. The orthosis should be loose
enough to slide over the PIP joint yet snug enough to not
migrate or twist on the finger. The orthosis should allow full
PIP flexion and effectively prevent the PIP from going into
hyperextension.
18. Trim the edges as needed.
19. Smooth all edges completely.

Technical Tips for Proper Fit of the

Hyperextension Block (Swan Neck Orthosis)
1. A common mistake is to allow the PIP joint to go into extension
while fabricating the orthosis. Closely monitor the PIP position
to make sure that it remains in slight flexion during the
fabrication process.
2. If the PIP joint is enlarged or swollen, it may be very difficult to
slide the orthosis off the finger once it is made. This can be
avoided by gently sliding the orthosis back and forth over the
PIP joint a few times before the thermoplastic material is fully
cooled.
3. Because this orthosis is meant to enable function, make sure to
minimize orthotic bulk by flattening the volar PIP bar and
lateral edges as much as possible so that the edges do not
impede the grasping of objects.

Safety Tip for Hyperextension Block Orthosis

1. Ensure that the device is not too tight because this will cause
 excessive edema and make the device difficult to remove.

Swan neck orthoses are commercially available, and they offer some
advantages over custom-fabricated thermoplastic orthoses. They are
more durable, less bulky, and often more cosmetically pleasing to
clients. Therapists use ring sizers to determine the size needed for
each finger. Custom-ordered ring orthoses made of silver or gold (Fig.
12.18) are attractive, unobtrusive, and flexible enough to be adjusted
for fluctuations in joint swelling; however, they are costlier.
Prefabricated orthoses made of polypropylene (Fig. 12.19) are a less
expensive alternative that offer durability and a streamlined fit. Their
fit can be slightly modified by a therapist using a heat gun, but they
cannot be adjusted by clients in response to variations in joint
swelling.

FIG. 12.18 A and B, Custom-ordered proximal interphalangeal

hyperextension block orthoses.
From Skirven, T. M., Callahan, A. D., Osterman, A. L., et al. [2002].
Hunter, Mackin & Callahan’s rehabilitation of the hand and upper
extremity [5th ed.]. St. Louis, MO: Mosby.
 FIG. 12.19 A and B, Prefabricated proximal interphalangeal
hyperextension block orthoses.
From Skirven, T. M., Callahan, A. D., Osterman, A. L., et al. [2002].
Hunter, Mackin & Callahan’s rehabilitation of the hand and upper
extremity [5th ed.]. St. Louis, MO: Mosby.
Impact of Swan Neck Deformities on
Occupations
Swan neck deformities often cause difficulty with hand closure. PIP
tendons and ligaments can catch during motion, and the long finger
flexors have less mechanical advantage to initiate flexion when the
PIP starts from a hyperextended position. A PIP hyperextension block
should improve the client’s hand function by allowing the PIP to flex
more quickly and easily, enabling the ability to grasp objects.
Fabrication of A Three-Point Proximal
Interphalangeal Extension Low-Profile
Orthosis
Boccolari and Tocco 1 provided directions for an orthosis that is
suitable for PIP joint flexion contractures of a single digit and can be
modified to accommodate contractures as severe as 70 degrees from
full extension. The device provides equal pressure distribution and is
low profile.

Materials
1. 5 × 5 cm thin elastic thermoplastic material for the proximal
plate (e.g., 1.6-mm Aquaplast or 2.0-mm Orfit Classic), ends
slightly distal to the palmar distal crease
2. 3 × 3 cm T-shaped piece of similar thermoplastic material for
the distal cuff
3. 40-cm long 1.6-mm copper-coated steel welding rod
4. Round-tipped pliers or 90-degree wire bender
5. Wire cutter
6. 1 × 2 cm adhesive hook Velcro
7. 1 × 15 cm nonadhesive loop Velcro

Fabrication Procedure1 ∗
1. “Position the pliers or wire bender at the half point of the
copper wire and bend the wire to 90 degrees (Fig. 12.20A).
2. Measure the width of the frame by placing the edge of the bent
wire on one side of the PIP crease (see Fig. 12.20B), leaving a
space of 0.5 cm between it and the finger (see Fig. 12.20C). Do
not use the DIP crease to measure, to avoid underestimating
 the width of the frame and later be faced with difficulties in
assembling the distal cuff onto the frame.
3. Bend the wire at a 90-degree angle to obtain a reverse U-shape.
4. At 0.5 cm from these bending points (bilaterally), tilt the U-
shaped portion 90 degrees anteriorly on a sagittal plane (see
Fig. 12.20D). This will avoid hyperextending the PIP joint
beyond the neutral position after achieving full passive PIP
joint extension—the longitudinal portion of the frame will lie
midway on either side of the finger once the joint has
recovered full extension.
5. Place the U-shaped portion just proximal to the DIP crease to
measure the length of the frame before applying another
bilateral 90-degree anterior tilt to the frame (similar to step 4).
The frame must be tilted just distal to the web space of the
finger (see Fig. 12.20E–F)
http://www.jhandtherapy.org/cms/attachment/2001330725/2005179457/gr7
6. Bend the wire 90 degrees in the opposite direction 0.5 cm from
the previous bending points on each side to redirect the
proximal rods toward the wrist (see Fig. 12.20G).
7. Curve the two proximal endings toward each other to end the
frame just proximal to the distal palmer crease (or proximal
crease when splinting the index finger (see Fig. 12.20H).
8. Wrap the 5 × 5 cm square piece of thermoplastic material
around the proximal portion of the frame and cut the excess
material around the frame (see Fig. 12.20I).
9. Place the reverse T-shaped thermoplastic piece over the DIP
crease (see Fig. 12.20J). Before it hardens, lay the distal portion
of the frame over the T-shaped piece just proximal to the DIP
crease. Flip the distal portion of the T-shaped piece over the
resting rod (see Fig. 12.20K). The cuff is not fixed to the copper
wire, rather it is molded around it. This technique allows the
distal cuff to rotate around the rod, which will allow maximal
pressure distribution on the middle phalanx as passive
extension improves.
10. Wrap the adhesive hook Velcro around the ulnar rod next to
 the PIP joint and stick both wings against each other to rest
dorsal to the finger (see Fig. 12.20 L).
11. Attach the loop Velcro on the internal side of the hook Velcro
(see Fig. 12.20M). Pass it over the PIP joint, and slip it between
the finger and the radial rod. Wrap it around this rod, and
pass it again over the PIP joint to end its attachment on the
external side of the hook Velcro (see Fig. 12.20N). Apply the
appropriate tension over the PIP joint to lever the middle
phalanx into extension (see Fig. 12.20O).”

Technical Tips for Proper Fit of the Three-

Point Extension Orthosis
1. Follow-ups should be scheduled 2 or 3 days after the first visit.
If skin redness is noted, a piece of Neoprene or other padding
can be added over the PIP joint under the Velcro strap. 1
2. It is therefore preferable to begin with gentle tension and
progressively increase the tension as the tissue allows. 1
3. The splint should be worn continuously for approximately 3 to
5 days. If full range of motion is not gained at this point, the
patient is instructed to wear the splint for an additional 2 to 3
days if skin redness is absent. 1
Prefabricated Proximal Interphalangeal
Extension Orthoses
The LMB spring wire, Reverse Knuckle Bender, Joint Jack, Capener
splint, and the Dynasplint are prefabricated mobilizing orthotics that
aid in PIP extension. Remember that prefabricated orthoses do not
always fit well or accommodate edema. Also, there can be problems
with distribution of pressure, skin tolerance, and excessive joint
forces.

Safety Tips for Three-Point Proximal

Interphalangeal Extension Orthosis
1. Instruct client not to tighten the strap too much because this
will compromise circulation.
Impact of Proximal Interphalangeal
Flexion Contractures on Occupations
PIP flexion contractures often cause difficulty with hand opening. The
client may have difficulty reaching his or her hand into narrow spaces
and may report jarring the joint. A PIP extension orthosis should
improve the client’s hand function by allowing the PIP joint to fully
extend, enabling the ability to fully open hand.
Fabrication of A Finger-Based Trigger
Finger Orthosis
1. Mark the length of the finger from the web space to the DIP
joint.
2. Measure the circumference of the finger, adding approximately
½ inch.
3. Mark the width of the finger, adding approximately ¼ inch on
each side.
4. Cut out the pattern, and round the four edges (Fig. 12.21A).
5. Trace the pattern on a sheet of thermoplastic material.
6. Cut the pattern out of the thermoplastic material. Cutting thin
material does not require heating of the plastic first.
 FIG. 12.20 A to O, Fabrication steps for three-point extension
orthosis.
Boccolari, P., & Tocco, S. [2009]. Alternative splinting approach
for proximal interphalangeal joint flexion contractures: No-profile
static progressive splinting and cylinder splint combo. Journal of
Hand Therapy 22[3], 289–293.
 7. Apply a light amount of lotion to the finger to enable the
material to slide over the finger easily.
8. Heat the thermoplastic material.
9. Lay the material over the volar surface of the finger, wrapping
the “tails” completely around the finger and attaching to the
back surface of the device (see Fig. 12.21B–C).
10. The dorsal surface of the PIP joint should be free (see Fig.
12.21D).
11. As the orthosis is formed on the finger, keep the PIP in
extension.
12. Roll the edges of the volar thermoplastic bar as needed to
allow unrestricted DIP and MP flexion.
13. Allow the material to cool completely before removing the
orthosis.
14. Ensure proper fit of the orthosis. The orthosis should be loose
enough to slide over the PIP joint yet snug enough to not
migrate or twist on the finger.
15. Trim the edges as needed.
16. Smooth all edges completely.

Technical Tips for Proper Fit of the Trigger

Finger Orthosis
1. If the PIP joint is enlarged or swollen, it may be very difficult to
slide the orthosis off the finger once it is made. This can be
avoided by gently sliding the orthosis back and forth over the
PIP joint a few times before the thermoplastic material is fully
cooled.
2. Because this orthosis is meant to enable function, make sure to
minimize orthotic bulk by flattening the orthotic material as
much as possible so that the device is not too bulky on the
finger and rubbing on the adjacent fingers.

Safety Tip for a Trigger Finger Orthosis

1. Ensure that the device is not too tight and that it can be slid on
and off and that it has not compromised circulation.
Prefabricated Trigger Finger Orthosis
Swan neck orthoses can be used if they are positioned on the PIP joint
“upside down” (two bands on the volar surface of the finger). These
orthoses are commercially available.
Impact of Trigger Finger on
Occupations
Trigger finger often cause difficulty with grasping and manipulating
of fine objects. The finger may lock into flexion after composite flexion
of the digit. A finger-based orthosis should improve the client’s hand
function by allowing the palm to be free and immobilizing only one
joint.
Fabrication of the Distal
Interphalangeal Stabilization Orthosis
1. Cut a 6-inch piece of 1-inch blue Orficast tape (Fig. 12.22A).
2. Heat the material.
3. Wrap the material around the DIP joint (see Fig. 12.22B–C).
4. As the orthosis is formed on the finger, keep the PIP in slight
flexion or extension.
5. Allow the material to cool completely before removing the
orthosis.
6. Ensure proper fit of the orthosis. The orthosis should be loose
enough to slide over the DIP joint yet snug enough to not
migrate or twist on the finger.
7. Trim the edges as needed.

Technical Tips for Proper Fit of the Distal

Interphalangeal Stabilization Orthosis
1. Make sure to minimize orthotic bulk by flattening the orthotic
material as much as possible so that the device is not too bulky
on the finger.
2. Ensure that the patient can slip the device on and off the finger.

Safety Tip for a Distal Interphalangeal

Stabilization Orthosis
1. Ensure that the device is not too tight and that it can be slid on
and off and that it has not compromised circulation.
Prefabricated Distal Interphalangeal
Stabilization Orthosis
Swan neck orthoses can be used if they are positioned on the PIP joint
“upside down” (two bands on the volar surface of the finger). They
are commercially available. If the joint is laterally deviated, the device
can be placed “sideways” on the finger with the two-band side placed
on the same side of the finger that the deviation is. If the finger is
severely deviated, a prefabricated device should not be used.
Impact of Distal Interphalangeal
Osteoarthritis on Occupations
Pain, joint deformity, and loss of extension lag lead to both functional
and cosmetic issues for clients with OA. Clients may experience loss
of sleep due to pain. Some individuals are concerned about the
appearance of the deformed joint. The DIP immobilization orthosis is
a safe and inexpensive intervention that reduces DIP joint pain and
improves joint extension.
Conclusion
There is emerging research and strong clinical support for the use of
finger orthoses as a mainstay of care for many common finger
problems. Finger biomechanics are very complicated. Added to this,
there are multiple custom and prefabricated orthotics to select from.
These challenges can understandably confuse decision making,
particularly for novice therapists. Hopefully this chapter helps
therapists use sound clinical reasoning to work collaboratively with
clients. Application of clinical reasoning ensures that the best orthosis
is selected based on each client’s clinical needs and occupational
demands.
FIG. 12.21 A to D, Fabrication steps for trigger finger orthosis.
Courtesy Kristin Valdes.
 FIG. 12.22 A to C, Fabrication steps for distal interphalangeal
stabilization orthosis.
Courtesy Kristin Valdes.

a
Self-Quiz 12.2

List the Diagnosis or Injury That Would

Type of Orthosis
Benefit From This Orthosis
1. Silver ring splint
2. Dorsal PIP orthosis that positions the PIP joint
in 20 to 30 degrees of flexion
3. Finger orthosis that blocks PIP flexion only
4. Buddy strap

a
See Appendix A for the answer key.

Review Questions
1. What is a mallet finger?
2. What is the posture of a finger with a boutonnière
deformity?
3. What is the posture of a finger with a swan neck
deformity?
4. What is fusiform swelling?
5. What structures provide joint stability and restraint against
PIP deviation forces?
6. What is the difference between an extensor lag and a
flexion contracture?
7. What type of finger orthosis is typically used for a swan
neck deformity?
8. How is the DIP positioned when providing an orthosis for
a mallet finger?
9. What position should the PIP be in when providing an
orthosis for a boutonnière deformity?
10. What position should the PIP be in when providing an
orthosis for a swan neck deformity?
References
1. Boccolari P, Tocco S. Alternative splinting approach
for proximal interphalangeal joint flexion
contractures; no-profile static progressive splinting
and cylinder splint combo. J Hand Ther
. 2009;22(3):289–293.
2. Cantero-Téllez R, Cuesta-Vargas A, Cuadros-
Romero M. Treatment of proximal interphalangeal
joint flexion contracture: combined static and
dynamic orthotic intervention compared with other
therapy intervention: a randomized controlled trial. J
Hand Surg . 2015;40(5):951–955.
3.
Glasgow C, Fleming J, Tooth L.R, Peters S. Randomized
control trial of daily total end range time (TERT) for
capener splinting of the stiff proximal
interphalangeal joint. Am J Occup Ther
. 2012;66(2):243–248.
4. Glasgow C, Fleming J, Tooth L, Hockey R. The long-
term relationship between duration of treatment and
contracture resolution using dynamic orthotic
devices for the stiff proximal interphalangeal joint: a
prospective cohort study. J Hand Ther . 2011;25(1):38–
47.
5. Hodkinson B, Maheu E, Michon M, et al. Assessment
and determinants of aesthetic discomfort in hand
osteoarthritis. Ann Rheum Dis . 2012;71(1):45–49.
6.
Ikeda M, Ishii T, Kobayashi Y, Mochida J, Saito I, Oka Y.
 made splint treatment for osteoarthritis of the distal
interphalangeal joints. J Hand Surg . 2010;35(4):589–
593.
7. Kjeken I, Dagfinrud H, Slatkowsky-Christensen B, et
al. Activity limitations and participation restrictions
in women with hand osteoarthritis: clients’
descriptions and associations between dimensions of
functioning. Ann Rheu Dis . 2005;64(11):1633–1638.
8. Leibovic S.J, Bowers W.H. Anatomy of the proximal
interphalangeal joint. Hand Clin . 1994;10(2):169–178.
9.
Makkouk A.L, Oetgen M.E, Swigart C.R, Dodds S.D. Trigger
finger: etiology, evaluation, and treatment. Curr Rev
Musculoskelet Med . 2008;1(2):92–96.
10. Tocco S, Boccolari P, Landi A, et al. Effectiveness of
cast immobilization in comparison to the gold-
standard self-removal orthotic intervention for closed
mallet fingers: a randomized clinical trial. J Hand
Ther . 2013;26(3):191–201.
11. Valdes K. A retrospective review to determine the
long-term efficacy of orthotic devices for trigger
finger. J Hand Ther . 2012;25(1):89–96.
12. Valdes K, Naughton N, Algar L. Conservative
management of mallet finger: a systematic review. J
Hand Ther . 2015;28(3):237–246.
13. Watt F.E, Kennedy D.L, Carlisle K.E, et al. Night-time
immobilization of the distal interphalangeal joint
reduces pain and extension deformity in hand
osteoarthritis. Rheumatology (Oxford)
. 2014;53(6):1142–1149.
Appendix 12.1 Case Studies
Case Study 12.1 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Marge is a 74-year-old right-hand–dominant woman who is retired
from her job. She likes to crochet and knit. She has pain and swelling
of her index and small finger DIP joints. Her physician diagnosed her
with osteoarthritis of the fingers and sent her to occupational therapy
for evaluation and treatment. At her initial evaluation she reports
night DIP joint pain that interferes with her sleep.

1. What joint(s) should her finger orthoses cross?

____________________________________________________________________
2. When does Marge need to wear the orthoses in a 24-hour
cycle?
____________________________________________________________________
3. How long is Marge likely to need to wear her orthoses?
__________________________________________________________________

Case Study 12.2 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Ryan is a 23-year-old right-hand–dominant man who jammed his
right middle finger while playing softball. He developed pain and
swelling of the distal finger, along with a droop of the DIP joint. His
physician diagnosed a mallet injury and sent him to occupational
therapy for orthotic fabrication.

1. What joint(s) should his finger orthosis cross?

____________________________________________________________________
2. What is the recommended orthotic wearing schedule?
 __________________________________________________________________
3. List two different types of orthoses that Ryan could use.
__________________________________________________________________
4. How long is Ryan likely to need to wear his orthosis?
__________________________________________________________________

Case Study 12.3 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Debbie is a 62-year-old left-hand–dominant woman who fell and
developed pain and swelling of her left ring finger PIP joint. She was
diagnosed with a PIP joint injury to the radial collateral ligament and
VP.

1. Should Debbie have a dorsal or volar finger orthosis?

_____________________________________________________________________
2. What joint(s) should the orthosis cross, and what position
should they be in?
_____________________________________________________________________
3. Which fingers would be good to buddy tape or buddy strap
together and why?
_____________________________________________________________________
4. Debbie loved to play tennis. When she was medically cleared
to play again, she experienced recurrence of swelling at the
ring finger PIP joint. What might help her manage her pain
and swelling so that she could play tennis again?
__________________________________________________________________

Case Study 12.4 a

Read the following scenario, and apply clinical reasoning skills to answer the
questions based on information in this chapter.
Alexa is a 41-year-old right-hand–dominant law firm receptionist
who has a 3-year history of rheumatoid arthritis. She was referred to
occupational therapy for evaluation of orthotic needs. She presents
with recent development of bilateral swan neck deformities of all
fingers. She can actively flex her PIPs, but it is awkward and effortful
to do so. She reports having difficulty with home and work tasks that
involve grasping objects.

1. Do you think Alexa would benefit from PIP hyperextension

block orthoses? Why or why not?
____________________________________________________________________
2. How could you and Alexa determine if orthoses will improve
her hand function?
____________________________________________________________________
3. What key client factors and orthotic options would you
consider in selecting the best orthoses for Alexa?
__________________________________________________________________
4. When should Alexa wear her orthoses?
____________________________________________________________________
Appendix 12.2 Laboratory Exercises
Laboratory Exercise 12.1 a

1. The following picture shows a mallet finger gutter orthosis.

What is wrong with this orthosis?

____________________________________________________________________
2. The following picture shows a PIP gutter orthosis. What is
wrong with this orthosis?
_____________________________________________________________________
3. The following picture shows a PIP hyperextension block
orthosis. What is wrong with this orthosis?
 ____________________________________________________________________

Laboratory Exercise 12.2

Practice fabricating a dorsal-volar mallet orthosis on a partner with
the DIP joint in neutral. Check to be sure that the PIP crease is not
blocked and that full PIP active ROM (AROM) is available.
Appendix 12.3 Form and Grading Sheet
Form 12.1 Finger Orthotic
Grading Sheet 12.1 Finger Orthotic
∗ Boccolari, P., & Tocco, S. [2009]. Alternative splinting approach for
proximal interphalangeal joint flexion contractures: No-profile static
progressive splinting and cylinder splint combo. Journal of Hand
Therapy 22[3], 290-292.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
13
Mobilization Orthoses

Serial-Static, Dynamic, and Static-

Progressive Orthoses
Paul Bonzani

CHAPTER OBJECTIVES
1. Identify the goals of mobilization orthoses.
2. Define the types of mobilization orthoses.
3. Apply biomechanical principles to mobilization orthoses.
4. Describe common features of mobilization orthoses.
5. Review clinical considerations for mobilization orthoses.
6. Use clinical reasoning skills through a case study presentation
applying the principles of mobilization orthotic provision.

KEY TERMS
area of force application
biopsychosocial approach
creep
dynamic orthosis
end feel
finger loops
mechanical advantage
mobilization orthosis
outrigger
serial-static orthosis
stages of tissue healing
static-progressive orthosis
torque

Jay was hiking with his best friend Sam 6 weeks ago. They were having
a wonderful time and were descending from the summit when they
encountered a group of wet rocks. There seemed to be no way to avoid
them so Jay walked over them and promptly tumbled to the ground. In
doing so, he landed on his right hand, injuring the proximal
interphalangeal (PIP) joint of the small finger.

Upon getting to the bottom of the trail, he wrapped and iced his finger
and felt much better.

He awoke the next morning with a stiff and swollen PIP joint but was
not worried about it. He tried to treat his finger on his own for 6 weeks;
“after all, it is just a little finger.” When the finger did not improve, he
went to a local physician, who immediately referred Jay to an
occupational therapist (OT) to mobilize the PIP flexion contracture that
had developed.

Acknowledgments: A special thanks to Jean Wilwerding-Peck,

OTR/L, CHT, for her contributions in the previous edition and to the
staff at Columbus Hand Therapy for their careful review and
suggestions.
The primary goal of every hand orthosis is to enhance the
occupational performance of a client with an upper limb impairment.
As a top-down approach to intervention, a client-centered,
biopsychosocial approach to orthotic provision is recommended as
best practice for enhancing occupational performance. 28 This
approach considers the thoughts, emotions, behaviors, and social
situations of a client as equal concerns to the physical manifestations
resulting from a hand injury or disease. This shifts the focus of care
from a paternalistic, reductionist, biomedical model to an empowered
and holistic approach to recovery.
To further promote the quality of functional outcomes,
classifications have been developed with four categories:
immobilization, mobilization, restriction, and torque transmission. 1
This chapter focuses on mobilization, including the goals, types,
biomechanical principles, and fabrication and design principles
specific to the application of mobilization orthoses. Mobilization
orthoses are used for a myriad of reasons, including but not limited to
joint flexion contractures, intra-articular fractures, limitations in
composite finger flexion, tendon repairs, joint implant arthroplasties,
peripheral nerve injuries, complex trauma, surgical wounds, second-
and third-degree burns, spinal cord injuries, and neurological
conditions. Finally, a case study integrates the use of a mobilization
orthosis in a client-centered, occupation-based context.
Goals of Mobilization Orthoses
Mobilization orthoses are selected to move or mobilize a primary or
secondary joint. 1 In providing constant or adjustable tension,
mobilization orthoses can achieve one of four possible goals:
correction of deformities, substitution for loss of muscle function,
provision of controlled motion, and facilitation of wound healing. 15
Explanations for each goal are provided. As with any orthosis, it is
important that the therapist collaborate with the referring physician
on obtaining information about the client’s injury, including the
interval between the onset of injury, the date of any surgery, surgical
intervention, the quality of the repaired structures, and finally, the
recommended treatment protocol.

Correction of Deformities
Passive motion limitations in a joint result from multiple factors,
including trauma, prolonged immobilization, decreased motion due
to pain, and excessive swelling that creates dense scar formation and
pericapsular adhesions. 33 A second reason for loss of motion is loss of
length of a muscle-tendon unit. The loss of length, through myotatic
contracture, creates passive insufficiency that causes the proximal
joint position to change to accommodate the shortened muscle-tendon
unit. 13,32 When active and passive motions are the same, the goal of
intervention begins with decreasing the joint contracture. From there,
greater active motion can be gained by incorporating a mobilization
orthosis into the client’s program. 12 However, if active motion is less
than passive motion, or if changes in passive motion occur with
changes in digit or wrist position, the focus of intervention shifts from
decreasing joint stiffness by means of a mobilization orthosis to
improving extrinsic and intrinsic tendon length and excursion.
Optimal results from mobilization orthotic intervention are attained
after edema and pain are reduced. A mobilization orthosis applied too
early after an injury can result in increased inflammation with
resultant increases in scar formation and decreased motion.
Furthermore, the best way to remodel tissue is to provide a tolerable
force over time. Evidence shows a relationship between the length of
time a stiff joint is held at end range and the resulting gain achieved
with passive motion. 10,17,18 Therefore mobilization orthotic
intervention appears to be more effective when orthoses are worn
over longer periods of time compared with shorter periods of time
using increased levels of force. This approach to mobilization of
stiffness is called low load, prolonged stress, 10 and positive results are
related to total end-range time (TERT). 17
Application of external forces necessitates careful monitoring of the
skin in case excessive levels of pressure and/or poor distribution of
forces are present. A general goal for a mobilization orthosis is to
increase passive joint motion by 10 degrees per week. 4 Should passive
motion not improve following 2 weeks of orthotic intervention, a
reevaluation of the orthosis, home program, and intervention
adherence should be completed. 14 In this chapter, fabrication of a
serial cast, composite finger flexion orthosis, and a hand-based
proximal interphalangeal (PIP) extension orthosis are described as
examples of the use of mobilization orthoses to resolve joint stiffness.

Substitution for Loss of Muscle Function

The principle of substitution for loss of muscle function is applicable
to central nervous system (CNS), peripheral nervous system (PNS),
and musculoskeletal system (MS) disorders. CNS disorders often have
the added variable of increased muscle tone, making dynamic orthotic
intervention challenging. For clients with either CNS or PNS
impairment, a mobilization orthosis can improve hand function. 15,21
This is readily seen in the application of Saebo orthoses, which are
specifically designed to substitute for the loss of digital extensor
function typically associated with multiple neurological conditions
(Fig. 13.1).
 FIG. 13.1 SaeboGlove.
Courtesy of Saebo, Inc.

The need to substitute for weak or absent muscle action occurs

commonly in conditions such as cerebral vascular accident, traumatic
brain injuries, peripheral nerve injuries, spinal cord injuries, and other
debilitating neurological conditions. Therefore the goals of orthotic
intervention in these cases are to substitute for loss of motor activity,
to prevent overstretching of nonfunctional muscles, and to prevent
joint deformity.
One common PNS injury is a high-level radial nerve palsy. The
functional use of the hand is limited in part due to loss of muscle
function for wrist and finger metacarpophalangeal (MCP) joint
extension and radial abduction and extension of the thumb. An
orthosis that provides passive assistance for loss of extrinsic muscle
function greatly increases the functional use of the hand (see Chapter
14, Fig. 14.8). Similar applications for mobilization orthoses are
recommended for clients with low-level median and ulnar nerve
injuries where the absence or weakness of intrinsic muscles to the
thumb and fingers limits hand use significantly. 21 The low-level ulnar
nerve injury can present with a strong claw deformity, creating a hook
grasping pattern (Fig. 13.2). This substitution of a hook grasp for
cylindrical grasp markedly reduces the ability of the client to
participate in valued occupations. Dynamic orthoses are one option to
rebalance the hand and restore cylindrical grasp. 41 The fabrication of
a dynamic anticlaw orthosis is described as one approach to substitute
for the loss of muscle function, resulting in improved occupational
performance.
Another example of substitution for loss of motor function involves
clients with spinal cord injuries. A client with a C6 and/or C7 lesion
may also benefit from mobilization orthotic provision. Because of the
anatomical or biomechanical effect that wrist extension has on finger
flexion, a client’s active wrist extension becomes the force to generate
pinch using a tenodesis orthosis (Fig. 13.3). A training tenodesis
orthosis can be fabricated using thermoplastic. The therapist fabricates
a static thumb post and finger flexion dorsal gutter and connects them
with an inelastic line. Wrist extension becomes the mobilizing force;
however, the client will require significant practice to learn to control
the tensile forces effectively. Tenodesis orthoses are often used to
assist with eating, dressing, and other self-care tasks requiring
prehension.
FIG. 13.2 Low ulnar nerve with claw deformity.
 FIG. 13.3 A tenodesis orthosis uses active wrist extension to aid
passive finger flexion.

Clients with neurological disorders resulting from degenerative

conditions (such as Guillain-Barré, amyotrophic lateral sclerosis, and
multiple sclerosis) experience muscle weakness, paralysis, and
changes in sensation. Specialized mobilization orthoses may be useful
in sustaining hand function, although the presence of spasticity and
concerns for sensory loss might preclude candidates from this
approach (see Chapter 15).
The use of mobilization orthoses may also be appropriate for clients
with conditions such as surgically repaired tendon lacerations of the
hand. There are three goals for clients following a tendon repair in the
hand. The first goal is to increase the flow of nutrient-rich synovial
fluid to enhance healing of the repaired tendon. This is typically
accomplished through an exercise regimen. The second goal is to
increase the tensile strength of repaired tendons. Tendons that are
allowed early protected mobilization have increased tensile strength
compared with immobile tendons. Third, tendon excursion reduces
edema, and therefore adhesion formation is minimized between
tendons and surrounding structures. 32,37 Mobilization orthoses for
tendon repairs can assist in attaining these goals by positioning the
wrist and fingers appropriately to remove tension from the repaired
tendon and in a protected position (i.e., tendon is on slack). A passive
assist from the orthosis substitutes for the loss of muscle function
during the required healing period. 32
In this chapter, fabrication of a dynamic anticlaw orthosis is
described as one approach to substitute for the loss of muscle function
resulting in improved occupational performance.

Provision of Controlled Motion

Occasionally mobilization orthoses are used to control motion after
reconstructive surgeries, such as joint implant arthroplasties 42 and
complex intra-articular fractures. 33 Mobilization orthoses assist with
controlling motion and precise alignment of the repaired tissues while
minimizing soft-tissue deformity. For example, a mobilization orthosis
with an outrigger provides traction forces to a finger, allowing
fracture alignment and maintenance of joint spaces. A second function
of a mobilization orthosis is to allow guarded movements of the
fingers during rehabilitative exercises. 31 In this chapter, fabrication of
a dynamic traction orthosis is used as an example to describe an
approach to controlled motion.

Facilitation of Wound Healing

The use of mobilization orthoses facilitates parallel collagen alignment
and scar formation that occurs in later stages of wound healing. 7 It is
during the proliferative stage, as leukocyte activity decreases and
fibroblasts begin the process of collagen deposition, that mobilization
orthoses are used to apply controlled stress for scar modeling in a
lengthened position. This is accomplished through serial static, static-
progressive, or dynamic orthotic application. 7 During the remodeling
stage, when the cells are realigned and the joint response to stress is a
firm end feel, collagen continues to remodel and reorganize based on
the amount of stress applied to the wound. During this stage, tensile
strength increases exponentially, and there is a complex system of
collagen deposition and collagen lysis, resulting in a firm scar.
Mobilization orthoses are particularly important in the proliferative
and remodeling stages of healing, especially following complex
trauma, surgical wounds, or second- or third-degree burns. 39
In this chapter, fabrication of a composite flexion orthosis is used as
an example of one approach to aid in scar remodeling.
Types of Mobilization Orthoses
Mobilization orthoses are divided into three types: serial-static,
dynamic, and static-progressive. 40 Each type provides unique
advantages for clients with limited passive motion and can be
recommended for specific diagnostic groups of clients. A review of
each orthosis type follows.

Serial-Static Orthotic Prescription

The purpose of a static orthosis is to immobilize a joint. However,
interpretations that the same orthosis is always static in its function
are misleading. 19 Tissue lengthening occurs when tissue is held under
constant tension that is greater than its resting tension (see Chapter 1).
3 Therefore serial-static orthoses are a type of mobilization orthosis

that positions a joint near its elastic limits to overcome a loss in

passive motion. 40 A serial-static orthosis is well tolerated over long
periods of time as the low-load, end-range positioning is applied over
a large surface area. This is called the area of force application. Fig.
13.4 provides a schematic of the appropriate types of orthoses to use
based on the three stages of healing. 13 Although a serial-static orthosis
is the only orthotic type recommended across the continuum of
healing, it is particularly useful for contractures with a hard end feel 39
or when joint tightness is due to muscle-tendon unit shortening. In
this chapter, fabrication of a serial-static orthosis is discussed.
 FIG. 13.4 The stage of healing helps to determine the most
appropriate type of orthosis.

Dynamic Orthotic Prescription

An orthosis is dynamic when it uses a stable static base and an elastic
mobilizing component. 1,19 A variety of self-adjusting dynamic
components can be used as the mobilizing force, including rubber
bands, springs, coils, Lycra, elastic thread, or cord. The purpose of a
dynamic orthosis is to apply sufficient tension that does not
overpower the joint and allows the client to overcome the resistance
with active motion in the opposite direction of the line of pull. In this
way, active motion with a dynamic orthosis assists in lubrication of
joints, flexibility of ligaments, activating muscle fibers, and
maximizing tendon gliding.
A dynamic orthosis is recommended primarily during the
proliferative stage of healing when collagen is forming. 7 Dynamic
orthoses take advantage of tissue elasticity, where tissue is stretched
at a constant load, even when it reaches its elastic limit and the
passive joint end range has a “soft end feel.” More progress can be
expected when using a dynamic orthosis for joints with less
pretreatment stiffness, shorter time since surgery (<12 weeks), and in
flexion rather than extension deficits. 19 For these reasons a dynamic
orthotic design may be selected over a static orthosis when active
motion is preferred or when the client is developing contractures early
in the treatment program. Larger joints such as the elbow and wrist
have useful commercial options available to the clinician. These may
be reasonable options for conditions such as postfracture elbow
flexion contracture, 24,43,44 distal radius fractures 6 with wrist
contracture, and post stroke. 23 In this chapter, fabrication of a
dynamic orthosis is used as an example for the management of PIP
flexion contractures, and this is contrasted with serial-static orthoses.
A final consideration for prescribing a dynamic orthosis is its use
with repaired tendons. Although this is not using the orthosis for
stiffness management, it is using dynamic traction to reduce strain on
repaired tendons and thereby substituting a dynamic action for active
function of the repaired tendon (Fig. 13.5).
 FIG. 13.5 Dynamic orthosis for use with repaired tendons that
substitutes for active function of the repaired tendon.

Static-Progressive Orthotic Prescription

A static-progressive orthosis includes a static orthotic base that uses
inelastic components to apply torque to a joint. The goal is to position
the joint as close as possible to the available end range 35 and sustain it
in that position for a specific period. Inelastic components may
include Velcro tabs, progressive hinges, screws, tuners/turnbuckles,
nylon cord, and strapping materials 24,40,43 (Fig. 13.6). Serial
adjustments are performed by the therapist or client as the tissue
lengthens. The stretch should be perceived by the client as
comfortable. 35 A static-progressive orthosis is recommended during
the proliferative, remodeling, and chronic stages of tissue healing,
when collagen is forming, remodeling, and reorganizing. Static-
progressive orthoses are considered when there is a decrease in tissue
elasticity, where tissue is stretched at a constant length, whereby the
force continues until the tissue accommodates and does not stress the
tissue beyond its elastic limit. Generally the passive joint end range
has a “hard end feel.” 19,26 Indications include but are not limited to
posttraumatic elbow stiffness, 11,34,46 forearm rotational stiffness, 27
wrist stiffness following distal radius and intercarpal injuries, 25,38,44
and in the management of digital stiffness. 5 In this chapter, fabrication
of a static-progressive orthosis is used as an example for increasing
composite finger flexion.
Biomechanical Principles
The successful fabrication and use of an orthosis demands that the
clinician has a basic mastery of the biomechanical principles that
govern orthotic intervention. 14 To safely benefit the client the
therapist must consider the force applied (magnitude) and the
direction of the force. An important point for the novice to remember
is that the purpose of a mobilization orthosis is to direct force to a
target tissue. 4 Therefore the goals for mobilization orthotic
intervention (e.g., correcting deformities, substituting for loss of
muscle function, providing controlled motion, and aiding in wound
healing) are accomplished through proper application of force.
Knowledge of complicated mechanical calculations is not required to
have a basic understanding of how to fabricate a mobilization
orthosis. However, several concepts for mobilization orthotic
fabrication are presented that build on the biomechanical principles
discussed in Chapter 3. They include anatomical considerations,
mechanical advantage and torque, and application of force.
 FIG. 13.6 Elbow turnbuckle orthosis.

Anatomical and Biomechanical

Considerations
Application of an external force to healing tissues poses several
clinical questions regarding the timing, the magnitude, and the
direction of the force. These questions include, what is the stage of
healing, 7 what should be the magnitude of the force, in what
direction should the force be applied, and what is the targeted tissue?
8 When applying force to a contracted joint, ongoing assessment of

inflammation and pain is essential before and after an orthosis is

applied. Connective tissue responds to excessive force by increasing
pain and prolonging or restarting the inflammatory process. 16 Mild
inflammation is acceptable, but edema should not increase
significantly. Connective tissue responds to prolonged stress by
changing or reforming in a lengthened or shortened position. This
property of connective tissue is called creep and results from the
application of prolonged force. 8 Through the application of controlled
stress, the therapist introduces gentle tension to the connective tissue,
thereby facilitating creep without causing tissue injury. Further, by
skillfully applying tension within the tissue’s elastic limits during the
proliferative phase of wound healing, the therapist can improve tissue
tensile strength. These results are also seen during the collagen
maturation phase but to a lesser extent. 13

Mechanical Advantage and Torque

Mastery of a few biomechanical principles is necessary for proper
application of a dynamic orthosis. One such principle is mechanical
advantage. This principle is defined as the capacity to balance and
overcome resistance using force and resistance lever arms. 30 The two
lever arms represent the forces applied by the orthotic base and the
dynamic portion of the orthosis. As shown in Fig. 13.7, applied force (F a
) refers to the lever that applies force, and force resistance (F r ) refers to
the lever that applies resistance. The magnitude of the middle
opposing force, force magnitude (F m ), is determined by summing the
opposing forces: Fa + Fr. 16 To calculate mechanical advantage, a ratio
of the lever arm length (l a ) for the applied force (F a ) is divided by the
lever arm length (l r ) for the applied resistance (F r ). Therefore,
increasing the amount of applied force or decreasing the amount of
applied resistance improves mechanical advantage.
By adjusting the length of the orthosis base or the length of an
outrigger, the mechanical advantage can be altered (Fig. 13.8). 36 The
goal of the orthosis is to maintain a mechanical advantage between 2:1
and 5:1, meaning that the lever arm of the applied force is between
two and five times longer than the lever arm of the applied resistance.
4 An orthosis with a greater mechanical advantage will be more

comfortable and durable. 14 A mobilization orthosis for MCP flexion

that is forearm based disperses pressure more effectively, thereby
providing greater mechanical advantage than a mobilization orthosis
that is only hand based. The mechanical advantage is due to the
longer lever arm of the applied force.
 FIG. 13.7 Mechanical advantage is demonstrated in two dynamic
orthoses. Orthosis A has a better mechanical advantage than orthosis
B.

Torque is defined as the effect of force on the rotational movement of

a joint. 15 The amount of torque is calculated by multiplying the
applied force by the length of movement around a pivot point or joint
axis. A proportional relationship exists between the distance from a
joint axis and the amount of force required to move the joint. To
achieve the same rotational result a force applied close to the axis
creates a short moment arm. A short moment arm requires a higher
force than a longer moment arm to achieve the same motion.
Therefore, orthoses with longer moment arms require less force to
attain the desired motion.
Clinically the force should be placed as far as possible from the
mobilized joint without affecting other joints. 9 For example, a
forearm-based dynamic wrist extension orthosis should be
constructed so that its mobilizing force is on the most distal aspect of
the palm, while not affecting MCP movement. An exception to placing
the force as far from the mobilized joint as possible occurs with
rheumatoid arthritis. If the joint is unstable, a force applied too far
from the joint will result in a tilt rather than a gliding motion of the
joint. This results in increasing subluxation deformities rather than
increasing motion (Fig. 13.9).20 Therefore, when fabricating an orthosis
for the hand of a person with rheumatoid arthritis, the force should be
applied as close to the mobilizing joint as possible.

Application of Force
Force application is a critical consideration for safe and effective
application of a dynamic orthosis. When the goal of the intervention is
to increase passive joint motion, the linear direction of pull must be at
a 90-degree angle to the axis of the joint and perpendicular to the axis
of rotation. 22 As the motion increases, adjustments are needed to the
outrigger to maintain the 90-degree angle (Fig. 13.10). 15 Furthermore,
extension outrigger lines should maintain neutral finger position in
radial and ulnar deviation to preserve collateral ligament integrity. A
variant of this alignment is when dynamic mobilization is used
following MCP implant arthroplasty or extensor tendon
centralization. 42 In these cases the 90-degree angle is maintained;
however, the lines are set in slight radial deviation to counteract the
natural pull into ulnar deviation (Fig. 13.11). Mobilization into finger
flexion is based on the number of fingers being mobilized. When one
finger is mobilized, the tip of the digits should touch the palm in line
with the scaphoid tuberosity 15 (Fig. 13.12). When multiple fingers are
mobilized simultaneously, the convergence point shifts to the radial
middle third of the forearm (Fig. 13.13). 15

FIG. 13.8 The 2-inch moment arm produces 24-inch ounces of

torque. The 3-inch moment arm produces 36-inch ounces of torque.

Other important considerations include the magnitude of force and

the duration of the orthotic application. When excessive force is
applied to the skin for a prolonged period, motion can be lost and
tissue damage can occur. The amount of pressure that the skin can
tolerate dictates the maximum tolerable force. A commonly accepted
amount of appropriate pressure or force per unit area is 50 g/cm. 2,4,8
This force approximates the same force as the weight of a banana
resting on one’s palm. As the area of application where force is
applied becomes larger, the force is dispersed, and the pressure per
unit area becomes less. A smaller sling with less skin contact area
concentrates the pressure and is less tolerable. 4 Skin grafts, immature
scar tissue, and fragile skin of older clients have less tolerance for sling
pressure. The client’s tolerance ultimately determines the amount of
force. The client should report the sensation of a gentle stretch, not
pain. 22 To avoid harm a new orthosis should be monitored for the
first 20 to 30 minutes of wear and at every treatment session
thereafter. Education is critical for a client to monitor his or her
orthosis for signs of pressure areas and skin breakdown, as well as
how to don and doff the orthosis properly.
 FIG. 13.9 A force applied too far from an unstable joint result in “tilt”
(A) rather than glide (B).

The issue of duration or wearing time remains controversial, and

research has not determined the precise amount of wear needed to
effect changes in motion. However, Glasgow 19 indicates that the most
effective duration is 6 to 8 hours per day. McClure’s algorithm 26 for
dynamic orthotic interventions indicated that a dynamic orthosis may
need to be used for up to 2 months before change is noted in passive
motion. However, Prosser 34 reported that resolving difficult
contractures can take up 4 months of dynamic mobilization.

a
Self-Quiz 13.1
For the following question, circle either true (T) or false (F).

1. T F When applying a force to the body, the most important

consideration is the magnitude or amount of force.
2. T F Creep occurs when soft tissue adapts through application of
a prolonged force.
3. T F Dynamic mobilization orthoses are used only to resolve joint
stiffness.
4. T F The focus of mobilization orthotic provision should be on
increasing tension rather than increasing the amount of time
that the orthosis is worn.
5. T F A general goal for mobilization orthotic provision is to
increase passive motion by 10 degrees per week.
6. T F Joint end feel is an important consideration when
determining whether to use static or dynamic tension.

a
See Appendix A for the answer key.
Common Features of Mobilization
Orthoses
Mobilization orthoses often use outriggers to direct force
appropriately to the target tissue. The outrigger is a projection from
the orthotic base and can be custom fabricated or a commercially
available kit can be used. The amount and direction of the force
needed determines the type of outrigger selected. The outrigger must
be securely attached to the base of the orthosis to ensure that the
direction of the force is correct. 11

FIG.13.10 The line of tension must be maintained at 90 degrees from

the long axis of the bone.

An outrigger is classified as either high or low profile (Fig. 13.14).

Each type has advantages and disadvantages. It appears that both
high- and low-profile outriggers respond in a similar manner to
changes in range of movement. 15 Therefore clients are seen in the
clinic frequently enough so that increases in motion can be
accommodated by outrigger adjustments, which subsequently
maintain the 90-degree angle of pull. 2,8,16 It should be noted that high-
profile outriggers are bulky and may decrease the client’s compliance
with wearing the orthosis (Fig.13.15). A low-profile outrigger is more
aesthetically pleasing and less cumbersome. Low-profile outriggers
are more readily worn with clothing, potentially improving
compliance. However, because low-profile outriggers are closer to the
base surface, their force distribution is decreased and can increase
discomfort during wearing times (Fig 13.16).
Outriggers are made from a variety of materials. Scraps of the
thermoplastic material can be rolled to form a strong tubular outrigger
that can be easily adjusted and adheres well to the orthotic base. Some
thermoplastic outriggers are made from commercially available tubes
that are easily formed and provide a more uniform look.

FIG. 13.11 Metacarpophalangeal (MCP) arthroplasty orthosis.

 FIG. 13.12 Line of pull for one digit.

Copper wire is a commonly used material for outrigger

construction (Fig. 13.17). Two thicknesses are available, a 1⁄8-inch wire
rod used for its durability and ability to transmit high forces and a
3⁄32-inch rod, which is more flexible and versatile and can be used in
low-profile, low-force circumstances. These rods are easy to form with
pliers or a bending jig, although, it takes practice to bend the wire into
the desired shape. There are several different commercially available
outrigger kits that add cost to the fabrication of the orthosis. Orthotic
costs are based on the cost of the materials and the fabrication time.
Although prefabricated outriggers are initially expensive, they require
less fabrication and adjustment time. Further, they are generally lower
in profile and have high acceptance rates by clients. Therefore, the
therapist should make a cost-benefit assessment before their use.
The therapist uses various methods for applying dynamic force to a
joint. Finger loops made from strong pliable material are usually best
because of the increased conformability to the shape of the finger. 19
The therapist can supply force by using rubber bands, springs, or
elastic thread. Although rubber bands are more readily available and
easy to adjust, springs offer more consistent tension throughout the
range. A long rubber band stretched over the maximum length of the
orthosis provides more constant tension than a short rubber band. 6
Rubber bands also lose tension over time due to repeated lengthening
and shortening. 14 Elastic thread is the easiest to apply and adjust,
thereby saving time in the fabrication process. Its unique properties
prevent wear even after 6 weeks of maximum stretch, making it useful
for persistent finger contractures. A nonstretchable string or
monofilament line is necessary to connect the finger loop to the source
of the force (Fig. 13.18). The choice is usually based on clinical
experience and preferences, as all accomplish the same goals.
Another method of applying force is through static-progressive
orthoses. Rather than providing the variable tension of a serial-static
or dynamic orthosis, a static-progressive orthosis uses nonelastic
tension to provide a constant force. An advantage of properly applied
static tension is that tissue is not stretched beyond its elastic limit. 36 In
place of the rubber band or spring the therapist may use a Velcro tab,
a turnbuckle, or commercially available static-progressive components
to apply the force. Tension is increased by gradually moving the
Velcro tab more proximally on the orthotic base or adjusting the
turnbuckle (Figs. 13.19, 13.20, 13.21). The force is static rather than
dynamic but is readily adjustable by the client throughout the wearing
time. Because the client has control over the amount of applied
tension, the static-progressive orthosis is more tolerable to wear than a
dynamic tension orthosis. 36
 FIG. 13.13 Line of pull for multiple digits simultaneously.

FIG. 13.14 A low-profile outrigger (left) versus a high-profile outrigger

(right).
FIG. 13.15 A high-profile outrigger dynamic traction on replanted
thumb.
 FIG. 13.16 A low-profile proximal interphalangeal (PIP) extension
outrigger for Charcot-Marie Tooth polyneuropathy.

FIG. 13.17 Copper wire outrigger for extensor pollicis longus (EPL)
repair.

Clinical decision making about the type of mobilization force used

is typically based on the joint end feel. End feel is assessed by
passively moving a joint to its maximal end range and is indicative of
the potential for regaining motion. A joint with a soft or capsular end
feel has greater potential for regaining movement than a joint with a
firm end feel. An orthosis with static-progressive or dynamic tension
is appropriate for a joint with a capsular end feel; however, a joint
with a hard end feel may respond only to static-progressive
mobilization. 36
Another determinant in selecting the type of tension to be used with
mobilization orthotic intervention is the stage of tissue healing. Thus
different types of orthoses are indicated at different stages of healing
(see Fig. 13.4) and can assist with safe mobilization of hand structures.
The common features of mobilization orthoses and their ability to
apply forces through serial-static, dynamic, and/or static-progressive
methods have been described. The following sections provide
technical tips, materials and equipment, and precautions that assist in
the fabrication of these orthoses.

FIG. 13.18 The therapist uses inelastic nylon string to attach finger
loops to the source of tension.
FIG. 13.19 A, Metacarpophalangeal (MCP) flexion static-progressive
turnbuckle. B, A turnbuckle can be easily adjusted to provide static
tension.
Technical Tips for Dynamic Orthotic
Fabrication
• To apply a thermoplastic outrigger to the orthotic base, which
is commonly applied to a wrist or hand immobilization
orthosis, both surfaces need to be clean and smooth.
• Most thermoplastic materials are treated or coated to minimize
self-adherence when accidentally touched to itself. The
coating can be scratched off; however, a bonding agent should
be used to increase the self-adherence.
• After determining where the outrigger should be placed, heat
both surfaces (with a heat gun, or immerse in hot water. If hot
water is used, dry the surfaces thoroughly before pressing
them together firmly and smoothing out the edges.
• Using cold spray speeds the hardening process. Alternatively,
the orthosis and outrigger can be held under cold water at the
sink to hasten hardening. Be aware that rapid cooling with
cold spray or cold water can increase material shrinkage,
changing the fit of the underlying base.
• To apply a wire outrigger, use a small patch of thermoplastic
material. Wire conducts heat more easily than the
thermoplastic material and will burn skin if touched
accidentally.
• Heat the orthotic base and the thermoplastic patch, and lightly
heat the end of the wire. The wire heating allows the wire
outrigger to lightly “melt” into the orthotic base while the
thermoplastic patch is placed over the ends of the outrigger
wire and smoothed into place.
 FIG. 13.20 The person may adjust Velcro tabs used for static-
progressive tension.

• Be careful that the wire does not deform the base or push
through the thermoplastic patch.
• If the orthotic base is curved, the wire needs to be contoured to
that shape before it is attached.
• The warm thermoplastic material will adhere to postoperative
bandages, dressings, or stockinette. Use a stockinette covering
over such dressing to avoid adherence.
• If the client’s skin is sensitive to the heat from the
thermoplastic material, use a damp paper towel or apply the
stockinette to the body part before applying the thermoplastic
material. When the orthosis has cooled and is removed, the
adhering stockinette can be cut off the arm and pulled from
the orthosis.
• Check the line of pull so that a 90-degree angle is present on
the finger loops when axial and lateral views are observed.
• Check all joints from various angles to ensure that joints are
not pulled into hyperextension, ulnar or radial deviation, or
torque/rotational forces to ensure proper direction of force
application.
Materials and Equipment Needed to
Fabricate A Dynamic Orthosis
In addition to the equipment necessary to fabricate a static orthosis, a
variety of items are used to fabricate a dynamic orthosis. The
following is a list of materials and equipment most commonly used,
although not all items are used for every orthosis.

• Thermoplastic materials of choice

• Finger loops/slings
• Nail hooks, an emery board, superglue, and superglue
remover, such as acetone or fingernail polish remover
• Solvent
• Inelastic nylon string (e.g., outrigger line—
monofilament/fishing line)
• An outrigger kit
• Wire rod (1⁄8 inch for high-force outriggers and 3⁄32 inch for
lighter duty outriggers)
 FIG. 13.21 Elbow turnbuckle to regain extension.

• Rubber bands, springs, elastic string, Velcro tabs, turnbuckles,

or commercially available static-progressive components,
rubber band posts
• Safety pins, paper clips, other material to make a hook or
pulley, eyelets
• Pliers, wire bender, wire cutters, scissors to assist with wire
bending

Fabrication of mobilization orthoses can be challenging, fun, and

very rewarding, particularly when clients’ function improves due to
the therapists’ skilled and creative intervention.
Precautions for A Mobilization
(Dynamic) Orthosis
Specific precautions are needed when applying mobilization orthoses.
The first rule of mobilization orthoses is to do no harm. Several
guidelines are provided for following this rule. 31

• The client must be responsible enough to care for the orthosis

and to follow a guided wearing schedule. A mobilization
orthosis is contraindicated for clients with compromised
mentation.
• Apply minimal force. The force used should provide a low-
grade stretch that is tolerable over a long period of time. 13
Clinical signs of excessive force include reddened pressure
areas, cyanosis of the fingertips, and complaints of pain or
numbness. A client will likely not wear an orthosis that causes
discomfort.
• Consider the risks posed by an ill-fitted orthosis. These include
pressure areas, skin breakdown, and prolonged
immobilization of noninvolved structures.
• Remember aesthetics. A client is more likely to wear an
orthosis that has a finished, professional appearance. An
orthosis with a low-profile outrigger is less cumbersome and
may be more aesthetically pleasing than a high-profile
outrigger.
• Monitor and adjust the orthosis frequently for accurate fit.
• Listen to the client. Complaints by the client require
reevaluation of the orthotic fit.
• Caution must be used when applying a mobilization orthosis
to an insensate hand. The lack of sensory feedback increases
the risk of skin breakdown.
• Dynamic mobilization is generally not indicated for the
conservative management of clients with collagen vascular
diseases such as rheumatoid arthritis and systemic lupus
erythematosus. They may be used in postoperative
management following implant arthroplasty or soft tissue
reconstruction.
Clinical Considerations for Mobilization
Orthoses
Four selected orthoses represent the four types of mobilization
orthoses. The fabrication procedure is described for each orthosis.

Serial-Static Casting (Orthosis) for Proximal

Interphalangeal Flexion Contractures
Serial casting is an excellent way to correct PIP flexion contractures
through low-load, prolonged stress. Serial casts are effective when the
contracture is greater than 45 to 50 degrees or less than 20 degrees
(Fig. 13.22A and B). Although a cast is worn full time, it does not
interfere with function of the hand as the MCP and distal
interphalangeal (DIP) joints remain free. The following steps are
instructions for creating a serial-static orthosis

1. Cut plaster casting tape into 1 × 8 inch lengths. A product

called Specialist Extra-Fast Plaster, Green Label sets in 2 to 4
minutes.
2. Roll plaster strips into rolls.
3. Fill the small bowl with hot water. The hotter the water, the
faster the plaster sets.
4. Dip one plaster roll into the hot water, squeeze the excess
water from the roll, and begin wrapping the finger with no
tension from the DIP crease to the MCP crease while the client
extends the finger straight and the therapist applies gentle
traction to the fingertip. Be careful not to pull plaster tight
during rolling.
5. Smooth the plaster with wet fingers while rolling to laminate
layers of plaster together (see Fig. 13.22B).
 FIG. 13.22 A and B, Demonstration of a serial cast being
applied to a finger with a proximal interphalangeal (PIP) flexion
contracture.

6. Be sure to smooth the edges at the MCP and DIP joints so that
the client can flex these joints.
 7. Do not push down on the PIP joint to straighten finger; instead,
smooth, roll, and pull along the finger to straighten the finger
while the plaster is setting.
8. The plaster cast should be changed every 3 to 5 days or a
maximum of 7 days if necessary. 17
9. To remove the cast, soak the hand in warm water for
approximately 5 to 10 minutes, and cut it off with small cast
scissors, which are commercially available.
10. Casts are durable and usually hold up during hand washing
and showers, but clients may want to wrap the finger in
plastic wrap (or Press’n Seal) to maintain the integrity of the
cast.
11. Fig. 13.23A and B show completed casts in various stages of
extension.

Dynamic Proximal Interphalangeal Extension

Orthosis: Fabrication Instructions
A hand-based PIP extension orthosis corrects deformities caused by
muscle-tendon tightness or joint contractures. A dynamic orthosis
with an outrigger is easily adjusted as the client’s motion increases.
There are several commercially available outriggers that include the
components necessary to attach, assemble, and adjust as needed, for
one or multiple fingers Fig. 13.24. As previously noted, these kits do
add cost but reduce fabrication and adjustment time. Outriggers can
be fabricated with the common materials available in the clinic, such
as thermoplastic material, outrigger wire, rubber bands, and paper
clips.
FIG. 13.23 A and B, Examples of finished plaster casts for different
proximal interphalangeal (PIP) flexion contractures.
 To fabricate a dynamic PIP extension orthosis, begin by using the
pattern for a dorsal-based hand-based orthosis as the base Fig. 13.25A
and B. Immobilize the MCP joint of the involved finger(s) in 45 to 50
degrees of flexion. Conform around the thumb web space and ulnar
side of the hand to provide a stable base with appropriate force
distribution. Clear the distal wrist crease adequately to ensure
comfortable wrist motion. Finally, roll all edges to permit motion of
the uninvolved digits.

1. The distal edge should extend the length of the proximal

phalanx but not impede PIP motion. The edges should be
flared. Soft adhesive-backed padding extending over the edges
may be added for comfort along the dorsum of the proximal
phalanx.
2. If an outrigger kit or wire outrigger is not used, the outrigger
can be made from a rolled rectangular piece of thermoplastic
materials or tubes that are approximately twice the length of
the MCP and finger.

FIG. 13.24 Low-profile hand-based extension orthosis.

3. With the thermoplastic outrigger warm and pliable, find the
center. Shape into a half square that is the width of the finger
and cool. The outrigger’s end should center on the middle
phalanx. Using a hole punch, “cut” a half hole or notch to act
as a pulley when the finger loop is attached. Immediately
proximal to the metacarpal, the outrigger should bend to
attach to the base of the orthosis. This angle should be
approximately 45 to 50 degrees (Fig. 13.26A). Mark the base
where the outrigger will attach with a grease marker or pencil;
the marking should follow the metacarpal of the involved
finger(s).
4. Remove the orthosis from the hand to attach the outrigger. To
create a low-profile outrigger, the outrigger should rise
approximately 1 inch above the distal end of the orthosis at the
proximal phalanx. Spot heat the ends of the outrigger and the
base of the orthosis with a heat gun and attach the outrigger. A
bonding solvent is needed for a strong, permanent bond.
5. When cool, reapply the orthosis, and add strapping to secure
the orthosis and prevent distal migration. This can be
accomplished by placing a strap around the base of the thumb
and through the palm.
6. A finger loop is made from soft leather or strapping material.
Commercial finger loops are typically used, although loops
can be fabricated from moleskin or Molefoam. The loop should
be 3 to 4 inches long and as wide as the middle phalanx. Trim
the width of the finger loops if they cover the DIP and PIP
flexion creases. If holes are punched on both ends of the loop,
they should be reinforced with grommets to prevent the line
from pulling through the material. The holes are threaded with
monofilament line, and this is attached to a force generator,
which can be elastic or static progressive (see Fig. 13.26B).
7. If using the Velcro tab, the Velcro hook is attached to the base
of the orthosis. If using the dynamic traction, use a needle-
nosed pliers to fold a paper clip (see Fig. 13.26C). The paper
clip is secured with a small piece of thermoplastic material.
 FIG. 13.25 A, Orthotic pattern for a hand-based proximal
interphalangeal (PIP) extension orthosis. B, Orthosis formed on
the hand.
 FIG. 13.26 A, The outrigger attaches to the base and extends
out over the finger. B, The finished orthosis, with the finger loop
extending the finger while maintaining a 90-degree angle of pull.
C, Folding the center of the paper clip while curving the ends with
needle-nose pliers makes a good anchor for dynamic
attachments. The loop can be threaded through the hook and
then adjusted by wrapping around the hook.
From Sousa, G.G.Q. & Macêdo MP [2015]. Effects of a dynamic
orthosis in an individual with claw deformity, Journal of Hand
Therapy, 28[4], 425-428.

8. While the client wears the orthosis, a rubber band is threaded

through the paper clip hook. The therapist pulls the finger
loop over the top of the distal end of the outrigger into the
notch and loop(s) around the finger. Make sure to have a 90-
degree angle of pull from anterior and lateral perspectives.
9. The therapist experiments to determine the appropriate length
of elastic thread or rubber band. After wearing the orthosis for
20 to 30 minutes, patients should not complain of their finger
getting cold, going numb, or turning “blue.” Patients should
describe feeling gentle tension at the end range.
10. This orthosis is worn 2 hours three to four times per day. Total
wearing time may take up to 4 months. 26

Comparison of the serial-static and dynamic mobilization

approaches to PIP flexion contracture management suggest that serial-
static casts have significant advantages (see Chapter 19). Serial-static
casting is more cost-effective than dynamic orthotic interventions.
Further, it is simple to apply, has no moving parts, and is readily
removed with hot water soaks. Finally, it is effective in all stages of
contracture formation. Problems with casting include an inability to
measure the corrective force accurately and patient acceptance of a
device that cannot be removed. A dynamic orthosis permits precise
measurement of the magnitude and direction of force application;
however, these orthoses are expensive, have multiple moving parts,
and require the client’s compliance with a complicated wearing
schedule. Further, they have limited value when joint contractures are
firm or chronic in nature.
Fabrication for Dynamic Anti–Claw-Hand
Orthosis: Substitution for Weak or Absent
Muscles
One of the major problems that occurs when a client sustains a low-
level peripheral nerve injury is muscle imbalance. Muscle imbalances
create characteristic deformities in the hand due to the loss of intrinsic
muscle function while extrinsic function remains intact. This creates
abnormal force generation by the intact extrinsic muscles. The result is
that movement occurs in line with the intact muscle. If the agonist of
that movement is absent, synergistic muscles will act as prime movers.
Further, if there is loss of an antagonist, the power of the agonist is
unbalanced. The classic presentation of this issue is the muscle
imbalance in the low, or wrist level, ulnar nerve injury. (Refer to
Chapter 14 for further discussion of these nerve injuries and other
orthotic options.)
The claw deformity in the low ulnar nerve injury is a result of the
imbalance that occurs when the volar and dorsal interosseous and the
third and fourth lumbrical are paralyzed. These muscles flex the MCP
joints and extend the PIP and DIP joints. When they are lost and the
flexor digitorum profundus and the extensor digitorum remain intact,
the small and ring fingers are imbalanced. The functional deficit is
that MCP joint flexion occurs only after the PIP and DIP are
completely flexed. This causes the fingertips to be rolled into the palm
from a hook position. The functional result is that items are pushed
out of the palm and the client loses the ability to use cylindrical or
spherical grasping patterns. 45 A static lumbrical blocking orthosis can
be used to address this issue (Fig. 13.27). However, some of these
orthoses are uncomfortable, are difficult to don, and limit the grasping
surface by restricting MCP extension, and they create areas of high
force concentration on the dorsum of the proximal phalanx. 46 An
alternative is the dynamic lumbrical block orthosis as described by
Sousa and Pereira de Macêdo. 41 This orthosis has been shown to
rebalance the third and fourth digits without causing difficulty in
donning the orthosis and skin issues. Orthosis construction
instructions follow.

FIG. 13.27 Static lumbrical block orthosis.

1. Fabricate a semilunar volar base from any thermoplastic

material. The orthotic base is the forearm, and it extends to the
level of the proximal wrist crease. The orthotic base is secured
with a Velcro strap.
2. Attach a hook to secure the rubber bands just proximal to the
scaphoid tubercle. Options here include a band post, a paper
clip, or a secured thermoplastic hook.
3. Finger slings/cuffs are attached to rubber bands. The small and
ring fingers are always secured with the middle finger being
optional.
4. A sling is also extended to the MCP joint of the thumb to act as
an adduction assist during pinch 41 (Fig. 13.28A–D).
 FIG. 13.28 Anticlaw orthosis. A, B, C, Different views of the orthosis.
D, Using the orthosis functionally.
From Sousa, G.G.Q. & Macêdo MP [2015]. Effects of a dynamic
orthosis in an individual with claw deformity, Journal of Hand Therapy,
28[4], 425-428.

This simple but biomechanically sound design is inexpensive, well

tolerated by the client, and can create improved pinch and grasp in
the selected client.

Traction Orthosis for Complex Proximal

Interphalangeal Fracture: Application of
Controlled Motion
The traction orthosis has a long history as a primary intervention for
the management of complex intra-articular fracture of the PIP joint.
47,48 Many designs have been advocated, and many of these have had

a high profile with poor patient compliance and patient acceptance. 32

Further, clients did not appreciate the need for a complex orthotic
regimen for what was perceived to be a relatively minor injury. 32
Technological advancements led to the creation of lower-profile
devices, which has improved the application and acceptance by some
clients. 32 Further, these devices often are used in lieu of surgical
intervention with similar outcomes in motion and functional use. 32,33
This intervention requires careful coordination with the hand surgeon
to determine both the clinical fracture need and the client’s ability to
accept this intervention and comply with a complex rehabilitation
regimen. However, the results can be rewarding when the
intervention is planned and executed effectively. Fabrication
directions and rehabilitation program are as follows:

1. A static base is fabricated. This forearm-based dorsal orthosis

positions the involved MCP joint in 70 degrees of flexion. The
MCP block extends to the level of the PIP joint. The block is an
open cylinder, which provides adequate support while
allowing access to the involved digit (Figs. 13.29 A and
13.29B).
2. The physician drills a K-wire through the head of the middle
phalanx (Fig. 13.30).
3. The copper wire or spring wire outrigger is contoured to the
digit. This is more difficult with the middle and long finger as
an over-top approach must be used (Fig. 13.31). The lateral
outrigger can be used for the small finger. It is easier to
fabricate, but it is more cumbersome (see Fig 13.29A).
4. The end of the outrigger is curled to form a circle, and it is
riveted to the base at the level of the PIP joint. Care is taken to
ensure that this aligns with the PIP axis of rotation.
5. The traction orthosis is then placed, and volar support is
provided to the digit as needed (Fig. 13.32).
6. Rubber band traction is applied by hooking the rubber bands
to the K-wire and adhering them to the distal component of
the outrigger (see Fig. 13.29).
7. Tape the end of the outrigger to prevent the rubber bands from
sliding laterally.
 8. Add traction force through the rubber bands. This force should
measure 200 g of force using a strain gauge. Occasionally,
greater traction forces are necessary; however, no more than
300 g should be applied to prevent soft- tissue complications.
9. The client will move the distracted joint through a passive
motion, 10 to 15 repetitions, five times per day for 6 weeks.
10. The client is seen frequently to ensure proper outrigger
placement and orthotic fit and to carefully monitor the skin for
potential breakdown.

Completed traction splinting programs typically have good results

as seen in Fig. 13.33A–C.

Static-Progressive Approach for Composite

Finger Flexion
It is common for the fingers to become stiff after trauma to the hand or
wrist. Stiffness may be due to joint pain or swelling, which prevents
an ability to achieve full finger flexion. Although clients may be
actively participating in a therapy program that focuses on edema
control, range of motion, and tendon gliding to achieve full composite
finger flexion, an orthosis that aids in wound healing or tissue
remodeling through low-load prolonged stress to the joints can
maximize return to function.
FIG. 13.29 A, Small finger traction orthosis. B, Middle finger traction
orthosis.

FIG. 13.30 Proximal interphalangeal (PIP) fracture with K-wire

placement.
FIG. 13.31 Traction outrigger conforming to digit.
 FIG. 13.32 Traction with volar support.

For the hand to function optimally, the PIP joint needs to extend
and flex to the palm. Different types of grasps are important for
occupational activities, such as the ability to slip the hand into a
pocket, to put on a glove, to grasp coins, or to hold a wrench. The PIP
joint can lose extension from the following:
 FIG. 13.33 A, Flexion at 5 weeks. B, Extension at 5 weeks post K-
wire removal. C, Posttreatment x-ray image (compare to Fig. 13.30).

• Crush injury
• Burn or fracture around the PIP joint
• Flexor tendon injury
• Ligament injury
• Excessive swelling of the hand following injury elsewhere
• Immobilization and disuse

There are several different ways to mobilize PIP joints to gain

passive flexion with either custom-fabricated or prefabricated
orthoses. The following steps are instructions for creating a custom-
fabricated static-progressive orthosis for the hand. Static-progressive
tension allows the person to maintain the tissue at a maximum
tolerable stretch. 35
 FIG. 13.34 The fishing line should start from the distal cuff through
both holes on the proximal cuff before ending on the other side of the
distal cuff, leaving enough fishing line to loop through the Velcro tab
and reach midway down the forearm.

1. Fabricate a volar-based wrist immobilization orthosis with the

wrist in 30 to 45 degrees extension to maximize finger flexion
(refer to Chapter 7 for instructions).
2. To fabricate the finger cuff, use a thinner (1⁄16 inch)
thermoplastic material. Cut two pieces ½ inch to ¾ inch wide
and 1½ to 2 inches long. Mold one cuff halfway around the
dorsum of the proximal phalanx and the other cuff over the
distal phalanx.
3. Punch small holes using a hole punch on either side of the two
cuffs. Cut a piece of monofilament line approximately 10 to 12
inches long. Tie the start of the monofilament line on one side
of the distal cuff. Thread it through one side of the proximal
cuff, and then through the other side of the proximal cuff. Tie
off on the other side of the distal cuff.
 FIG. 13.35 When completed, the fingers can be pulled into a
composite fist position, adjusting the Velcro loop as tolerated
every 5 minutes with a goal of wearing the orthosis 30 minutes at
a time.

4. Find the center of the monofilament line, and slip it through

the small hole at one end of a Velcro loop ½ × 2 inches to create
a completed flexion cuff.
5. Repeat this for additional fingers as needed.
6. This cuff is applied to the stiff finger(s) when pulled toward the
forearm. The tension should cause the finger to flex first at the
DIP, then at the PIP, and finally at the MCP into the palm
(composite fist).
7. Replace the volar orthosis, and apply straps across the dorsum
 of the hand, at the wrist and forearm.
8. Fit the individual finger flexion cuffs, and gently pull them
toward the forearm. The fishing line should start from the
distal cuff through both holes on the proximal cuff before
ending on the other side of the distal cuff, leaving enough
fishing line to loop through the Velcro tab and reach midway
down the forearm (Fig. 13.34).
9. Determine where to place the Velcro hook on the volar aspect
of the wrist orthosis
10. The cuffs should be pulled tight enough to provide gentle
tension to the fingers (Fig. 13.35. After a 5-minute iterval,
attempt to tighten the tension as tolerated. Repeat this every 5
minutes with the goal of wearing the orthosis 30 minutes five
to six times per day.

There are other options for finger cuffs, including leather,

commercially available finger loops, or strapping material.

Review Questions
1. What are four possible goals of mobilization orthotic
provision?
2. What criteria determine the use of static-progressive or
dynamic tension?
3. What is the angle of pull between the long axis of the bone
and the outrigger line that must be maintained?
4. What are the complications associated with a mobilization
orthosis that uses excessive force?
5. What is the acceptable force per unit area for sling
pressure?
6. What information should the therapist gather before
 considering fabrication of a mobilization orthosis?
7. What is the difference between a high- and a low-profile
outrigger? What are the advantages and disadvantages of
each?
8. What are three methods of force application?
9. What are the steps for attaching a wire outrigger to the
base of an orthosis?
10. What are three precautions when using a mobilization
orthosis?
References
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Appendix 13.1 Case Study
Case Study 13.1 a

Joseph is a 27-year-old right-handed man who was out late with his
friends after work. When he awakened the next morning, he was
surprised to find that he was unable to move his right wrist and
fingers. He became alarmed and went to the local emergency
department and was diagnosed with a radial nerve palsy. He was
given an elastic wrist splint and was told to see an orthopedic
physician if it did not resolve in a few weeks. After 4 weeks, things
were no better, and he saw a local hand surgeon. The surgeon was not
considering therapy until Joseph began to talk about his inability to
use his right (dominant) hand for work activities (he is a video-
terminal worker) and simple daily living tasks such as preparing
meals. He also reported difficulty putting his hand in his pocket and
in donning gloves, which is an important skill for Joseph in his
environment. He is now 6 weeks’ post injury, and your referral
includes the option for orthotic fabrication as indicated in addition to
functional retraining to attain activities of daily living (ADLs)
independence with a full return to work goal.

1. What clinical evaluation is required before fabrication of the

orthosis? Circle yes (Y) or no (N) to the following options:
a. Y N Evaluation of active and passive motion of the
wrist and fingers
b. Y N Manual muscle testing of the elbow, wrist, and
hand
c. Y N Evaluation of sensibility
d. Y N ADLs evaluation
e. Y N Occupational performance measure
2. Which of the following is the appropriate orthosis for this
client?
a. Hand-based digital extension
 b. Forearm-based low-profile wrist and digital
extension
c. Anticlaw
d. Static-progressive digital flexion
3. What is the primary purpose of this orthosis?
a. To increase active extension of the fingers
b. To protect damaged nerves in the hand
c. To provide controlled stress or motion to the
involved digits
d. To substitute for weak or absent muscles
4. What is the most desirable source of finger traction for this
orthosis?
a. Rubber band traction
b. Spring wire
c. Turnbuckle
d. Static Velcro tabs
5. How often should Joseph wear the orthosis?
a. 60 minutes, four times a day
b. 30 minutes, two times a day
c. As needed for occupational performance
improvement
d. 4 hours at a time
Appendix 13.2 Form and Grading Sheet
Form 13.1 Static-Progressive Finger
Flexion Orthosis
Grading Sheet 13.1 Static-Progressive Finger
Flexion Orthosis
a See Appendix A for the answer key.
14
Orthotic Intervention for Nerve
Injuries
Helene L. Lohman, and Brenda M. Coppard

CHAPTER OBJECTIVES
1. Identify the components of a peripheral nerve.
2. Describe a peripheral nerve’s response to injury and repair.
3. Describe the operative procedures used for nerve repair.
4. Explain the three purposes for orthotic intervention of nerve
palsies.
5. Describe nerve injury classification.
6. Identify the locations for low and high peripheral nerve lesions.
7. Explain common causes of radial, ulnar, and median nerve
lesions.
8. Review the sensory and motor distributions of the radial, median,
and ulnar nerves.
9. Explain the functional effects of radial, ulnar, and median nerve
lesions.
10. Identify the orthotic intervention approaches and rationale for
radial, ulnar, and median nerve injuries.
11. Use clinical judgment to evaluate a problematic orthosis for a
nerve lesion.
12. Use clinical judgment to evaluate a fabricated hand-based ulnar
nerve orthosis.
13. Apply documentation skills to a case study.
 14. Summarize the importance of evidence-based practice with
provision of orthoses for nerve conditions.

KEY TERMS
axonotmesis
cubital tunnel syndrome
cumulative trauma disorder (CTD)
median nerve
neurapraxia
neurotmesis
posterior interosseous nerve syndrome
pronator tunnel syndrome
radial nerve
radial tunnel syndrome
ulnar nerve
wallerian degeneration
Wartenberg neuropathy

Your friend, Madison, is an avid bicyclist. She bikes almost every day to
work and weekly with members of several bicycling clubs. After
completing a particularly rigorous event biking across the state,
Madison developed pain and a “pins and needles” feeling in the ring
and little fingers of both hands. Over the next several months, she began
complaining of feeling clumsy picking up objects and spreading her
fingers apart to grasp items. Madison approached you about her hand
problems stating, “I believe that I might have carpal tunnel syndrome!”
From listening to her symptoms and how they developed, you suspect
compression of the ulnar nerve at the wrist and suggest that she go to an
 orthopedic physician for a diagnosis. After her appointment she shares
with you that she did have an ulnar nerve compression at the wrist
called Guyon canal syndrome, and she received an order for therapy and
an orthosis.

NOTE: This chapter includes content from previous contributions

from Mackenzie Raber.
Orthotic interventions for nerve lesions require therapists to possess
a thorough knowledge of static (immobilization) and dynamic
(mobilization) principles as well as sound critical-thinking skills.
Comprehension of kinesiology, physiology, and anatomy is
paramount to understanding the motor, sensory, and vasomotor
implications of a nerve injury. Competence in manual muscle-testing
skills is also necessary to evaluate affected muscles as nerves recover
from injuries. 18 This chapter addresses peripheral nerve anatomy;
nerve injury classifications; nerve repair; and types, effects, and
interventions for radial, ulnar, and median nerve injuries. The focus is
orthotic intervention with these peripheral nerves. Beyond the
foundational information provided, therapists should always
remember the huge impact that a nerve condition has on function and
ultimately the quality of a person’s life. 54 As realistically as possible,
therapists must address occupation with intervention. Finally,
although this chapter focuses on nerve conditions, therapists must be
aware that nerve conditions do not always appear in isolation and can
be quite complicated as traumatic nerve injuries are often
accompanied by bone, tendon, ligament, vessel, and soft tissue
conditions.
 FIG. 14.1 Components of a peripheral nerve: epineurium,
perineurium, endoneurium, funiculi, axons, and blood vessels.

The following sections provide foundational education about nerve

anatomy and classification. An understanding of this information is
essential for effective intervention.
Peripheral Nerve Anatomy
A peripheral nerve consists of the epineurium, perineurium,
endoneurium, funiculi, axons, and blood vessels (Fig. 14.1). 41 The
epineurium is made of loose collagenous connective tissue. There are
external and internal types of epineurium. The external epineurium
contains blood vessels. The internal epineurium protects the funiculi
from pressure and allows for gliding of fascicles. The amount of
epineurium varies among persons and nerve types and along each
individual nerve. The perineurium surrounds funiculi, and the
endoneurium surrounds the axons. A funiculus, or fascicle, consists of
a group of axons that is surrounded by endoneurium and is covered
by a sheath of perineurium. An individual fascicle contains a mix of
myelinated and unmyelinated fibers. The myelin sheath encapsulates
the axon. Myelin is a lipoprotein, which allows for conduction of fast
impulses. Each nerve contains a varied number and varied sizes of
funiculi.
Nerves are at risk for injury when laceration, avulsion, stretch,
crush, compression, or contusion occurs. 11 Peripheral nerves can also
be attacked by viruses, bacteria, or the body’s immune system. 11
Accompanying conditions such as tendon lacerations increase the
complexity that therapists manage with intervention.
Nerve Injury Classification
Nerve injuries are categorized by the extent of damage to the axon
and sheath. 11 Nerve compression lesions often contribute to
peripheral neuropathies. When a specific portion of a peripheral nerve
is compressed, the peripheral axons within that nerve sustain the
greatest injury. Initial changes occur in the blood/nerve barrier
followed by subperineural edema. This edema results in a thickening
of the internal and external perineurium. 59 As the compression
worsens, the motor, proprioceptive, light touch, and vibratory sensory
receptor specific functions are compromised. 86 All the nerve fibers
may be paralyzed after enduring severe and prolonged compression.
Seddon 80 originally described three levels of nerve injury (Fig. 14.2):

1. Neurapraxia
2. Axonotmesis
3. Neurotmesis

Neurapraxia, often occurring from compression or crush injuries,

impairs conduction because of damage to the myelin. With
neurapraxia (see Fig. 14-14.2), spontaneous recovery occurs in
approximately 3 to 6 weeks. 31 As illustrated by Fig. 14.2, axonotmesis
results in complete interruption of the axon. With this level and higher
wallerian degeneration occurs. Wallerian degeneration occurs when a
nerve is completely severed or the axon and myelin sheath are
damaged. The segment of axon and the motor and sensory end
receptors distal to the lesion become ischemic and begin to
degenerate, thus preparing the nerve for regeneration. 41,57 The third
level, neurotmesis (see Fig. 14.2), results in complete transection of the
axon and other tissues. Penetrating and gunshot wounds, fractures,
high-energy blunt trauma, traction, and crush are examples of injuries
that can lead to axonotmesis or neurotmesis types of injury. 31
 FIG. 14.2 The three classifications of nerve injuries are (1)
neurapraxia, (2) axonotmesis, and (3) neurotmesis.
From Duffy, B. & Tubog, T. [2017]. The prevention and recognition of
ulnar nerve and brachial plexus injuries, Journal of PeriAnesthesia
Nursing, 32[6], 636–649. Copyright Elsevier [Figure 2]

Later in 1968 Sunderland 87 extended the classification to five levels,

which are termed first- through fifth-degree injuries. Mackinnon and
Dellon 47 describe an added sixth-degree injury, which addresses
mixed grades of nerve injuries. Although it is helpful to learn the
Sunderland classifications, therapists must recognize that most nerve
injuries do not exactly fit into these categories due to being mixed-
grade types of injuries. Furthermore, there is no specific
discriminatory test for Sunderland grades II and IV, especially during
the initial 6 weeks after a nerve injury. 32 Early physician diagnosis
occurs with clinical and or surgical examination. Nerve conduction
studies (NCSs) and electromyograms (EMGs) are beneficial diagnostic
measures at 6 weeks post injury, when nerve fibrillation occurs. Thus
nerve recovery can be charted over time. 32

First-Degree Injury
A first-degree injury usually occurs from compression 32 and involves
the demyelination of the nerve, which temporarily blocks conduction.
8,60 This level of injury corresponds to the neuropraxia level with

axonal integrity remaining. 31 The prognosis for persons with this

injury is extremely good; recovery is usually spontaneous within 3
months, 86 although maximum outcome can take as long as 7.15
months. 77

Second-Degree Injury
A second-degree injury corresponds to the axonotmesis level with the
axon severed and the sheath remaining intact. A typical cause of this
degree of injury is from a crush. 32 At this level wallerian degeneration
can occur. However, the intact endoneurial tube allows for potential
regrowth for the proximal part of the nerve to regenerate. With the
ideal scenario the rate of regeneration is approximately 1 inch per
month. Complete recovery usually occurs if regeneration happens in a
timely manner before muscle degeneration, 60 but it is not unusual to
have incomplete recovery. 32 Research indicates a recovery time up to
10.69 months. 77

Third-Degree Injury
A third-degree injury varies from a second-degree injury in that the
“continuity of the endoneurial tube [is] destroyed from a
disorganization of the internal structures of the nerve bundles,” 87 and
scarring is present within the tube. 27 This level corresponds to
axonotmesis or neurotmesis levels. Recovery is more complicated
with possible delayed or incomplete axonal growth. 87 Because fibers
are often mismatched, clients benefit from motor and sensory
reeducation. 60 Research indicates a maximum recovery time up to
14.08 months for this level. 77
Fourth-Degree Injury
With the fourth-degree injury “the involved segment is ultimately
converted into a tangled strand of connective tissue, Schwann cells,
and regenerating axons which can be enlarged to form a neuroma.” 87
Fourth-degree injuries correspond to the neurotmesis level. The effects
are more severe than a third-degree injury with increased neuronal
degeneration, misdirected axons, less axon survival, 87 and more scar
tissue. 27 Complete “distal loss of function” occurs with this level of
injury. 27 Surgical intervention is necessary to remove a neuroma
(tumor of nerve fibers and cells). Research indicates a maximum
recovery time up to 17.66 months for this level. 77

Fifth-Degree Injury
A fifth-degree injury corresponding to the neurotmesis level results in
partial or complete severance of the axon and the sheath with loss of
motor, sensory, and sympathetic function. 87 Without the directional
guidance from an intact endoneurial tube, malaligned axon growth
may lead to a complicated recovery. Microsurgery is required as the
person will not restore distal functioning without surgery. 27
Occasionally grafting is necessary if the severance gap is too large for
approximation of the two nerve ends. 86 Research indicates a
maximum recovery time up to 19.03 months for this level. 77

Sixth-Degree Injury
A sixth-degree injury is a mixed injury involving a “neuroma-in-
continuity.” 27 This type of injury involves many of the aspects of the
earlier five degrees to varying degrees. 47 Surgery needs will vary
according to the specific condition, and in some cases surgery may not
be required.
Surgical Nerve Repair
Peripheral nerve lesions often occur to the median, radial, and ulnar
nerves. The location of the lesion determines the impairment of
sudomotor, vasomotor, muscular, sensory, and functional
involvement. 8 Sometimes nerves can be compressed at more than one
site, and this is known as double crush syndrome. 72,89 Although the
concept is controversial, it is believed that proximal compressions in
the upper arm predispose the distal portions of the arm to developing
additional nerve compressions 40 due to decreased blood flow. 57 For
example, a therapist might be treating a client for carpal tunnel
syndrome at the wrist and may recognize symptoms of a higher-level
median nerve condition called C6 radiculopathy. Therefore it is
important to be aware of key diagnostic procedures (e.g., cervical
nerve root rule out) to determine the extent and placement of
compressions, and such rule outs might be considered with all
peripheral nerve injuries.

Operative Procedures for Nerve Repair

There are five procedures used to surgically repair nerves 74 :

1. Decompression
2. Repair
3. Neurolysis
4. Grafting (conduits)
5. Nerve transfers

Nerve decompression is the most common surgery performed on

nerves. An example of surgical decompression is the transection of the
transverse carpal ligament to decompress the median nerve or release
the carpal tunnel.
Surgical nerve repairs involve microsurgical sutures to fix the
epineurium, which is the current standard of care for lacerations. 31
End-to end repairs completed with little tension result in more
predictable results. 31 Surgical nerve repairs are classified as primary,
delayed primary, or secondary. 14 A primary repair occurs within
hours of the injury. A delayed primary repair occurs within 5 to 7
days after the injury. Any surgical repair performed beyond 7 days is
considered a secondary repair. 14
Neurolysis is a procedure performed on a nerve that has become
encapsulated in dense scar tissue. The scar tissue compresses the
nerve to surrounding soft tissues and prevents it from gliding. When
the client attempts to move in a way that would normally glide the
nerve, the movement instead stretches the nerve, affecting circulation
and chemical balance. Scars may also physically interfere with the
axon regeneration.
Nerve grafting and nerve conduits are necessary when there is a
large gap in a nerve and an end-to-end tensionless nerve repair is not
possible. Nerve conduits serve as scaffolds and guides to provide
structure for nerve regeneration. 52 Autografts from donated nerves
such as the sural nerve are commonly performed surgically to fill a
large gap. Risks exist with autografts for donor site morbidity with
sensory and functional loss, neuroma, and infection. 29,65

Nerve Transfers
A relatively recent surgical approach for peripheral nerve injuries is
nerve transfers to the elbow, forearm, and hand. 56 Nerve transfers
involve moving a healthy innervated nerve or nerve fascicles to a
denervated nerve to facilitate nerve regeneration. 56,88 Post surgery,
provision of orthotic intervention is variable. However, in some cases,
after the bulky dressing is removed, application of an orthosis may be
an option as prescribed by the surgeon. Nerve transfers for elbow
flexion and forearm are typically immobilized briefly for 7 to 10 days.
56 Transfers for the wrist and hand are also surgically performed. For

example, the flexor carpi radialis can be transferred to the extensor

carpi radialis brevis to facilitate wrist extension. 88
Following surgical repair, orthoses may be ordered by the
physician. However, there are various reasons for orthotic provision
with nerve conditions, which are summarized in the next section.
Purposes of Orthotic Intervention for
Nerve Injuries
The three purposes for orthotic intervention of an extremity that has
nerve injury are protection, prevention, and assistance with function.
3,50 If a nerve has undergone surgical repair, the physician may order

application of a cast or an orthosis to place the hand, wrist, or elbow

in a protective position, thus reducing the amount of tension on the
repaired nerve. Avoiding tension on a repaired nerve is extremely
important because outcomes of nerve repairs are directly related to
the amount of tension across the repair site. 83
Prevention of contractures is important because nerve lesions result
in various degrees of muscle denervation. For example, a short
opponens orthosis prevents contracture of the thumb web space after
a median nerve injury. 26 Sometimes a client does not seek immediate
medical attention after nerve injury, resulting in contracture
development in which an orthosis is required for contracture
correction. For example, a client with a claw hand deformity from an
ulnar nerve injury may require a mobilizing ulnar gutter orthosis. This
orthosis helps remodel the soft tissues to increase passive extension of
the ring and little fingers’ proximal interphalangeal (PIP) joints 11 by
placing the metacarpophalangeal (MCP) joints in a flexed position.
Concurrently intervention focuses on regaining maximum passive
range of motion (PROM). After normal PROM is regained, orthotic
interventions for the muscle imbalance becomes an option. 25
Often function after a nerve injury can require or be enhanced by
orthotic intervention. For example, a client may be better able to grasp
and release objects after a radial nerve injury while wearing an
orthosis that reestablishes the tenodesis action of the hand and wrist.
This orthosis assists the wrist and MCP joints with extending to open
the hand for grasp and release. Without the orthosis the wrist and
MCP joints are unable to extend, resulting in difficulty with grasp and
grasp release activities.
General Guidelines for Orthotic
Provision with Nerve Injuries
Every nerve condition requires specific positioning to address nerve
deficits. Obtaining the right position with orthotic intervention can be
challenging because of issues with denervated muscles and insensate
areas. Selection of a custom versus a prefabricated orthosis is based on
the condition and therapeutic objectives. With orthotic fabrication,
extreme care is taken to protect insensate areas from further damage
and for general patient safety (see Patient Safety Tips and Precautions
Box). Thus selecting conforming and drapable thermoplastic materials
and recognizing areas to round, pad, or push out to prevent pressure
are important considerations.
The next section summarizes various nerve conditions that
therapists encounter. A brief overview of cumulative trauma
disorders (CTDs) is provided.
Nerve injuries occur either from trauma (e.g., lacerations, gunshot,
crush) or from compressions with CTDs. During therapy the therapist
must note any substituted motions to prevent further muscle
imbalance. Knowing the challenges, location, and prognoses for nerve
conditions helps the therapist be realistic with setting objectives for
intervention and collaborating with client goals.
Upper Extremity Compression
Neuropathies
Cumulative trauma disorder (CTD) is not a medical diagnosis but an
etiological label for a range of disorders. 53 The cause of CTD is not
solely from engaging in work activities. Social activities, activities of
daily living (ADLs), and leisure pursuits may enhance the
development and exacerbation of CTD. 53 Most CTDs are classified as
neuropraxia or Sunderland grade 1 injuries. They can further be
characterized as acute or chronic conditions. An example of an acute
CTD is a radial nerve compression in the upper arm sometimes
nicknamed Saturday night palsy. An example of a chronic condition
may be long-standing carpal tunnel syndrome condition. 54 The first
step in managing the CTD derives from understanding the
compressive neuropathies of the upper extremity. 90 Table 14.1
outlines the nature and intervention of compressive neuropathies that
occur at the wrist, elbow, and forearm. The compressive neuropathies
are discussed in more detail later in this chapter.
Locations of Nerve Lesions
The location of a nerve lesion determines the sensory and motor
involvement. Lesions are referred to as low or high. Low lesions occur
distal to the elbow, and high lesions occur proximal to the elbow. 5
High lesions affect more muscles and may influence a larger sensory
distribution than low lesions. Therefore knowledge of relevant
anatomy is important for determining physical and functional
implications of nerve injuries.
Substitutions
When a nerve lesion occurs, “there is no opposing balancing force to
the intact active muscle group.” 18 If a person with a nerve lesion does
not receive orthotic intervention, the intact musculature overpowers
the denervated muscles. Intact musculature takes over and produces
movement normally generated by the denervated muscles. 15 The
person learns to adapt to the imbalance through substitutions and
compensation. 18,71 An example of a substitution or trick movement is
the pinch that develops after a low-level median nerve injury. With
the help of the adductor pollicis, the flexor pollicis longus pinches
objects against the radial side of the index finger. A therapist may
mistakenly think that motor return has occurred for the abductor
pollicis brevis, flexor pollicis brevis, opponens pollicis, and the first
and second lumbricals. However, the pinch movement observed is
actually a substitution.
Prognosis
Many factors affect the prognosis for recovery from nerve injuries,
particularly following surgical repair. Full motor and/or sensory
recovery may not always occur. Less than half of people undergoing
surgical repair have good to excellent results. 32 Prognostic factors
include the extent and location of the injury, cleanliness of the wound,
method of repair, timing of repair and the client’s age. 11,83 Other
factors that impact recovery from nerve repair include the person’s
general health and cognitive capacities and whether the person
smokes or has a concurrent diagnosis such as diabetes.
Extensive injuries, such as from a crush mechanism, add challenges
to the repair and generally have less positive prognoses. In contrast,
injuries that are solely a motor or sensory fiber repair have a better
prognosis. 46 Generally, proximal nerve injuries have worse prognoses
than distal injuries because regeneration takes longer to reach the
hand, resulting in irreversible nerve end plate damage. 46 Proximal
wounds at the level of the brachial plexus can take as long as 2 to 3
years to regenerate to the hand. 32 It is postulated that the rate of
axonal regeneration is 1 to 2 mm per day. 73 Because nerve
regeneration is slow, the therapist conducts periodic monitoring;
furthermore, orthotic intervention is often part of the intervention
protocol. Correct alignment of axons and avoidance of tension on the
damaged nerve improve the prognosis. However, regardless of
surgical technique, axonal mismatching occurs as surgeons cannot
repair individual Schwann tubes or axons. 46 A clean wound has a
better prognosis than a dirty wound. 8 Sharply severed nerves, such as
from a laceration, recover better than frayed nerves resulting from a
gunshot wound. 28 Early surgical repair is associated with better
outcomes, 11 , 45 and delayed repairs usually require grafts because of
scarring and nerve retraction. 46 Age is also a critical factor in the
speed and extent of recovery. A child’s potential for nerve
regeneration is greater than an adult’s. 11 Adults rarely fully recover
from a nerve injury. 45 As with any injury, a person’s general health is
related to recovery, and cigarette smoking is linked to poorer results. 9

TABLE 14.1

Upper Extremity Compression Neuropathies

DIP, Distal interphalangeal; IP, interphalangeal; MCP, metacarpophalangeal.

The following section summarizes radial, ulnar, and median

peripheral nerve injuries. Accompanying each type of nerve injury is a
discussion of the causes, muscles involved, functional implications,
and orthotic intervention.
Radial Nerve Injuries
Radial nerve palsies are very common with the most prevalent
causative factor being midhumeral fractures or compressions. 3,13,17
Other causes of superficial radial nerve palsies at the wrist include
pressure, edema, and trauma on the nerve from crush injuries; de
Quervain tendonitis; handcuffs; and a tight or heavy wristwatch. 22
The location of the radial nerve injury determines which muscles are
affected (Fig. 14.3).
Three types of lesions are possible when the radial nerve is injured.
18 The first type of lesion involves a high-level injury at the humerus

resulting in wrist drop and lack of finger MCP extension (Fig. 14.4).
With this type of lesion the triceps are rarely affected unless the injury
is extremely high. Radial nerve palsy, sometimes known as Saturday
night palsy, is a sensory and motor compression of the radial nerve in
the upper arm. The term Saturday night palsy refers to a person who is
drinking and falls asleep with his or her arm over a chair, putting
pressure on the upper arm and causing hyperesthesia or diminished
sensation on the dorsal forearm and hand and weak or absent wrist,
digit, and thumb extensors. 69 Radial nerve palsy usually presents as a
neuropraxia type of nerve injury that spontaneously resolves in a few
months. 57
The second type of lesion involves the posterior interosseous nerve.
After spiraling around the humerus and crossing the elbow, the radial
nerve divides into a motor and a sensory branch. 22 The motor branch
is the posterior interosseous nerve, and the sensory branch is the
superficial branch of the radial nerve. Compression usually causes the
posterior interosseous nerve injury, but lacerations or stab wounds
can be sources of lesions to the posterior interosseous nerve. Radial
tunnel syndrome and posterior interosseous nerve compression are
two distinct types of compression syndromes described in the
literature that occur in the same tunnel with the same nerve. As
Gelberman and colleagues 30 stated, “It is difficult for the
conscientious diagnostician to accept the reality that the same nerve
compressed in the same anatomical site can result in two entirely
different symptom complexes.” Radial tunnel syndrome refers to
compression of the radial nerve just distal to the elbow between the
radial head and the supinator muscle, 69,83 and it is linked to repetitive
forearm rotation. 16 With radial tunnel syndrome, complaints of pain
occur usually at night in the radial nerve distribution of the distal
forearm, 38 and the condition involves pain without muscle weakness.
20,22,30 Radial tunnel syndrome is controversial because it is

complicated to diagnose a pain syndrome that does not have motor

components. The condition needs to be differentiated from lateral
epicondylitis, which is close to the same area. 20

FIG. 14.3 Radial nerve motor innervation.

 FIG. 14.4 Wrist drop deformity from a radial nerve injury.

Posterior interosseous nerve compression results in rapid motor

loss 30 with no sensory loss. 22,30,42 This compression is characterized
by aching on the lateral side of the elbow, weakness in supination,
difficulty with MCP finger and thumb extension, and difficulty with
thumb abduction. Wrist extension is intact, but the wrist tends to
radially deviate due to muscle imbalance. 42
The third type of lesion is damage to the sensory branch of the
radial nerve. Compression of this superficial branch is called
Wartenberg syndrome. 61 Compression can occur between the
brachioradialis and extensor carpi radialis longus. The condition is
caused by repetitive pronation and at the distal forearm, repetitive
wrist flexion and ulnar deviation, and tight wrist bands. 69
Wartenberg syndrome does not result in functional loss. However,
symptoms include numbness, tingling, burning, and pain over the
dorsoradial surface of the forearm and in the areas of the thumb and
index finger. 84

Functional Involvement From Radial Nerve

Lesions
Table 14.2 outlines lesion locations and the muscles and motions that
are affected in radial nerve lesions. After crossing the elbow and
dropping below the supinator, the radial nerve divides and forms the
posterior interosseous nerve. 18 Refer to Table 14.2 for a list of muscles
affected with the posterior interosseous nerve at the forearm level.
Loss of these muscles results in absent MCP extension of all digits,
thumb radial abduction, and thumb extension. With attempts at wrist
extension, strong wrist radial deviation is present. With attempts at
finger extension, the MCPs flex and the PIPs extend because the
extensor digitorum muscle is affected. In addition to the muscles
previously indicated, a radial nerve injury at the elbow level can affect
the supinator and extensor carpi radialis longus and brevis. Along
with motions lost at the forearm level, an injury at the elbow level
involves inability to produce radial wrist extension, MCP joint
extension, thumb extension, thumb radial abduction, and weakened
forearm supination.

TABLE 14.2

Radial Nerve Lesions

CMC, Carpometacarpal; IP, interphalangeal; MCP, metacarpophalangeal.

With a high-level lesion or compression in the upper arm (i.e., axilla

level), the injury affects the triceps and brachioradialis muscles. Loss
of these muscles results in lost elbow extension, weak supination,
absent wrist and finger extensors, and lost thumb extension and
abduction.
The functional results of an axilla-level lesion include an inability to
stabilize the wrist in an extended position, extend fingers and thumb,
and abduct the thumb. For example, a client with a high radial nerve
lesion has poor grip and coordination because of the lack of wrist
extensor opposition to the flexors. 8,25 The resulting deformity is called
wrist drop (see Fig. 14.4).
Significant impairment of sensation is not present with radial nerve
injuries. The superficial sensory branch of the radial nerve supplies
sensation to the dorsum of the index and middle fingers and half of
the ring finger to the PIP joint level (Fig. 14.5). Laceration or contusion
to the sensory branch of the radial nerve can be bothersome to a client.
This often occurs in conjunction with de Quervain release. Sensory
compromise over the dorsum of the thumb may result in
hypersensitivity. An orthosis or padded device can protect the area
while a desensitization program is implemented. 79

Orthotic Intervention for Radial Nerve Injury

The client with a radial nerve injury benefits from orthotic
intervention and a therapeutic program. There are several orthotic
options for radial nerve injuries. Orthoses specific for diagnoses are
discussed first, followed by various orthotic design options.

FIG. 14.5 Radial, median, and ulnar nerve sensory distribution.

Orthotic Intervention for Radial Nerve Palsy
Forearm-level orthoses promote function usually with the wrist
positioned in 30 to 45 degrees of extension. 69 Many options exist, such
as a traditional low-profile design as illustrated in Fig. 14.7, a
tenodesis orthosis as illustrated in Fig. 14.8, a low-profile radial nerve
palsy orthosis with radial and ulnar deviation as illustrated in Fig.
14.9, or a low-profile static wrist extension and MCP mobilization
extension orthosis as illustrated in Fig. 14.14. A hand immobilization
orthosis to support the MCPs in extension with the wrist in neutral to
slight extension can be provided for nighttime wear to promote a
functional hand position that prevents “shortening of the flexors and
overstretching of the extensors” 21 (see Chapter 9.) As wrist function
returns, a hand-based orthosis can be fabricated to promote wrist and
finger extension. For example, the hand portion of the low-profile
static wrist extension and MCP extension orthosis (see Fig. 14.11) can
be solely used with wrist musculature return and if only the MCPs
and thumb need support.

Orthotic Intervention for Radial Tunnel Syndrome

Currently the trend for orthotic intervention for radial tunnel
syndrome is to immobilize only to the extent needed to relieve
symptoms. Conservative management may involve immobilization
when symptomatic in a volar wrist immobilization orthosis in slight
extension and/or Kinesio taping 70 to reduce tension. Another
conservative suggestion is a yoke orthosis to support the middle MCP
joint to allow functional activities (Fig. 14.6). 70

Orthotic Intervention for Posterior Interosseous Nerve

Syndrome
It is important to apply orthotic intervention as much as possible for
posterior interosseous nerve syndrome to prevent stretch of
structures innervated by the radial nerve. The same various orthotic
options are suggested for posterior interosseous nerve syndrome as
for radial nerve palsy.

FIG. 14.6 Yoke orthosis for support of the middle

metacarpophalangeal (MCP) joint with radial tunnel syndrome.
From Porretto-Loehrke, A., & Soika, E. [2011]. Therapist’s
management of other nerve compressions about the elbow and wrist.
In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, et al. [Eds.],
Rehabilitation of the hand and upper extremity [6th ed.]. Philadelphia,
Elsevier.

Orthotic Intervention for Wartenberg Neuropathy

For Wartenberg neuropathy a wrist immobilization orthosis is
fabricated with the wrist in 20 to 30 degrees of extension. If pain
occurs with thumb motion, the thumb is also incorporated into the
orthosis. Padding or other ways to relieve pressure over the
aggravated areas, especially over the radial styloid, is helpful with
orthotic fabrication. 24,57,69 (See Chapter 8 for information on thumb
orthoses.)
The next section summarizes the two types of orthoses for radial
nerve conditions: immobilization and mobilization orthoses.

Immobilization and Mobilization Orthoses

Immobilization orthoses
The therapist applies a wrist immobilization orthosis to place the wrist
in a functional position of 30 degrees of extension. 12 When wearing a
wrist immobilization orthosis, the client can usually extend the IP
joints of the fingers to release an object by using the intrinsic hand
muscles. 8 The therapist keeps in mind the advantages, disadvantages,
and patterns of volar and dorsal wrist orthoses (see Chapter 7). A
wrist immobilization orthosis is appropriate to wear on occasions
when the client desires a more inconspicuous design than a
mobilization orthosis. A wrist or hand/thumb immobilization orthosis
(see Chapter 9) may also be more appropriate for nighttime wear than
a mobilization orthosis with an outrigger. Wearing a traditional
mobilization orthosis with an outrigger at night may result in damage
to the outrigger and injury to the client. Some people who have heavy
demands on their hands prefer the simple wrist immobilization
orthoses to the more fragile outrigger-mobilization designs. A
therapist may offer both a wrist immobilization orthosis and a wrist
mobilization orthosis to the person. Alternating the orthoses is
another solution that may maximize function. The low-profile
mobilization orthoses discussed later in this chapter is an alternative
for the client to wear both day and night because it is less
cumbersome and allows for functional movements.
 FIG. 14.7 Low-profile designs with pre-purchased outrigger parts.
From Fess EE, Gettle KS, Philips CA, et al: Hand and upper extremity
splinting: principles and methods, ed 3, St Louis, 2005,
Elsevier/Mosby.

Mobilization orthoses
Mobilization orthotic intervention for a radial nerve injury promotes
functional hand use, 7 and several options exist. One traditional
option involves fabricating a dorsal wrist immobilization orthosis as
the base for a mobilization extension finger/thumb orthosis (using
elastic for the source of tension). 3 The dynamic component for this
orthosis positions the MCPs in neutral (extension). Several low-profile
options exist that can be made with purchased outrigger parts (Fig.
14.7). The costs of using purchased outrigger parts should be
considered. Alternatively, the therapist can use wire or thermoplastic
material to fabricate an outrigger. (See Chapter 13 for more
information on outriggers).
A mobilization MCP extension orthosis for radial nerve injury
substitutes for the absent muscle power by assisting the MCP
extensors. This orthosis is worn throughout the day until the impaired
musculature reaches a manual muscle testing (MMT) grade of fair (3).
10 Colditz 18 cautions that “the powerful unopposed flexors often

overcome the force of the dynamic splint during finger flexion.” A

client who shows no clinical improvement in 3 months should return
to the physician for consideration of surgical intervention. 22 Because
wrist control usually returns first, the therapist closely monitors and
modifies the orthotic design and uses a hand-based mobilization
orthosis after the forearm-based mobilization orthosis has been worn
and improvement in wrist control is demonstrated. 3,93 If only one
finger is lagging in extension, the therapist dynamically incorporates
that finger into the orthosis. 93
Another type of mobilization orthosis for radial nerve injuries is a
mobilization orthosis that reestablishes the tenodesis action of the
hand. 17–19 A tenodesis action occurs when the client flexes the wrist
and the fingers extend. When the client extends the wrist, the fingers
flex (Fig. 14.8). The tenodesis orthosis includes a dorsal base with a
low-profile outrigger that spans from the wrist to each proximal
phalanx. This orthosis is sometimes called a dynamic tenodesis
suspension orthosis. 34 Finger loops are worn on each proximal phalanx,
and a nylon cord attaches the finger loops to the dorsal base.
The tenodesis orthosis has many advantages. First, the design
allows the palmar surface of the hand to be relatively free for sensory
input and normal grasp. 18 The wrist is not immobilized and moves
only with the natural tenodesis effect, whereas the thumb can move
independently. 17 In addition, the hand arches are maintained. 18 The
components of the tenodesis orthosis “follow the contours of the hand
and take up less space.” 51 As wrist extension returns, the client
continues to wear the orthosis because it does not immobilize the
wrist and it enhances the strength of the wrist extensors for functional
tasks. 18 Therefore a hand-based orthosis is not required. The low-
profile design enhances the performance of functional tasks.
There are some disadvantages with the tenodesis orthosis. Because
finger MCP flexion and extension mobilize as a group, independent
finger motion is not achieved. An additional orthotic component is
added if the thumb is to be included in the orthosis. Because the
orthotic design supports the weight of the hand through the finger
cuffs, wearing the orthosis can be fatiguing. 50 The tenodesis orthotic
design is usually not sturdy enough for people with high load
demands on their hands. 79 Newer options for mobilization orthoses
for the radial nerve continue to be developed. The next section
provides two pattern options for mobilization orthoses for radial
nerve palsy.

FIG. 14.8 A tenodesis orthosis for a high-level radial nerve injury.

From Colditz, J. C. [2002]. Splinting the hand with a peripheral nerve
injury. In E. J. Mackin, A. D. Callahan, T. M. Skirven, et al. [Eds.],
Rehabilitation of the hand and upper extremity [5th ed., pp. 622–634].
St. Louis, MO: Mosby.

Fabrication of a Low-Profile Radial Nerve Palsy Orthosis

With Radial and Ulnar Deviation
This low-profile radial nerve palsy orthosis allows for radial and ulnar
deviation. The orthosis is very comfortable to wear as the client can
use the hand functionally. 67 A beneficial aspect of the design is that
the hand piece can be separated from the forearm piece for use with
radial nerve functional return. This orthotic adaption was first
conceived by Sally Fistler Desilva, OTR, CHT. 67
Before fabrication, assemble the following materials: 3 mm
thermoplastic material, adhesive hook, nonadhesive loop, ½-inch (1.9-
cm) elastic band that adheres to Velcro, 3-mm elastic cord, screw rivet,
piece of stockinette, and hard-grade Theraputty. Fig. 14.9 illustrates
the finished orthosis, and Fig. 14.10 provides the pattern for the
orthosis.

Procedure for Low-Profile Mobilization

Orthosis for Radial Nerve Palsy
 1. Place a piece of Theraputty over the dorsal aspect of the wrist to
protect the skin surface from the hinge. Secure the Theraputty
with the piece of stockinette wrapped around the extremity.
2. Position the thumb between palmar and radial abduction and
the wrist in 20 to 30 degrees extension to mold the hand section
of the orthosis. Cut out an open area on the dorsal surface of
the orthosis to align with the MP joints of the index through
small finger (Fig. 14.11).
3. Over the distal aspect of the hand piece of the orthosis put a
damp paper towel where the two thermoplastic pattern pieces
will overlap. This damp towel prevents the two pieces from
sticking together (Fig. 14.12).
4. Fabricate the forearm piece, making sure to overlap it on top of
the distal hand piece by approximately 2 cm. Make sure that
the forearm piece is two-thirds the length and one-half the
circumference of the forearm.
5. Remove the paper towel, Theraputty, and stockinette. Remove
the thermoplastic pattern pieces.
6. Mark the forearm section of the orthosis for the pivot point
where the screw rivet will be placed directly over the capitate
bone, which is located proximal to the base of the middle
metacarpal.
7. Punch the correct size hole with a hole punch for the screw rivet.
8. After positioning the hand piece beneath the forearm piece,
mark the corresponding pivot placement, and punch a second
hole.
9. Check for adequate ulnar and radial deviation with the two
pieces positioned on the client.
10. For MP finger extension, place the ¾-inch piece of elastic on the
hand portion distal to the cutout hole. The elastic piece will fit
beneath the proximal phalanges of the index through middle
fingers. Cut a smaller piece of elastic to secure the thumb at the
proximal phalanx. Secure the elastic pieces with Velcro.
11. On the dorsal surface of the hand piece mark two parallel
vertical points between the PIP and MP joints of the fingers
 above the three locations of the finger web spaces. Then punch
out two small holes. Refer to Figs. 14.9 and 14.11 for placement.
12. To create the slings to position the MP joints in extension, loop
the elastic thread through the holes, and tie them on top (Fig.
14.13; see Figs. 14.9 and 14.11).
13. Place the forearm piece of thermoplastic material over the hand
piece to secure the screw rivet at a tightness that allows for
ulnar and radial deviation.
14. Complete the orthosis by securing it with two straps on the
forearm.

MP, Metacarpophalangeal; PIP, proximal interphalangeal.

Instructions were modified and reprinted with permission from Peck,
J., & Ollason, J. (2015). Low profile radial nerve palsy orthosis with
radial and ulnar deviation. Journal of Hand Therapy, 28(4), 421–424.
 FIG. 14.9 A low-profile radial nerve palsy orthosis with radial and
ulnar deviation.
From Peck, J., & Ollason, J. [2015]. Low profile radial nerve palsy
orthosis with radial and ulnar deviation. Journal of Hand Therapy, 28[4],
421–424.
 FIG. 14.10 Pattern for the low-profile radial nerve palsy orthosis with
radial and ulnar deviation.
Modified from Peck, J., & Ollason, J. [2015]. Low profile radial nerve
palsy orthosis with radial and ulnar deviation. Journal of Hand Therapy,
28[4], 421–424.

Fabrication of a Low-Profile Mobilization Orthosis for

Radial Nerve Palsy
A unique mobilization orthosis for radial nerve palsy is a static wrist
extension and dynamic MCP extension orthosis, which was originally
designed by Mark Walsh and Sue Blackmore with adaptations by the
Philadelphia Hand Center Therapy Department. Besides radial nerve
palsy, this orthosis may be used with other conditions that require
immobilization, such as post cerebrovascular accidents (CVAs). 92 The
instructions are based on an adaptation for making the orthosis with
moleskin loops. The original design by Walsh and Blackmore is
fabricated slightly differently. Walsh and Blackmore’s design includes
 FIG. 14.11 A, Molding of the hand section of the orthosis. B,
Completed hand product by itself.
From Peck, J., & Ollason, J. [2015]. Low profile radial nerve palsy
orthosis with radial and ulnar deviation. Journal of Hand Therapy, 28[4],
421–424.
FIG. 14.12 Placement of damp paper towel where the pieces overlap
to prevent sticking.
From Peck, J., & Ollason, J. [2015]. Low profile radial nerve palsy
orthosis with radial and ulnar deviation. Journal of Hand Therapy, 28[4],
421–424.

FIG. 14.13 Elastic thread creates sling effect to maintain MP

extension.
From Peck, J., & Ollason, J. [2015]. Low profile radial nerve palsy
orthosis with radial and ulnar deviation. Journal of Hand Therapy, 28[4],
421–424.
Procedure for Mobilization Low-Profile
Orthosis for Radial Nerve Palsy
1. Position the person’s hand palm-side up on a piece of paper.
The wrist should be as neutral as possible with respect to radial
and ulnar deviation. The fingers are abducted, and the thumb
is radially abducted.
2. Trace the hand and forearm. With the person’s hand still on the
paper, mark X’s corresponding to (Fig. 14.15):
• Each web space between the fingers
• PIP joints (both ulnar and radial sides) of all four
fingers
• IP joints (both ulnar and radial sides) of the thumb
• Two-thirds the length of the forearm
• ¼ to ½ inch lateral and parallel from the side of the
little finger PIP joint on the ulnar side of the hand
• ¼ to ½ inch lateral and parallel from the ulnar side of
the thumb IP joint
3. Draw the pattern (see Fig. 14.15). Start with the PIP joint of the
index finger radial side, and draw a straight line across the joint
to the ulnar side. Draw a straight line down from the ulnar side
of the PIP joint to the marking at the web space between the
index and middle fingers. Continue the same process of
drawing lines across the PIP joints and connecting them to a
line down to the marking at the base of the web space for all
digits. Connect the line from the little finger to the marking ¼
to ½ inch outside of the PIP joint and continue the line down
the side of the forearm, curving it to adjust to the forearm
muscle bulk. End the line at the two-thirds marking. Connect
the line that is ¼ to ½ inch parallel to the index finger to the
middle of the thumb IP joint, curving it to follow the C shape of
the index and thumb. From the middle of the thumb, cross the
IP joint and curve the line down the side of the forearm, ending
 it at the two-thirds marking. Connect the two lines at the two-
thirds marking.
4. Cut out the pattern, making certain to completely cut through
web space marks.
5. Trace the pattern onto the sheet of thermoplastic material.
6. Heat the thermoplastic material.
7. An option is to place padding on the dorsal MCPs and on the
ulnar styloid during orthotic formation and later adhere the
padding to the orthosis.
8. Cut the pattern out of the thermoplastic material. Wait until
later to cut out the markings between the web spaces so that
they do not adhere together. Another approach is to cut the
area between the web space as a V shape to prevent the
thermoplastic material from sticking together.
9. Position the person’s upper extremity on a table with the elbow
resting on a pad (folded towel or foam wedge) and the forearm
in pronation. Place the wrist and hand in the following
position:
• Wrist: Approximately 10 to 20 degrees extension
• Index through small MCPs: Neutral
• Thumb: Functional position of palmar abduction
10. Reheat the thermoplastic material, and cut out the markings
between the web spaces.
11. Mold the warmed thermoplastic material over the dorsum of
the wrist and hand, making sure to conform the orthosis around
the proximal phalanx of each finger and thumb. Push out the
material at the area of the ulnar styloid, or use Theraputty over
the styloid.
12. Make any adjustment for proper fit, and position the orthosis on
the person.
13. Once the orthosis is formed, cut a piece of ½-inch to ¾-inch
elastic to comfortably fit over and around each proximal
phalanx within the orthosis. Allow the elastic material to
overlap ½ inch to ¾ inch. After the size of loop is determined,
using a small stapler, place two staples in the elastic to secure
 each loop.
14. Remove the orthosis; be careful that the elastic pieces stay in the
proper place for each finger.
15. With strips of moleskin that are approximately ¾ inch × 4
inches, secure loops in place for each finger and thumb.
16. Apply straps to the wrist and forearm. When placing the
orthosis on the person, position the staples on the dorsal side of
the orthosis.

IP, Interphalangeal; MCP, metacarpophalangeal; PIP, proximal

interphalangeal.

slits approximately ½ inch wide and 1 inch long between each of the
fingers, leaving enough material distally to heat the area to allow a
3⁄32-inch wire to be pushed into the material. The wire creates a bar to
support the elastic between each finger. The elastic is woven through
this part of the orthosis (Fig. 14.14).
Steps for fabricating a mobilization orthosis for radial nerve palsy
can be found in the following procedure.
Ulnar Nerve Injuries
Ulnar compression syndromes are the second most common upper
extremity compression neuropathies. 71 An ulnar nerve lesion can
occur in conjunction with a median nerve lesion 23 and can arise
because of compression in many places throughout the extremity.
Thoracic outlet syndrome (TOS) is sometimes initially considered as
an ulnar nerve injury or a high-level median nerve injury because
symptoms can resemble such nerve compressions. 55 Thus it is
postulated that for TOS the concept of double crush applies with
compression higher up in the arm making lower areas more
susceptible to symptoms of nerve compression. 44 Compression with
TOS can occur as the brachial plexus passes through the scalene
muscles (scalene triangle) in the neck, between the clavicle and first
rib (costoclavicular region), or underneath the pectoralis minor muscle
(subcoracoid space) due to many reasons such as whiplash, posture,
or repetitive motions. 44
FIG. 14.14 A, Static wrist extension and metacarpophalangeal (MCP)
mobilization extension orthosis for radial nerve palsy originally
designed by Mark Walsh and Sue Blackmore. B and C, Adapted static
wrist extension and MCP mobilization extension orthosis using
moleskin and elastic finger loops.
 FIG. 14.15 Pattern for dorsal base of static wrist extension and
metacarpophalangeal (MCP) mobilization extension orthosis.
(Redrawn from Coppard, Introduction to Orthotics, 4th edition.)

Lesions to the ulnar nerve often result from a fracture of the medial
epicondyle of the humerus, a fracture of the olecranon process of the
ulna, or a laceration or ganglia at the wrist. Typically the site of ulnar
nerve compression at the elbow is the epicondylar groove, or where
the ulnar nerve courses between the two heads of the flexor carpi
ulnaris muscle. 71
Ulnar nerve compressions at the wrist level within the Guyon canal
are less common. 37,71 Those that develop from downhill bike riding
are also known as “cyclist or handle bar palsy.” 37,58 The Guyon canal
is a small tunnel, and it is also called the ulnar tunnel. It consists of
several key structures on the ulnar side of the hand, including the
roof–palmar carpal ligament, medial wall–pisiform bone, lateral wall–
hook of hamate, and floor–transverse carpal ligament. 37 Symptoms
can be motor or sensory depending on the location of the
compression. 37 Wrist-level injuries usually result from compression
because of the superficial nature of the ulnar nerve within the Guyon
canal (see Table 14.1). 71

FIG. 14.16 A claw hand deformity caused by an ulnar nerve injury.

From Seftchick, J. L., Detullio, L. M., Fedorczk, J. M., et al. [2011].
Clinical examination of the hand. In T. M. Skirven, A. L. Osterman, J.
M. Fedorczyk, et al. [Eds.], Rehabilitation of the hand and upper
extremity [6th ed.]. Philadelphia, Elsevier. Photo by Mark Walsh, PT,
 DPT, MS, CHT, ATC.

McGowan 49 developed a grading system for ulnar nerve

conditions: grade I manifests with paresthesias and clumsiness, grade
II exhibits interosseous weakness and some muscle wasting, and
grade III involves paralysis of the ulnar intrinsic muscles. Ulnar nerve
injuries at the elbow are classified as acute, subacute, or chronic. 71
Acute injuries result from trauma. Subacute injuries develop over time
and involve continual elbow compression, such as a factory worker
whose elbow is continuously positioned on a table while doing work.
Both acute and subacute injuries respond to conservative
interventions, such as reducing elbow flexion during tasks and/or
orthotic intervention.
Chronic conditions require surgery, especially if daily living tasks
are severely impacted. 71 Clinically a person with an ulnar nerve
compression at the elbow (cubital tunnel syndrome) complains of
discomfort on the medial side of the arm and numbness and tingling
in digits 4 and 5. 36 Prolonged flexion and force from occupations or
sports such as baseball and tennis are common causes of ulnar nerve
compression and irritation. 26
Regardless of the cause or location, if a deformity results from an
ulnar lesion it is called a claw hand. Anatomically this deformity occurs
because the MCP joints of the ring and little fingers are positioned in
hyperextension. This position, which is more pronounced in lower-
level ulnar nerve injuries, 68 occurs because the lumbricals and the
intrinsic muscles responsible for interphalangeal (IP) extension are
paralyzed. 8 The fourth and fifth digits are incapable of fully extending
the PIP and distal interphalangeal (DIP) joints because of the
unopposed action of the extensor digitorum communis and the
extensor digiti minimi (Fig. 14.16). In the early stages of an ulnar
nerve injury, a person may have difficulty performing ADLs and may
experience hand fatigue. Muscle weakness is not usually evident until
after the condition progresses. 71 Table 14.3 identifies the muscles that
the ulnar nerve innervates in a low-level or wrist lesion and a high-
level lesion that occurs at or above the elbow. If an ulnar nerve lesion
occurs just distal to the elbow, the extrinsic muscles of the hand are
lost because they are innervated distal to the elbow. At the wrist level,
compression of the ulnar nerve in the distal part of the ulnar tunnel
results in different functional effects based on the zone location of the
nerve. 33,71

TABLE 14.3

Ulnar Nerve Lesions

CMC, Carpometacarpal; DIP, distal interphalangeal; IP, interphalangeal; MCP,
metacarpophalangeal.

Generally the functional result from a high- or low-level ulnar nerve

lesion is loss of pinch and power grip strength. 11,25 The client is
unable to grasp an object fully because of the denervation of the finger
abductors, atrophy of the hypothenar eminence, inability to oppose
the little finger to the thumb, and ineffective pinch with the thumb. 8,76
The loss of the first dorsal interosseous and the adductor pollicis leads
to unstable pinching of the thumb and index finger. 8 Loss of lateral
finger movements and diminished sensory feedback can affect
functional occupational activities, such as typing on a computer 76 and
other daily tasks. With a high lesion the loss of the flexor digitorum
profundus of the ring and small fingers further compromises hand
grasp. 11 In addition, the client presents with weakened wrist ulnar
deviation.
 FIG. 14.17 Froments sign with flexion of the thumb IP joint and
Jeanne’s sign with hyperextension of the thumb MP joint.
From Seftchick, J. L., Detullio, L. M., Fedorczk, J. M., et al. [2011].
Clinical examination of the hand. In T. M. Skirven, A. L. Osterman, J.
M. Fedorczyk, et al. [Eds.], Rehabilitation of the hand and upper
extremity [6th ed.]. Philadelphia, Elsevier.) Photo by Mark Walsh, PT,
DPT, MS, CHT, ATC.

Three abnormal postures can develop from ulnar nerve injuries:

Froment sign, 10 Jeanne sign, 91 and Wartenberg sign. 57 The Froment
sign functionally results in flexion of the thumb IP joint during
pinching activities. 10 The Froment sign is apparent because the
adductor pollicis, the deep head of the flexor pollicis brevis, and first
dorsal interosseous muscle are not working. Because of these losses,
performance of the fine dexterity tasks of daily living is remarkably
affected. The Jeanne sign occurs with the advancement of ulnar nerve
conditions. In addition to displaying a positive Froment sign, with
Jeanne sign (Fig. 14.17) the MP joint of the thumb becomes
hyperextended with pinch secondary to weakness of the flexor pollicis
brevis muscle. 91 The Jeanne sign can be managed with a thumb
orthosis placing the MP joint in a functional position with slight
flexion to counterbalance the hyperextension. 39 The Wartenberg sign
develops because of interossei weakness resulting in the fifth digit
abducted from the other fingers. 57 Often, buddy taping the last two
digits with Coban helps this interossei weakness.
The sensory distribution of the ulnar nerve typically innervates the
little finger and the ulnar half of the ring finger on the volar and
dorsal surfaces of the hand (see Fig. 14.5). Clients who have ulnar
nerve compression can experience numbness, tingling, and
paresthesia in this nerve distribution. When designing an orthosis for
ulnar nerve lesions, the therapist monitors the areas of decreased
sensation for pressure sores and skin irritation. Fig. 14.18 illustrates
the muscles an ulnar nerve lesion affects.

Orthotic Interventions for Ulnar Nerve Injury

The client with an ulnar nerve injury benefits from orthotic
intervention and a therapeutic program. There are several orthotic
options for ulnar nerve injuries. Orthoses specific for diagnoses are
discussed first, followed by various orthotic design options.

Orthotic Intervention for Ulnar Nerve Compression at the

Elbow
A common intervention for compression at the cubital tunnel is an
elbow orthosis with the elbow typically flexed 30 to 45 degrees 1,35
with a maximal flexed position of 70 degrees. 45 (Refer to Chapter 10
for elbow orthoses.) Fig. 14.19 illustrates an anterior elbow orthosis for
cubital tunnel. Thermoplastic material with conformability and
drapability works well for this anterior-based orthosis. Sometimes the
wrist is included with the elbow design. The wrist is positioned in
neutral to 20 degrees of extension. Incorporating the wrist into the
orthotic design decreases the effects from flexor carpi ulnaris
contraction 71 (Fig. 14.20).
FIG. 14.18 Ulnar nerve motor innervation.
FIG. 14.19 An anterior-based elbow orthosis for cubital tunnel.
 FIG. 14.20 A long arm orthosis for cubital tunnel that includes the
hand and wrist.
From Lund, A. T., & Amadio, P. C. [2006]. Treatment of cubital tunnel
syndrome: Perspectives for the therapist. Journal of Hand Therapy,
19[2], 174.

FIG. 14.21 A sleeve with a gel pad protects the elbow during the day.
From Porretto-Loehrke, A., & Soika, E. [2011]. Therapist’s
 management of other nerve compressions about the elbow and wrist.
In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, et al. [Eds.],
Rehabilitation of the hand and upper extremity [6th ed., p. 702].
Philadelphia, Elsevier.

The elbow orthosis helps prevent repetitive or prolonged elbow

flexion. Prolonged elbow flexion can stress the ulnar nerve via traction
35,81 and increase pressure in the cubital tunnel. 48 This flexed position

commonly occurs during sleep or with computer usage. 81 For

sporadic or mild symptoms the elbow orthosis may be worn during
the night for approximately 3 weeks. 6 If demonstrating dysthesia,
decreased sensibility, and continuous symptoms, the client may wear
the elbow orthosis all the time. 6,12,71 However, it is generally
recommended that instead of daytime elbow orthosis wear, the
patient is educated to avoid flexing the elbow and/or resting the
elbow on a surface during activities. A sleeve with a gel pad (Heelbo
pad) is an option for day protection (Fig. 14.21). 70
Many therapists recommend a soft elbow orthosis for comfort.
Commercial soft elbow orthoses allow some movement but limit
flexion to less than 45 degrees. Fig. 14.22 provides options for
commercial soft orthoses. Other options are pictured in Chapter 10. If
finances are tight, simply securing a towel with the arm correctly
positioned can work for comfort. 70
FIG. 14.22 Two prefabricated options for cubital tunnel. A, A soft pre-
fabricated orthosis (IMAK ® Elbow Support). B, Comfort Cool ® Ulnar
Nerve Elbow Orthosis. (Orthosis from North Coast Medical &
Rehabilitation Products.)
 FIG. 14.23 The hand position for orthotic intervention of an ulnar
nerve injury in a static orthosis.

Wrist- and Hand-Based Orthotic Intervention for Ulnar

Nerve Injury
In recent published treatment guidelines for Guyon canal syndrome
(based on a European Delphi consensus strategy), experts suggested a
neutral wrist orthosis for nonsurgical treatment. 37 Another option for
some ulnar nerve conditions, including Guyon canal syndrome, with
potential for developing a claw deformity is a hand-based orthosis.
The orthosis (Fig. 14.23) positions the ring and little fingers in 30 to 45
degrees of MCP flexion 11 as a counterforce to prevent a claw hand
deformity. 11 Fig. 14.24 depicts the pattern for this orthosis. This
position (30 to 45 degrees of MCP flexion) prevents attenuation of the
denervated intrinsic muscles and the MCP volar plates of the ring and
little fingers 18 and corrects the claw hand deformity of MCP
hyperextension and PIP flexion. With the MCPs blocked in flexion, the
power of the extensor digitorum communis is transferred to the IP
joints and allows them to extend in the absence of the intrinsic
muscles. Ultimately, the orthosis facilitates functional grasp. 11 A client
usually wears an immobilization orthosis continuously with removal
only for hygiene and exercise. Some therapists recommend daytime
use only. 66
 FIG. 14.24 A hand-based pattern for an ulnar nerve orthosis.

Colditz 18 suggests the fabrication of a less bulky orthosis to keep

from impeding the palmar sensation and function of the hand. One
such orthosis is the figure-eight orthotic designed by Kiyoshi Yasaki
and developed at the Hand Rehabilitation Center in Philadelphia,
Pennsylvania (Fig. 14.25). 11 The instructions in the following
procedure include one method to fabricate a figure-eight hand-based
orthosis for an ulnar nerve injury.

Procedure for Fabrication of an Orthosis

for Ulnar Nerve Injury
1. Cut a ½-inch strip of thermoplastic material approximately 12 to
14 inches.
2. Heat the strip of thermoplastic material.
3. Position the arm with the elbow resting on a towel on a table
and the hand in an upright position. Position the ring and small
fingers in 30 to 45 degrees of MCP flexion. (IPs are in
extension.)
4. Determine the midpoint of the strip, and place it midway
between the ring and little fingers on the dorsal side of the
fingers at the level of the MCP joints over the proximal
phalanx.
5. Wrap one end of the strip around the ulnar side of the little
finger to the volar surface and one end of the strip around the
radial side of the ring finger to the volar (palmar) surface.
6. On the volar surface, cross straps (proximal to the MCP joints)
over each other at the level of the metacarpals circling the ring
and little finger.
7. Bring the straps back around to the dorsal surface proximal to
the heads of the MCP joints. Overlap the straps approximately
1 inch, and adhere the pieces together.
8. Roll any areas that could interfere with function, such as rolling
the area on the volar surface distal to the second and third
digits and around the thenar crease.

IP, Interphalangeal; MCP, metacarpophalangeal.

Mobilization Orthoses for Ulnar Nerve Injuries

With a mobilizing (dynamic) orthosis, the therapist places the hand in
the same position with the fourth and fifth digits in 30 to 45 degrees of
MCP flexion. The therapist uses a mobilization orthotic design that
includes finger loops attached to the ring and little fingers’ proximal
phalanges (Fig. 14.26). The rubber band is connected to a soft wrist
cuff and uses traction to pull the two fingers into MCP flexion. The
client wears the orthosis throughout the day with removal for hygiene
and exercise. Physicians usually prescribe this type of orthosis when
there is a need for a strong force to prevent hyperextension
contractures at the MCP joints. To supplement this orthosis, a
positioning (immobilization) nighttime orthosis may be necessary.
Another mobilization option for orthotic intervention of the ulnar
nerve lesion is a spring-wire-and-foam orthosis, which is available
commercially or can be custom made. Clients appreciate the low-
profile design of the spring-wire-and-foam orthosis, and adherence
tends to be high. 79
Median Nerve Lesions
Traumatic median nerve lesions result from humeral fractures, elbow
dislocations, distal radius fractures, dislocations of the lunate into the
carpal canal, and lacerations of the volar wrist. 11 The median nerve
innervates the muscles depicted in Fig. 14.27 (Table 14.4) in a low-
level or wrist lesion and a high-level lesion involving the elbow or
neck area.

Functional Implications of Median Nerve

Injuries
The impact on function from a median nerve lesion results in
clumsiness with pinch and a decrease in power hand grip. 8 Power
grip is affected because the thumb is no longer a stabilizing force due
to the loss of the abductor pollicis brevis, flexor pollicis brevis, and the
opponens pollicis. Weakness in the lumbricals of the index and
middle fingers further affects skilled movements of the hand. 7 The
sensory areas innervated by the median nerve are used for identifying
objects, temperature, and texture. 3 With lack of sensation in the
fingers, skilled functions are difficult to perform with the hand.

Locations and Types of Median Nerve Injuries

The classic deformity associated with low-level median nerve damage
is called an ape (or simian) hand because the thenar eminence appears
flattened due to denervation. A loss of thumb opposition occurs (Fig.
14.28). The thumb is positioned in extension and adduction next to the
index finger because of the unopposed action of the extensor pollicis
longus and the adductor pollicis. 8 The thumb web space may
contract, and the fingers may show trophic changes. In addition, a
slight claw deformity of the index and middle fingers may occur
because of the loss of lumbrical innervation. 76
 The most common type of lower-level median nerve compression is
carpal tunnel syndrome (CTS). Compression at the wrist occurs
because of a discrepancy in the volume of the rigid carpal canal and
its contents, consisting of the median nerve and flexor tendons. Some
conditions (such as, diabetes, pregnancy, Dupuytren disease, and
carpometacarpal [CMC] arthritis) are associated with CTS. Home,
leisure, and occupational activities involving repetitive or sustained
wrist flexion, extension, and ulnar deviation; forearm supination;
forceful gripping; and pinching all contribute to the development and
exacerbation of CTS. Vibration, cold temperatures, and constriction
over the wrist can also be contributing factors. 4,24,64,78
FIG. 14.25 Figure-eight orthosis for ulnar nerve injury.
 FIG. 14.26 A flexion mobilization orthosis for an ulnar nerve injury.
From Colditz, J. C. [2002]. Splinting the hand with a peripheral nerve
injury. In E. J. Mackin, A. D. Callahan, T. M. Skirven, et al. [Eds.],
Rehabilitation of the hand and upper extremity [5th ed., pp. 622–634].
St. Louis, MO: Mosby.

Higher lesions can weaken or impair forearm pronation, wrist

flexion, thumb IP flexion, and flexion of the proximal and distal IP
joints of the index and middle fingers. Compression syndromes that
occur from higher median nerve injuries are pronator syndrome and
anterior interosseous syndrome. Pronator syndrome often results
from strong and repetitive pronation and supination motions, with
the most common compression site between the two heads of the
pronator teres. 61 Anterior interosseous syndrome is rare and is
characterized by a vague discomfort in the proximal forearm. It
usually involves compression of the deep head of the pronator teres
and results in a motor rather than sensory injury. Clinically the person
presents with an inability to make an O with the thumb and index
finger because usually there are no sensory losses with this condition.
61
 FIG. 14.27 Median nerve motor innervation.

Because median nerve injuries occur throughout the extremity, it is

possible that a person is mistakenly thought to have one type of
median nerve injury when he or she has another. Therefore, the astute
therapist carefully considers the symptoms present for each person.
For example, a person may have pronator syndrome instead of CTS if:
61,72,74

• Pain is experienced with resisted pronation and passive

supination activities
• A positive Tinel sign at the proximal forearm is present
• Tenderness of the pronator muscle is evident
• “Numbness in the thenar eminence in the distribution of the
palmar cutaneous branch of the median nerve” is present 72
• Nocturnal symptoms are absent
• Muscle fatigue is present

TABLE 14.4

Median Nerve Lesions

 CMC, Carpometacarpal; DIP, distal interphalangeal; IP, interphalangeal; MCP,
metacarpophalangeal; PIP, proximal interphalangeal.

• Thenar atrophy is absent

• Phalen test is negative

CTS is a likely diagnosis for persons who have complaints of night

pain, symptoms with repetitive wrist movements (especially flexion),
weakness in thumb opposition and abduction, a positive Phalen test,
and a positive Tinel sign at the wrist. 74 If a person is referred with a
diagnosis of CTS and has symptoms of pronator syndrome, it is
recommended that the therapist call the referring physician and
discusses examination findings.
Frequently in persons with these syndromes, surgical procedures
are required to decompress the nerve. 7 On occasion a physician may
request an orthosis for conservative management of mild cases. For
example, for a mild case of pronator tunnel syndrome the physician
may prescribe an elbow orthosis to position the forearm in neutral
between pronation and supination and the elbow in flexion (Table
14.5). 10 This elbow position takes tension off the nerve, and the
forearm position prevents compression via pronator contraction or
stretch.
 FIG. 14.28 The classic median nerve deformity called an ape (or
simian) hand. Note thenar muscle atrophy of the left hand.

TABLE 14.5

Orthotic Interventions for Peripheral Nerve Lesions

MCP, Metacarpophalangeal.

The median nerve’s classic course and sensory distribution include

the volar surface of the thumb, index, middle, and radial half of the
ring fingers and the dorsal surface of the distal phalanxes of the
thumb, index, middle, and radial half of the ring finger (see Fig. 14.5).
Clients who have median nerve compression can experience
numbness, tingling, and paresthesia in this nerve distribution.
Because the area of sensory distribution is large, the therapist
monitors and educates clients or caregivers about the associated risks
and prevention of skin injury or breakdown.

Orthotic Interventions for Median Nerve

Injuries
Understanding the functional effects of the muscular loss resulting
from a median nerve injury or compression syndrome is important
because it influences the therapist’s orthotic provision. With a median
nerve lesion, if the therapist can maintain good passive mobility of the
joints, extensive orthotic intervention may be unnecessary, and
occasional night orthotic intervention may be sufficient. 25

Orthotic Intervention for Pronator Syndrome

Clients with pronator syndrome should avoid resisted pronation and
passive supination. 74 Other than changing activities that contribute to
pronator syndrome, the person may benefit from orthotic
intervention. One orthotic option is to place the elbow in 90 degrees
flexion and forearm in neutral rotation. 85

Orthotic Intervention for Anterior Interosseous Nerve

Compression
Besides the suggestion to avoid elbow extension and extreme forearm
pronation and supination, orthotic intervention options are
recommended for anterior interosseous nerve compressions. One
option is to immobilize the elbow in 90 degrees flexion and the
forearm in neutral. As discussed, impairments to the anterior
interosseous nerve result in difficulty making an O with the thumb
and index finger flexed. To compensate for this deficit, the therapist
fabricates a small thermoplastic orthosis to block thumb IP and index
DIP extension (Fig. 14.29). 17

Orthotic Intervention for Carpal Tunnel Syndrome

When manifestations of CTS are primarily sensory and occur from
overuse or occupational causes, orthotic intervention of the wrist often
reduces pain and symptoms. 7 To accompany the orthotic intervention
program for CTS, include interventions as follows: ergonomic
adaptations for home, leisure, and work environments; education on
prevention; activity modifications; range-of-motion program with
emphasis on tendon gliding exercises; and edema control techniques.
75 See Chapter 7 for an overview of efficacy studies on orthoses with

carpal tunnel intervention.

Usually, any orthosis for CTS positions the wrist as close to neutral
as possible. 62 This neutral position maximizes available carpal tunnel
space, minimizes median nerve compression, and facilitates pain
relief. 43,55 A newer approach to wrist immobilization orthotic design
includes the MCP joints to decrease pressure in the carpal tunnel (see
Chapter 7). A wrist immobilization orthosis is commonly worn at
night and sometimes during home, leisure, or work activities that
involve repetitive stressful wrist movements. 63 As discussed in
Chapter 7, the wearing schedule can vary. Minimally, nighttime wear
is required 63 to prevent extreme wrist flexion postures that often
occur during sleep. 75 Immobilization orthotic intervention with CTS
has shown to improve long-term nerve conduction outcomes when
consistently worn every night. 82 The wearing schedule is carefully
monitored to prevent weakening of the muscles as a result of
inactivity. 55 The orthosis may exacerbate symptoms if the person
fights against the orthosis. 79

FIG. 14.29 To encourage fingertip to thumb prehension, these small

orthoses help someone with anterior interosseus nerve palsy.
From Colditz, J. C. [2002]. Splinting the hand with a peripheral nerve
injury. In E. J. Mackin, A. D. Callahan, T. M. Skirven, et al. [Eds.],
Rehabilitation of the hand and upper extremity [5th ed., pp 622–634].
St. Louis, MO: Mosby.

Volar Wrist Immobilization Orthosis

Some clients and therapists prefer volar wrist orthoses, which provide
adequate support to the wrist. A volar wrist orthosis with a gel sheet
or elastomer putty insert may be beneficial to control scar formation
after carpal tunnel release surgery. A disadvantage of the volar wrist
orthotic design for CTS is that the orthosis may interfere with palmar
sensation. 7 Positioning the wrist in the orthosis is important. A poorly
designed wrist orthosis may compress the carpal tunnel area of the
wrist. Some people may benefit from a volar wrist orthosis because it
also immobilizes the MCP joints (see Chapter 7).

Dorsal or Ulnar Gutter Wrist Immobilization Orthoses

Other orthotic intervention approaches for CTS include fabrication of
a dorsal, ulnar gutter, or circumferential wrist orthosis. An advantage
of the dorsal wrist orthosis is that there is no thermoplastic material
directly over the carpal tunnel, thus avoiding compression as well as
no interference with palmar sensation. However, a disadvantage of
the dorsal wrist orthosis is that it may not provide as much support
and/or distribute pressure as well as the volar wrist orthosis. Some
therapists fabricate the dorsal orthosis with a larger palmar area to
increase support. An ulnar gutter wrist orthosis positions the wrist in
neutral and is less likely to compress the carpal tunnel. A
circumferential wrist orthosis provides a high degree of wrist
immobilization (see Chapter 7).
 FIG. 14.30 A thumb web spacer for median nerve injuries.

Some clients may be more comfortable with soft prefabricated wrist

orthoses that are appropriately sized based on manufacturer
recommendations. The therapist must check the orthosis on the client
to ensure a correct fit for function and preservation of hand structures
based on clinical reasoning. 2 (Refer to Chapter 7 for ideas for
prefabricated orthoses.) Clients are educated to avoid pulling the
strapping too tightly to avoid inadvertent compression of the median
nerve.

Orthotic Intervention for Median Nerve Injuries

With Thumb Involvement
For a client who has a median nerve injury involving the thumb,
which occurs in the later stages of CTS, the therapist addresses loss of
thumb opposition for functional grasp and pinch. The orthosis
positions the thumb in opposition and palmar abduction, which
assists the thumb for tip prehension. A C bar between the thumb and
the index finger helps maintain the thumb web space. The thumb web
space is a common site for muscular shortening of the adductor
pollicis after median nerve damage. The orthotic design is usually
static. A person with a median nerve injury with thumb involvement
may benefit from a hand-based thumb orthosis (see Chapter 8).
For a low-level median nerve injury the therapist may fabricate a
thumb web spacer orthosis constructed from thermoplastic material
or out of other materials, such as out of Neoprene. Prefabricated
orthoses that position the thumb can also be provided (Fig. 14.30).

Orthotic Intervention for Combined Median

and Ulnar Nerve Injuries
Sometimes with extensive low-level injuries, both median and ulnar
nerves are involved and clawing is evident in all fingers due to
intrinsic weakness and the loss of the flexor digitorum profundus. In
such cases, orthotic intervention to prevent further deformities entails
designs that are for a singular nerve injury but with all digits
included. The thumb may be incorporated if it is affected (Fig. 14.31).

FIG. 14.31 This orthosis inhibits metacarpophalangeal (MCP)

extension with a combined median and ulnar nerve.
From Fess, E. E., Gettle, K. S., Philips, C. A., et al. [2005]. Hand and
upper extremity splinting: Principles and methods [3rd ed.]. St. Louis,
MO: Elsevier Mosby.
Summary
There are various orthotic interventions with general guidelines to
consider for nerve injuries. Orthotic intervention for nerve injuries
involves comprehensive knowledge of the muscular, sensory, and
functional implications for each client. The therapist must note that
there are general guidelines and physicians and experienced
therapists may have other protocols for positioning and orthotic
intervention.

Patient Safety Tips and Precautions Box

• Be aware of natural reactions to a nerve injury, including skin

changes, muscle imbalance with possible deformity and joint
contracture, and circulatory changes such as cold skin.
• Teach patients to regularly inspect their skin, especially with
median/ulnar nerve injuries because of sensory loss.
• Avoid heavy lifting or resistance, as well as forceful or repetitive
motions.
• Pay attention to potential pressure areas from the orthosis, and
pad or push out thermoplastic material over any sensitive areas.
• Pay attention to cleaning the orthosis and wound care
management.
• Do not neglect nail care despite orthotic intervention.
• Be aware of protecting versus overprotection. Overprotection of
injury while wearing the orthosis may cause decreased motion
and put the client at further risk for contractures or deformity.
• Be aware of substitution motions, which are a normal reaction
after a nerve injury to protect and decrease pain. These unnatural
movements may cause further harm to a recovering nerve and
put the client at risk for muscle imbalance.
Review Questions
1. Which factors are important in the prognosis of a
peripheral nerve lesion?
2. What are the common deformities resulting from radial,
ulnar, and median nerve lesions?
3. What are the functional implications of radial, ulnar, and
median nerve lesions?
4. What are the orthotic intervention options for radial nerve
injuries? In which position should the therapist place the
hand?
5. What is the proper type, position, and thermoplastic
material needed for fabrication of an orthosis for ulnar
nerve compression at the elbow?
6. What is the proper orthotic position for a claw hand
deformity? Why is this a good position?
7. What are the advantages and disadvantages of the
different approaches to wrist orthotic intervention for
CTS?
8. What is the appropriate position in which to place a hand
with a median nerve lesion that includes thumb
symptoms?

a
Self-Quiz 14.1
For the following questions, circle either true (T) or false (F).
1. T F With neurapraxia, the prognosis is extremely good
 because recovery is usually spontaneous.
2. T F Functionally a client diagnosed with a radial nerve
injury has a poor grip because of wrist positioning.
3. T F The main purpose of orthotic intervention for a nerve
injury is to immobilize the extremity.
4. T F The claw hand deformity is more pronounced with a
low-level ulnar nerve injury.
5. T F The therapist should position an elbow orthosis in 110
degrees of flexion for a client who has an ulnar nerve
compression at the elbow level.
6. T F For an ulnar nerve orthosis the therapist should
position the ring and little fingers in approximately 30 to
45 degrees of MCP flexion.
7. T F An option for orthotic provision for radial nerve
injuries is a wrist or hand immobilization orthosis for
nighttime use and a mobilization orthosis that places the
wrist in extension and the MCPs in neutral extension.
8. T F The therapist should immobilize radial, ulnar, and
median nerve injuries only in static orthoses.
9. T F The Froment, Jeanne, and Wartenberg signs are
postures indicative of median nerve injuries.
10. T F Functionally a client diagnosed with an ulnar nerve
injury has loss of pinch strength and power grip.
11. T F The therapist may use a thumb web spacer orthosis
for a median nerve injury.
12. T F Low-level nerve injuries occur only distal to the wrist.
a
See Appendix A for the answer key.

a
Self-Quiz 14.2
Match the following nerve conditions with the appropriate upper extremity
positions required for conservative orthotic intervention.
1. Ulnar tunnel syndrome
2. Pronator syndrome
3. Anterior interosseous syndrome
4. Radial tunnel syndrome
5. Posterior interosseous nerve syndrome
6. Cubital tunnel syndrome
7. Wartenberg neuropathy
8. Carpal tunnel syndrome (CTS)
a. 90 degrees elbow flexion and neutral forearm and/or a
small orthosis to block index DIP and thumb IP extension
or hyperextension
b. 30 to 45 degrees MCP flexion of the fourth and fifth digits
c. 20 to 30 degrees wrist extension
d. 30 to 40 degrees wrist extension and neutral MCP
extension
e. 30 to 45 degrees elbow flexion
f. 90 degrees elbow flexion and neutral forearm
g. Slight wrist extension
h. Neutral wrist

a
See Appendix A for the answer key.
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85. Slutsky D.J. New advances in nerve
repair. In: Skirven T.M, Osterman A.L, Fedorczyk J.M, et
al., eds. Rehabilitation of the hand and upper extremity
. 6th ed. Philadelphia: Elsevier Mosby; 2011:611–618.
86. Spinner M. Nerve lesions in
continuity. In: Hunter J.M, Schneider L.H, Mackin E.J, et
al., eds. Rehabilitation of the hand . 3rd ed. St.
Louis: Mosby; 1990:523–529. .
87. Sunderland S. The peripheral nerve trunk in relation
to injury: a classification of nerve
injury. In: Sunderland S, ed. Nerves and nerve injuries
. Baltimore: Williams & Wilkins; 1968:127–137.
88. Tung T.H. Nerve
transfers. In: Skirven T.M, Osterman A.L, Fedorczyk J.M, et
al., eds. Rehabilitation of the hand and upper extremity
. 6th ed. Philadelphia: Elsevier/Mosby; 2011:813–822.
89. Upton A.R, McComas A.J. The double crush in nerve
entrapment syndromes. Lancet . 1973;2:359–362.
90. Vender M.I, Truppa K.L, Ruder J.R, et al. Upper
extremity compressive neuropathies. Phy Med
Rehabil: Stat Art Rev . 1998;12(2):243–262.
91. Waldman S.D. The Jeanne sign for ulnar nerve
entrapment at the elbow. In: Waldman S.D, ed.
Physical diagnosis of pain: an atlas of signs and symptoms
. 3rd ed. St. Louis: Elsevier; 2016:132.
92. Walsh M. Personal communication . June 2012.
93. Ziegler E.M. Current concepts in orthotics: a diagnosis-
related approach to splinting . Germantown, WI: Rolyan
Medical Products; 1984.
Appendix 14.1 Case Studies
Case Study 14.1 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Mark is a 52-year-old man who is employed as a truck driver.
During driving his elbow is positioned in flexion, and he often rests
his left elbow on the window seal. Mark sleeps with his elbow flexed
behind his head. Over time Mark developed compression of the ulnar
nerve at the elbow, which manifested by interosseous weakness with
a positive Wartenberg sign and a positive Froment sign. He complains
of discomfort on the medial side of the arm and continuous numbness
and tingling in digits 4 and 5.

1. Functionally, what might Mark have difficulty doing?

2. What is the correct orthosis for his condition?
3. What are the correct positions for his joints in the orthosis?
4. After being fitted with a custom thermoplastic orthosis, Mark
complains that he does not like the hard feel of the material.
What would you do?
5. What is your suggested wearing schedule?
6. What other lifestyle adjustments would be suggested?

Case Study 14.2 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter. Indicate all answers that
are correct.
Diana sustained a fall breaking the middle third of her right
humeral shaft. Diana later reflected that it was a classic beautiful
summer evening when the fall happened. She had been taking a
leisurely walk with her fiancé, and when walking across a bridge, she
turned around to admire the view. In the dark she did not see a pole
sticking out of the middle of the bridge. This led to a fall on the hard
surface of the bridge. In the emergency department the physician
identified not only a fracture of the right humeral shaft, which needed
to be set, but a complete transection of the radial nerve. After surgery
you (the therapist working with her) have been ordered to provide
therapy for Diana and an orthosis for her radial nerve condition.

1. Which of the following motion difficulties would you expect to

see with Diana?
a. Difficulty with abduction of the carpometacarpal
(CMC) joint of the thumb, weakness with thumb
opposition and with interphalangeal (IP) extension,
and weakness with metacarpophalangeal (MCP)
flexion of the second and third digits.
b. Difficulty with MCP extension, wrist extension,
thumb abduction and extension, as well as
weakness with elbow flexion/extension, wrist
extension, and deviation.
c. Difficulty with wrist flexion and adduction, flexion
of the distal interphalangeal (DIP) of the fourth and
fifth digit, MCP flexion of the fifth digit and
opposition, and abduction and adduction at the
MCP joints. Difficulty also with some thumb
motions, especially with thumb adduction.
d. Diana will not have motion difficulties and will
experience only sensory difficulties.
2. What is one optional type of orthosis for the condition that you
might consider providing?
a. Volar wrist orthosis
b. Dynamic tenodesis suspension orthosis
c. Thumb immobilization orthosis
d. Elbow extension orthosis
3. What is the functional advantage of this orthosis?
a. The design allows the dorsal surface of the hand to
be relatively free
 b. The wrist and thumb can move
c. The fingers are not immobilized
d. The hand is completely free to move
4. What would be your suggested wearing schedule?
a. Only during painful activities
b. All the time with removal for hygiene
5. What could be another orthotic option for Diana?
a. A low-profile orthosis for the condition that allows
radial and ulnar deviation
b. Thumb immobilization orthosis
c. Static orthosis with fourth and fifth digits in 30
degrees of flexion
d. Thumb web spacer orthosis
Appendix 14.2 Laboratory Exercises
Laboratory Exercise 14.1 a
Metacarpophalangeal Extension Hand-
Based Orthosis
Read the following scenario, and use your clinical reasoning skills to answer
the question based on information from the chapter.
Adena is a 36-year-old right-handed woman who presents with left
forearm level posterior interosseous nerve syndrome. The physician
referred Adena to a therapist for orthotic fabrication and a home
exercise program. The therapist wrote the following SOAP note in an
electronic health record system:

S: “I really want to get better fast.”

O: Pt. presented with posterior interosseous nerve syndrome.
Manual muscle testing (MMT) scores for the extensor
digitorum communis, extensor digiti minimi, extensor indicis,
abductor pollicis longus, and extensor carpi ulnaris were all 0
(zero). Pt. reports no pain in the left upper extremity (LUE). A
left low-profile radial nerve palsy orthosis with radial and
ulnar deviation was fabricated and fitted. Pt. was instructed in
how to don and doff the orthosis and how to grasp and release
objects. Pt. was also instructed verbally and given written
information on the wearing schedule, orthotic care, and
precautions. Pt. was given a home exercise program to be
completed five times daily.
A: Pt. was receptive to the orthosis and home exercise program.
Pt. could independently grasp objects while wearing the
orthosis. Anticipate compliance with wearing schedule and
home exercise program.
P: Will monitor needs for modifications of the orthosis and home
exercise program.
 Several appointments later the client regained muscle strength with
an MMT score of fair (3) wrist extensors. The forearm portion of the
orthosis was removed, and the client was instructed to wear the hand
component of the orthosis. The therapist encouraged the patient to
continue with activities of daily living (ADLs) and the home exercise
program and initiated gentle strengthening activities. The orthotic-
wearing schedule and home exercise program were modified. The
client was instructed to complete the program five times daily. The
client had no complaints and was able to independently grasp light
objects while wearing the orthosis.
Write the next progress note.

Laboratory Exercise 14.2 Anticlaw Orthosis

On a partner, practice fabricating a hand-based orthosis in the
anticlaw position for a client who has an ulnar nerve lesion. Refer to
options provided in the chapter (figure-eight orthosis, hand-based
static orthosis, or hand-based mobilization orthosis). Before starting,
determine the position to place the person’s hand. Remember to
position the MCP joints of the ring and little fingers in approximately
30 to 45 degrees of flexion. After fitting the orthosis and making all
adjustments, use Form 14.1. This check-off sheet is a self-evaluation of
the orthosis. Use Grading Sheet 14.1 as a classroom grading sheet.
Appendix 14.3 Form and Grading Sheet
Form 14.1 Anticlaw Orthosis
Grading Sheet 14.1 Anticlaw Orthosis
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
15
Orthotic Provision to Manage
Spasticity
Salvador Bondoc, and Elizabeth Kloczko

CHAPTER OBJECTIVES
1. Define spasticity.
2. Compare the strengths and weaknesses of dorsal and volar
forearm platforms.
3. Discuss orthotic design based on a neurophysiological rationale.
4. Discuss orthotic design based on a biomechanical rationale.
5. Differentiate between the elastic and contractile properties of
muscle and describe their implications on using an orthosis.
6. Describe the properties of alternative materials to thermoplastics
and plaster and fiberglass casts used for neurological orthoses.
7. Successfully fabricate and clinically evaluate the proper fit of a
dorsal forearm–volar hand immobilization orthosis.
8. Use clinical judgment to correctly analyze two case studies.

KEY TERMS
biomechanical
composite extension
contracture
minimalist design
Neoprene
neurophysiological
orthosis
plaster bandage
serial casting
spasticity
stretch reflex
submaximal range
task-oriented approach

Lucille is a homemaker and a stroke survivor. Three years ago she

sustained an infarction to her right middle cerebral artery that resulted
in left-sided weakness (hemiparesis) and spasticity. She underwent
nearly 4 months of rehabilitation, starting with an intensive inpatient
rehabilitation stay followed by home health until she was able to walk
with a cane. Although outpatient services were recommended, she did
not pursue this due to insurance limitations. During her annual
physical she told her primary care provider that she has been
experiencing increased pain and stiffness in her left arm and hand, along
with fatigue and unsteady balance. Her provider recommended a
neurologist to rule out a recurrence of a stroke. After a series of
diagnostic procedures, the neurologist determined that what Lucille was
experiencing was a syndrome of late effects from her hemiparesis. Her
neurologist suggested antispasticity medications and a referral to
occupational and physical therapy as an outpatient. During her first
therapy session the occupational therapist determined that Lucille could
benefit from an orthotic program to prevent further stiffness of her wrist
and hand. Both the therapist and Lucille collaborated on priority goals
and a plan of care, which includes a modified form of constraint-induced
movement therapy to help her regain as much functional use of her arm
and hand while also reducing her pain and stiffness.
 Occupational therapy practitioners, throughout the continuum of
care, encounter individuals who are developing abnormally or who
are recovering from damage to the central nervous system (CNS).
Damage and abnormal development of the brain or spinal cord can
result in an imbalance of muscle activity. Therapist and client
collaborative goals when addressing spasticity must revolve around
functional outcomes, pain management, and health and hygiene. In
this chapter spasticity will be defined, options for orthotics will be
outlined to guide the therapist in critically thinking about the
intervention used in an individualized manner, splinting patterns will
be provided, and case studies will be applied for clinical learning.
Spasticity
Spasticity is defined as a velocity-dependent increase in muscle tone
due to hyperactive stretch reflex. 5,44 The defining feature of velocity
dependence is highlighted when clinicians assess spastic tone by the
degree and extent of resistance to passive stretch. Some scholars have
expanded on the definition of spasticity to highlight other
manifestations of impaired motor control, including the loss of normal
reciprocal inhibition and abnormal coactivation of agonist and
antagonist muscles during active movement. 12,40,46 This definition has
important implications for therapy management using a problem-
solving and evidence-based approach.
The onset of spasticity is associated with upper motor neuron
lesions (UMNLs) seen in many common CNS conditions, such as
cerebrovascular accident, cerebral palsy, traumatic brain injury, spinal
cord injury, and multiple sclerosis. During the acute stages following
the onset of the lesion, spasticity affects motion by restricting active
and passive movement in the direction of the agonist (e.g., spasticity
in the flexors limits agonistic extension). From acute to chronic stages
the loss of upper motor neuron (cortical) inhibition on the reflex arc 72
continues to perpetuate the spasticity, which further exacerbates the
loss of motion. Movement restriction brought on by spastic or
hypertonic muscles leads to contracture formation, or tissue
shortening in the immobile muscles. Muscles atrophy, sarcomeres are
lost, and muscle fibers undergo fibrotic changes. 20,53,62 This state of
shortening of spastic muscle further increases the muscle’s sensitivity
to stretch 32 and therefore greater resistance to agonist movement and
more subsequent loss of motion. In addition to the muscle shortening,
contractures may also develop to the soft tissues that surround the
joints where the spastic muscles cross, causing joint stiffness, and in
severe cases, joint ossification or arthrodesis. Unabated spasticity may
cause pain and muscle spasms with either passive or active
movement, further leading to immobility. Thus, with the onset of
spasticity a negative cycle of neurological and biomechanical
pathophysiological processes ensues. Early intervention and ongoing
management are key to abating the impairment process.
Given the complexity of spasticity, effective management requires a
multidisciplinary effort. Medical management is conducted primarily
using pharmacological agents. These agents vary in their
pharmacokinetics and therapeutic effects, including a generalized
reduction in the excitability of the spinal reflex arc (via oral or
intrathecal medications) or localized functional denervation of
muscles (via nerve block or neurotoxin injections). 29 Medical
management must be complemented by rehabilitative intervention
with major considerations to the pathophysiological processes
associated with spasticity and their functional consequences.
Rehabilitative intervention for spasticity should be multipronged
with the goals of maintaining biomechanics, preventing further
musculoskeletal and neuromuscular impairments and pain, regaining
motor control, and relearning functional limb use. To achieve these
goals the use of multiple techniques or modalities, including orthotics,
is necessary, in combination with pharmacological treatment options.
6,8 (A discussion of other modalities or therapeutic procedures goes

beyond the scope of this chapter.) Furthermore, the development of an

intervention plan should be individualized. Specific to the use of
orthoses to manage spasticity, there is no one-size-fits-all approach
(Table 15.1). The therapist’s challenge is to use clinical reasoning to
problem solve the issues brought on by spasticity and minimize their
negative impact on function and activity. It must be stressed that the
use of orthotic devices is only part of a comprehensive intervention
plan for persons with neurological conditions with UMNL
manifestations.
In terms of research-based evidence, studies present conflicting
recommendations, making the practice of orthotic provision to
manage spasticity controversial. Systematic reviews such as those by
Hellweg and Johannes, 34 Autti-Ramo and colleagues 3 and Mortenson
and Eng 50 favor the use of orthoses to manage spasticity, whereas
systematic reviews by Lannin and Herbert 42 and Katalinic and
colleagues 38 provide counterevidence for the use of orthoses as a
modality for spasticity management. Furthermore, a comprehensive
review of theory and evidence indicates that “static splinting has not
been able to demonstrably reduce either spasticity or contracture and
since it was shown to do neither, a subsequent effect on activity was
also not detected.” 43 This statement should, however, not be
construed as a call to abandon the practice of orthotic provision
altogether. To reiterate, orthoses should not be regarded as the sole
modality to manage spasticity but rather an important component of a
multidimensional and multidisciplinary approach. Hardy and
colleagues 33 studied the collaboration of use of an orthotic and
electrical stimulation, which were shown to reduce spasticity as
measured by the Modified Ashworth Scale and to improve overall
function over time, specifically in the fingers. 33 An in-depth
understanding of the pathophysiological process of spasticity,
knowledge of current evidence to manage spasticity, and sound
clinical judgment are keys to a successful orthotic intervention
program.
Orthotic Designs for the Neurologically
Impaired Hand
Applying orthotics to the neurologically impaired upper extremity is a
widespread and long-held practice in physical rehabilitation.
However, there remains a lack of consensus among practitioners and
researchers on which approach is best. Two surveys of practitioners,
conducted 30 years apart, illustrate this lack of consensus in terms of
when orthotics is indicated and which design and theoretical rationale
is preferred. 1,52 Scholars have criticized the continued use of orthoses
for persons with neurological impairment in the clinic for its lack of
“effect in reducing spasticity… or in preventing contracture.” 43
Katalinic and colleagues 38 further concluded that stretch (as often
accomplished through orthotic provision for the hand) “does not
produce clinically important changes in joint mobility, pain, spasticity
or activity limitation.” 33 Others have found no significance in
improvement of spasticity, range of motion, or function. 4 Alternatives
such as adhesive taping have also proved to be more effective than
manual stretching and passive splinting after botulinum toxin type A
injections. 60 Although these evidence-based statements may be
bothersome to adherents of clinical traditions, they should not be
construed as a call to abandon orthotic provision altogether. As
comparison, Charlton 16 highlights that because of muscle imbalance
the potential exists for contracture development due to loss of range of
motion, which can lead to pain, impaired function, and hygiene and
skin breakdown issues. Applying an orthotic can be used as
prevention or work toward remediation of motion range. Thibaut and
colleagues 68 found that using a soft design has advantages for clients
with disorders of consciousness. This design allows for client
contraction and reflexes while maintaining positioning specifically in
the hand. 68 Therefore clinicians should undergo deep critical
reflection on how orthoses should be used in practice. It should be
noted that results of systematic reviews and meta-analyses are
aggregates of select information to answer a broad clinical question.
Nuances of original studies are lost. In an attempt to generate
homogeneity, many smaller studies including “N = 1” or single-case
designs and case series studies are routinely excluded from systematic
reviews, even though they are considered acceptable alternatives to
large randomized experiments. Given that clients are unique not only
in their clinical manifestations but also in how they respond to
rehabilitative interventions, it may be argued that managing spasticity
is an “N = 1” practice. Evidence-based reasoning requires that
clinicians not only critically appraise the evidence but also reflect on
the individual client’s needs and how they match with the evidence.

TABLE 15.1

Evidence-Based Practice of Orthotic Intervention to Manage Spasticity

VS/UWS, Vegetative state/unresponsive wakefulness syndrome.

Contributed by Whitney Henderson.

Client-centered practice indicates that the client’s needs and

concerns are the main consideration. To that end, therapists need to
consider the individualization of the intervention plan based on the
client’s presentation. Not all clients with neurological impairment
present with the same muscle tone, not all clients with spasticity
benefit from the same orthotic type and prescription, and not all
clients require an orthosis. One important consideration is whether
the use of an orthosis for the neurologically impaired hand can, in
some cases, contribute to disuse or learned nonuse. 66 If the impaired
hand is further obstructed by the orthotic device during task
performance, the potential benefit of the orthosis is outweighed by the
negative consequence on function. Therapists must reflect on the
clinical rationale for orthotic provision, including inhibition of tone,
management or prevention of contractures, or active facilitation of
neuromotor recovery. It stands to reason that depending on the goal
or indications of the orthosis and the clinical presentation of the client,
clinicians vary in their designs and prescriptions for use. Ways in
which designs vary may be categorized based on theoretical
orientation, biomechanics, and overall practical considerations.
However, key to a successful management is constant monitoring of
the client’s response and ongoing problem solving with the client to
attain therapeutic goals.

Design Based on Theory

There are two prevailing theoretical orientations that inform the use of
orthoses for spasticity: neurophysiological and biomechanical. From a
neurophysiological perspective, orthoses may be used to influence
muscle tone by either inhibition or facilitation. From a biomechanical
perspective, orthoses may be used to provide stretch to muscles to
minimize the onset of contractures brought on by spasticity. The
biomechanical orientation is discussed in later sections.
 FIG. 15.1 Prefabricated resting hand orthosis.
Courtesy North Coast Medical, Gilroy, CA.

In general, design incorporating the neurophysiological perspective

varies according to (1) location of the hand-wrist-forearm platform
and (2) the configuration of the hand component (including the
position of the digits). Rehabilitation science literature contains
proponents for volar platforms 10,54,74 and dorsal platforms. 13,15,37,63
Dorsal platform adherents argue that cutaneous stimulation of the
volar surface of the hand and forearm triggers greater spasticity.
19,35,47 Volar platform adherents argue that sustained pressure on

flexor tendon insertions results in muscle relaxation. 24,64 Both

assertions have yet to be proven through well-designed empirical
methods because other authors see no greater advantage for one
platform design over the other. 42,49,59 Both volar- and dorsal-based
forearm platforms may be custom fabricated (refer to Chapter 13) or
prefabricated, which can be accessed through vendors and catalogs.
Fig. 15.1 is an example of a prefabricated orthosis.
In terms of the configuration of the hand component, one design
approach based on neurophysiological theory relies on the positioning
of the thumb and fingers. As with the platform location, the
positioning of the digits in either flexion over a rigid cylinder 24,25,58 or
extension and abduction using a “finger spreader” 8,18,74 is purported
to reduce spasticity. In addition to reducing spasticity, other factors
such as improved mobility and functional ambulation have been
connected to use of a reflex inhibitory design. This design involves the
wrist at 20 to 25 degrees extension, thumb positioned in opposition,
and fingers spread with a dorsal cover to provide complete volar
contact to reduce stimulation potential for reflex. 65 Earlier designs
incorporating positioning of the thumb and fingers did not
incorporate a forearm platform to provide support to the wrist and
take advantage of biomechanical leverage to maintain the position of
the orthosis on the hand. Over the years, commercial providers of
orthoses and expert clinicians (through textbooks) have incorporated
the forearm platform as an important design feature (Fig. 15.2).
Examples of the cone configuration are the Rolyan Deluxe Spasticity
Hand Splint and the Comfy Adjustable Cone Hand Orthosis. An
example of the finger spreader configuration is the Rolyan Deluxe
Spasticity Hand Splint (Fig. 15.3). Adding a forearm component not
only improves the leverage of the orthosis but also prevents the
spastic long flexors from acting on the wrist.
 FIG. 15.2 A, Prefabricated cone orthosis with forearm trough. B,
Prefabricated cone orthosis without forearm trough.

There are two types of cylindrical orthotic designs for the hand
component found in the literature: cone orthoses and dowel orthoses.
Cone orthoses are constructed of rigid thermoplastic material with the
smaller end placed radially and the larger end placed ulnarly to
provide maximum palmar contact. The optimal contact is designed to
provide deep tendon pressure on the wrist and finger flexor insertions
at the base of the palm. Farber 24 observed that the total contact from
the hard cone provides maintained pressure over the flexor surface of
the palm, thus assisting in the desensitization of hypersensitive skin.
MacKinnon and colleagues 45 adapted the standard hard cone to a
solid wood dowel that exerts pressure on the palmar aspect of the
metacarpal heads and exposes a larger surface area of the palm for
sensory input compared to a cone. Although the shape of the hand
may appear similar, the authors’ rationale could not be any more
different from each other. Pressure on tendon insertion created by the
cone orthosis was intended to inhibit spasticity, 25 whereas the
pressure applied on the palmar surface around the metacarpal head
region by the hard dowel was purported to provide facilitation of the
deep hand intrinsics. 23,45 The efficacy of these orthotic designs has yet
to be evaluated through studies with a larger sample and more
rigorous methods.
 FIG. 15.3 Prefabricated finger spreader/ball orthosis.

In contrast to keeping the fingers in a flexed position, there are

proponents of orthoses that require maintaining finger and thumb
abduction and extension. Largely based on neurodevelopmental
treatment, 8,18 the position of digital extension and abduction is
considered a reflex-inhibiting pattern (RIP) that inhibits flexor
spasticity of the hand. From Bobath’s original foam block design that
spreads the fingers apart, clinicians developed versions with more
rigid and custom-molded thermoplastic materials that also
incorporate the wrist and forearm. 21,41 The abducted thumb
component is key to the RIP effect (relaxation of spasticity) and for
proper fit and comfort. 21 The elements of the RIP pattern described
earlier are to be contrasted with those of Pizzi and colleagues, 55
where the RIP pattern for the hand is described as the “…wrist in 30
degrees of extension, normal transverse arch, thumb in abduction and
opposition with the pads of the 4 fingers, and metacarpal and
proximal interphalangeal (PIP) joints in 45 degrees of flexion.” 55

Design Based on Biomechanics

Orthoses may be designed to address the biomechanical properties of
muscles. Muscles are made of contractile and elastic components. 26
The contractile components are composed of the myofilaments that
respond to neural excitation. These myofilaments are serially arranged
into myofibrils, which are bundled to form muscle fibers. The elastic
components of a muscle are part of connective tissue, along with
collagen, that wraps around and runs parallel with the muscle fibers
and muscle tissues. The maintenance of the number of the contractile
myofilament units, or sarcomeres, and the size of the muscle are use
dependent. Therefore, lack of use or disuse leads to muscle atrophy
via reduction in the size or number of sarcomeres, especially when the
muscle is in a shortened state. 30 Muscle disuse in persons with CNS
conditions is brought on by lack of motor control, muscle weakness,
decreased movement or immobilization, and spasticity. Confounding
the loss of muscle mass is the onset of contractures, which causes a
decrease in range of motion.
Contractures or shortening of soft tissues may occur to the joint
capsule that is immobilized and to the connective tissue surrounding
the inactive or disused contractile muscle tissues. The onset of
contractures is time dependent; that is, with prolonged immobility or
lack of use, there is loss of elasticity to the soft tissues, which makes
for increased resistance to passive or active stretch. In spastic muscles
the presence of contractures may accentuate the stretch reflex
sensitivity 32,48 further, causing the muscles to shorten at rest and
become more resistant to movement in the antagonist direction. The
stretch reflex can be triggered at any point of the range of motion arc,
thus limiting free range of motion. This phenomenon makes clinical
measurement of spasticity challenging because it may be masked by
the presence of contractures.
Given the biomechanical properties of muscles, an intervention
program for spasticity incorporates promoting muscle activity to
address disuse atrophy and maintain the elasticity of tissues through
stretch to address the onset of contractures. Stretch for the hand, wrist,
and/or elbow may be best achieved through prolonged orthotic use or
casting. Orthoses may be preferred if the intervention plan requires
active use since they are removable. Casts are preferred if prolonged
and sustained stretch is needed, especially when the spasticity is
severe and the soft tissue contractures significantly limit range of
motion. At times a bivalve configuration allows for both prolonged
stretch and removal for intervention. The bivalve cast can be removed
to allow for additional techniques such as weight bearing and
functional reaching to be incorporated into spasticity management.
For the lower extremity, full weight bearing may suffice to maintain
the requisite stretch. 72
Controversies exist regarding the amount of time needed to sustain
the stretch to maintain soft tissue length. In a meta-analysis conducted
by Katalinic and colleagues 38 there is a wide variation in the
frequency and duration in the application of stretch to address
contractures in persons with neurological conditions. The pooled
outcomes neither favor the control nor the intervention (stretch).
Study results varied in relationship to the immediate, short-term, and
long-term effects of the intervention. Despite the variations in
intervention protocol and outcomes, the authors concluded the
following: “Regular stretch does not produce clinically important
changes in joint mobility, pain, spasticity or activity limitation in
people with neurological conditions.” 38 It must be noted that studies
included in the meta-analysis are exclusively randomized control or
controlled clinical trials. Thus, studies that do not have a control or
comparison group were excluded.
 FIG. 15.4 Prefabricated Neoprene thumb orthosis.

Adding to the confusion is the debate on how much stretch is

applied. Lannin and Ada 43 criticized the use of submaximal orthotic
positioning (5 to 10 degrees below maximum passive range), citing the
“functional” position described in textbooks is not supported by
evidence and contradictory to findings about the benefits of maximal
stretch. Many authors recommended positioning the spastic muscles
in optimal stretch to achieve an inhibitory effect. 25,32,63,70 On the other
hand, some authors recommended orthotic positioning with the wrist
and hand in extension but with substantial consideration to the point
when the stretch reflex is triggered. 48,54,59,69 Scherling and Johnson 61
suggested that wrist extension of 10 to 15 degrees and
metacarpophalangeal (MCP) joint extension of −45 degrees offers a
good starting position that is less likely to trigger the stretch reflex
while gradually introducing passive stretch to the spastic muscles.
 Given the dynamic nature of spasticity, the optimal position may
not be the same for all clients. Even with the same client, spasticity can
fluctuate at any given time. Anecdotal reports from clients indicate
that the time of day, type of activity, fatigue/energy levels, emotional
status, and weather may influence tone. In consideration of this issue,
therapists should adopt a concept of spasticity management as a 24-
hours-a-day regimen. With regards to the use of orthoses, there are
alternatives that are flexible or conformable to the fluctuations in a
client’s tone. Examples of softer, more dynamic materials found to be
effective in managing the spastic arm and hand include Lycra 7,22,31
and Neoprene. 14,67 Neoprene-based thumb orthoses such as the
TheraKool Breathable Neoprene Thumb Spica and the Benik Pediatric
Neoprene Glove are commercially available (Fig. 15.4). Another
design that combines both flexible and rigid components is the
SaeboStretch (Saebo Inc., Charlotte, NC), where the forearm volar
platform is made of thin rigid metal and the flexible metal-based volar
hand component is interchangeable (Fig. 15.5). The metal components
are padded adequately with Neoprene-based material, and the straps
vary in widths according to the body part and are made of rigid
silicone material. While case reports have been described, 9 the
orthosis requires further examination through rigorous empirical
studies. The dynamic hand wrist orthosis with Ultraflex hinge serves
as an alternative, incorporating a low-load prolonged-stretch
approach, which reduces spasticity and reduces pain caused from
static stretch in chronic stroke clients. 2
 FIG. 15.5 SaeboStretch orthosis.

With various conflicting evidence to draw from, the best

recommendation is always to be judicious in the interpretation of the
studies and consider the client’s unique clinical presentation. Because
a client’s neuromuscular presentation varies, a successful intervention
plan is one that is consistently monitored and adjusted as needed in
response to the client’s changing status.
Managing the Neurologically Impaired
Hand Using a Problem-Solving
Approach
When a client sustains an UMNL, a clinical syndrome consisting of
impaired reflex function (hyperreflexia), muscle weakness, and
impaired motor control is expected. As described earlier, spasticity,
though associated with UMNL, may not be clinically manifested. In a
longitudinal study of clients with stroke conducted by Wissel and
colleagues, 73 nearly 25% developed spasticity in the first 2 weeks of
onset. Some of the clients with initial spastic manifestation have a
decrease in spasticity to levels that are not clinically detectable,
whereas others have a worsening condition, especially if early
intervention is not provided. There are clients who develop spasticity
at a much later time, yet many will not develop any spasticity. With or
without spasticity, the focus of intervention is on regaining active
function and preventing secondary impairments (i.e., disuse, atrophy,
and contractures).
Many clients who develop spasticity are preceded with a
flaccid/hypotonic and a reflexive/hyporeflexive presentation. When
muscles are flaccid, the hand rests in a dependent position, such as a
“wrist drop” with an “ape hand” posture. The dropped wrist position
is due to lack of extensor muscle control, whereas the ape hand
position of hyperextended MCP joints with partial interphalangeal
flexion is due to the passive tension of the extensor digitorum caused
by the flexed wrist. To preserve the normal length-tension balance
between the flexors and the extensors of the wrist and hand, an
orthosis that positions the wrist in slight extension and the digits in
composite extension is recommended. (Note: Composite means that the
entire kinematic chain of a digit involving MCP, PIP, and distal
interphalangeal joints is positioned as a unit.) The resting position of
the hand places the digits in partial flexion (due to passive tension of
the elastic components of the flexors). This position keeps the joints in
extension, which provides gentle, static stretch to the flexors to
preserve the length of the muscle fibers. A volar forearm hand
immobilization orthosis is appropriate as a resting and positioning
device, especially when muscle tone is considered flaccid. With a
greater than neutral extension of the wrist, the orthosis may facilitate
edema reduction to the hand.
In clients with acute UMNL, there is a propensity for flexor
contractures. Early anticipation of the contracture and subsequent
preventive orthotics in extension is good practice. Over time the
elastic properties of the muscle adapt to the position of static stretch.
Depending on the extent to which the extensors of the digits needed
to approximate the requisite aperture size for the hand during
pregrasp and release, the orthosis can be adjusted to increase the
stretch on the flexors. For example, to actively grasp a water bottle, the
wrist is stabilized in slight extension, and the fingers and the thumb
must compositely extend to an aperture slightly greater than the
diameter of the bottle. Therefore the clinician must assess whether the
client can be passively stretched pain-free in composite wrist, hand,
and elbow extension that approximates the desired hand-wrist
position during reach-to-grasp. The therapist trains the client to
tolerate this position through an orthosis. The elbow is included in the
assessment of composite extension because the wrist and finger
flexors are attached proximal to and can influence kinematics at the
elbow joint. However, orthotic provision including the elbow is not
necessary. Positioning the elbow in extension and encouraging motion
in elbow extension assists with providing stretch to proximal and
distal attachments of the hand and wrist flexors.
Using a minimalist design, 71 a dorsal forearm-based orthosis with
a volar hand immobilization component and dorsal thumb extension
is recommended to achieve passive stretch to the flexors. Unlike an
entirely volar forearm and hand configuration, this “crowbar” design
offers better leverage by pulling the “dropping” hand rather than
pushing it into extension. As the client’s hand evolves with spasticity,
the orthosis is adjusted with increased wrist extension while
maintaining the digits extended to provide constant stretch to the
finger and thumb flexors. Even with significant muscle stiffness, the
orthotic design is mechanically more advantageous in dispersing
pressure over a large surface area, unlike in volar designs, where
significant flexor spasticity pulls the wrist and the MCP joints into
greater flexion and away from orthosis contact. This design creates a
three-point friction and concentrated pressure areas. The following
are instructions on how to fabricate a dorsal forearm volar hand
immobilization orthosis with a dorsal thumb extension component
(Fig. 15.6).

FIG. 15.6 Volar forearm hand immobilization orthosis (pattern and

orthosis).

Dorsal Forearm Volar Hand Immobilization

Orthosis Construction
Material
The ideal thermoplastic material for this orthosis has moderate drape
and resistance to stretch, moderate to excellent rigidity and memory,
and low flexibility. The recommended dimensions are nonperforated
to 1% perforated (for rigidity) and 3⁄32- to ⅛-inch thickness,
depending on the severity of tone. Rolyan Ezeform, Kay-Splint III
Basic, TailorSplint, and PolyFlex II meet these criteria.

Pattern Making

1. Place the hand and wrist in a neutral position over a tracing

paper (Fig. 15.7). If the client has significant spasticity, the
therapist may trace the less involved hand and then invert the
pattern on the thermoplastic material before cutting.
a. Trace the forearm (Fig. 15.8) and hand (Fig. 15.9),
and mark the following anatomical locations:
posterior one-third of the forearm, radial and ulnar
styloids, and the middle of the second and fifth
proximal phalanges.
b. Exclude the thumb by not terminating at the first
web space distally and at the base of the first
metacarpal proximally. Connect the two thumb
points to create a straight edge.
c. Draw an arc that connects the phalangeal points
(Fig. 15.10). Cut a slit along this arc.
d. Trace the thumb on a separate piece of paper (Fig.
15.11). For the thumb, create ¼-inch margins on the
medial and lateral sides and a 1-inch margin
proximally.
FIG. 15.7 Positioning the hand to trace the pattern.
 FIG. 15.8 Tracing the forearm.

2. Mark ¾-inch margins on the radial and ulnar side of the

forearm and ½-inch margins on the radial and ulnar side of the
wrist shown in Fig. 15.12. Complete the pattern by drawing
trim lines along the margins. The distal and proximal ends
may not require additional margin because most thermoplastic
materials appropriate for this type of orthosis tend to elongate
when heated and draped on the body. The position of wrist
extension may also create excess thermoplastic material during
fabrication.
3. Transfer the hand-forearm and thumb patterns on the
thermoplastic material. Mark the phalangeal arc using the slit
on the pattern (refer to step 1c).
a. Using a box cutter, cut the thermoplastic material in
a rectangular configuration that contains the pattern
before trimming the pattern to shape.
b. Punch holes at the ends of the phalangeal arc using
a leather puncher (Fig. 15.13).

FIG. 15.9 Tracing the hand.

 FIG. 15.10 Completing the pattern.

c. Heat the material slightly and trim the

thermoplastic material by the pattern. Cut a slit
along the phalangeal arc as shown in Fig. 15.14. Do
not heat the material to its maximum heating point
to maintain its optimal integrity before molding.

Fabrication

4. Before molding, establish the optimal wrist position by

performing the following:
a. Place the forearm on a table surface with the elbow
flexed at 80 to 90 degrees, the wrist flexed, and the
hand resting freely over the edge of the table.
b. Stabilize the forearm against the elbow and support
the hand by the distal palm and fingers while
maintaining the fingers in composite extension.

FIG. 15.11 Tracing the thumb.

 FIG. 15.12 Marking the margins.

c. Slowly extend the wrist passively to minimize the

stretch reflex response (spastic tone). Feel for a
palpable stretch until the PIP and distal
interphalangeal joints begin to passively or
reflexively flex. Use this as a reference angle for
optimal wrist extension. A goniometric
measurement may be useful to have an estimate of
the optimal position. Note, however, that this angle
may change during fabrication because some clients
will respond to the heat and/or pressure of the
thermoplastic material with either relaxation or
excitation of spasticity. Ideally, the greater the
composite wrist and finger extension is, the more
the stretch can be optimized.
5. Apply foam padding to the ulnar head and radial styloid (Fig.
15.15).
FIG. 15.13 A and B, Punching holes for the phalangeal arc.
 FIG. 15.14 Trimming the thermoplastic for the thumb piece.

6. Apply a stockinette cover to the hand and forearm (Fig. 15.16).

7. Heat the thermoplastic material to the recommended time and
optimum temperature per the manufacturer’s instructions.
 FIG. 15.15 Padding bony prominences.

FIG. 15.16 Applying stockinette to protect the skin.

 FIG. 15.17 Draping the thermoplastic.

8. Begin the molding process by inserting the fingers through the

phalangeal slit so that the fingers are supported to the
proximal phalanx. Drape the rest of the material over the
dorsum of the hand and the dorsal wrist and forearm (Fig.
15.17).
 FIG. 15.18 A and B, Stabilizing the hand with digits in extension
(A) and Folding the radial and ulnar sides for stability (B).

9. Stabilize the hand by maintaining the digits in extension. Fold

the ulnar and radial margins dorsally from the digits to the
wrist (Fig. 15.18).
10. While the material remains warm, contour the dorsal platform
on the wrist and forearm to maintain the wrist and fingers in
optimal composite extension (Fig. 15.19).
11. Heat the lateral and medial folds, and seal them against the
body of the orthosis to reinforce the radial and ulnar folds
(Fig. 15.20).
12. Smooth the edges and fit the orthosis to the client (Fig. 15.21).
13. Apply a 1½- to 2-inch rough adhesive-backed Velcro on the
proximal forearm aspect of the dorsal platform. Secure the
orthosis on the client using a 2-inch-wide Neoprene strap (Fig.
15.22).
14. Apply thin foam padding on the corresponding contours
created by the ulnar head and radial styloid pads (Fig. 15.23).
15. Reapply the orthosis on the client, and check for comfort (Fig.
15.24). Ensure that the edges of the hand opening do not touch
or cause pressure on the metacarpal heads.
16. Heat the thumb component, and drape thermoplastic material
on the dorsal aspect of the thumb while the orthosis is on (Fig.
15.25A). Maintain the thumb in optimal extension and
abduction (see Fig. 15.25B). Take caution when positioning the
thumb by observing its color. Too much pressure or stretch
 causes the thumb to blanch and/or turn dark red to bluish
purple.
17. Spot heat the proximal end of the thumb platform, and smooth
it against the orthosis to keep it adhered. For materials that
have a coating that prevents bonding, sand or scrape the
surface coating or apply an adhesive agent before finishing
(Fig. 15.26).
18. Apply adhesive-back rough-side Velcro to the dorsal aspect of
the hand and the thumb (Fig. 15.27).
19. Secure the hand and the thumb with a 1½- and 1-inch wide
Neoprene strap, respectively (Fig. 15.28).
FIG. 15.19 A and B, Molding the wrist and forearm.
20. Optional step: The purpose of the hand strap is to prevent the
hand (palm) and wrist from lagging volarly and the fingers
from migrating proximally. This strap maintains the MCP
joints in neutral. In rare occasions during wear, the MCP joints
may become hyperextended and the PIP joints flexed due to
unexpected increase in long flexor tone. To prevent this
“buckling” of the fingers, an extra strap over the proximal
phalanx may be applied. The strap should not go over the PIP
joint so as not to cause PIP hyperextension.
 FIG. 15.20 A and B, Finishing and reinforcing the radial and
ulnar folds.

Orthotic Provision and Task-Oriented

Intervention
At the earliest sign of volitional control of a mass movement pattern,
the orthotic program is complemented with intensive task-oriented
practice with or without therapeutic modalities that facilitate active
control of the extensors to gain in passive motion that translates into
daily functioning. The practice of positioning the hand and wrist to
maintain the required alignment for arm and hand use in various
daily living activities is deemed an effective method to prepare a
client for intensive task training. 66
The need to constantly monitor the success of the orthotic program
in relation to the client goals cannot be overemphasized. As suggested
in the study conducted by Wissel and colleagues, 73 many clients may
not develop spasticity, and of those who do, a few have diminished to
full resolution of spasticity over time. Therefore, orthoses to manage
the secondary effects of spasticity may outlast their usefulness.
However, clients with diminished motor control, especially in hand
opening for pregrasp and release and in achieving precision grip (e.g.,
picking up a pen or finger food), regardless of the presence and
severity of spasticity, may require a different orthosis. This orthosis
constrains select joints or positions for certain digits to enable more
active and functional use of the hand. For example, for a client with a
cortical thumb or thumb-in-hand resting posture (i.e., the thumb is
flexed and adducted into the palm), a short opponens or C-bar
orthosis may accomplish two purposes:
 FIG. 15.21 Smoothing the edges of the orthosis.

1. The orthosis preserves the soft tissue integrity of the structures

around the thumb, including the first web space.
2. The orthosis positions the thumb in opposition and palmar
abduction to facilitate precision or cylindrical grip during task
practice (Fig. 15.29).

An alternative orthosis is a Neoprene- or Lycra-based thumb

extension design. 14,22,67
As discussed in the beginning of the chapter, there are two
predominant theoretical orientations that guide the use of orthotic
provision for the neurologically impaired hand—neurophysiological
and biomechanical. With neurorehabilitation shifting toward more
contemporary models of task-oriented and repetitive task training,
therapists consider task-oriented approaches when it comes to the
use of orthoses. Two additional examples of orthoses that promote
intensive active practice of the hand are the SaeboFlex and the
SaeboGlove (Saebo Inc., Charlotte, NC). The SaeboFlex orthosis is a
dynamic forearm-based orthosis that positions the wrist in slight
extension and the digits in composite extension through spring-
loaded traction (Fig. 15.30) and is typically indicated for clients with
significant to moderate spasticity. A client wearing the orthosis is
trained to actively flex the fingers in limited excursion by grasping
large-diameter balls against the resistance of the spring-loaded
mechanisms followed by active relaxation of the finger flexors (Fig.
15.31A). The SaeboGlove has a similar purpose as the SaeboFlex but is
low profile, made of semirigid parts, and best indicated for those with
mild spasticity. The digits are positioned similarly in extension using
silicone rubber traction anchored by a rigid plastic base (see Fig.
15.31B). As demonstrated in several studies, 11,27,36 the device when
used in intensive repetitive task training facilitates gains in hand and
arm function for persons with strokes.
FIG.15.22 A and B, Applying straps to the forearm.
FIG. 15.23 Padding contours for bony prominences.
 FIG. 15.24 Reapplying the splint to assess comfort.

Serial Casting to Manage Spasticity

In clients with significant joint and muscle stiffness due to severe
spasticity and prolonged immobilization, serial casting presents an
evidence-based solution that translates into increases in active and
passive range of motion. 17,51,56,57,69 In addition to providing sustained
passive stretch, the circumferential nature of the cast creates a
warming effect on the soft tissue for increased relaxation. 39 Although
effective, serial casting is known for various complications, such as
pressure sores, pain, and swelling. 56 Therefore it is highly
recommended that a therapist who is a novice in casting receive on-
the-job or postprofessional training and appropriate supervision from
an experienced practitioner before attempting the procedure.
 FIG. 15.25 A and B, Molding the thumb component.

Circumferential casting techniques involve specialized fabrication

skills and orthopedic casting materials. Solid serial casting is designed
to increase range of motion and decrease contractures caused by
spasticity through a series of periodic cast changes. Typically, the
affected joint is casted in submaximal range (5 to 10 degrees below
maximum passive range). Cast change schedules range from every
other day for recent contractures to every 5 to 7 days for chronic
contractures. Blood circulation, edema, skin condition, sensation, and
range of motion are closely monitored during the casting process. The
serial progression of the cast is discontinued when range-of-motion
gains are no longer noted between a couple of cast changes. When no
range-of-motion gains are noted, a final cast with bivalve
configuration is applied daily to maintain range of motion. 28
FIG. 15.26 A and B, Spot heating and bonding the thumb component
to the rest of the orthosis.

FIG. 15.27 Applying the adhesive Velcro for the thumb.

 FIG. 15.28 A and B, Reapplying/applying the straps for the forearm
and thumb.

Therapists use plaster or synthetic resin materials such as fiberglass

or stretch bandage with polyurethane resin for casting. Plaster is a
cost-effective choice if the practitioner desires to gradually increase
passive range of motion by using a series of static orthoses in brief
intervals. A plaster bandage is easy to handle, and it conforms/drapes
easily to body parts. However, the disadvantages of using plaster
casts include porousness (non–water resistant), difficulty with
maintenance, potential for allergic reactions, and heaviness compared
to lighter weight alternatives. Fiberglass and bandage orthopedic resin
materials are more costly and require specialized training. These are
lighter in weight, more durable, and ideal for long-term use. A review
of studies 51,56 on serial casting reveals preference for synthetic
materials for reasons not clearly specified. Both materials require six
to eight layers of thickness for adequate strength. They harden in 3 to
8 minutes (depending on water temperature). A special type of
synthetic material made of bandage impregnated with polyurethane
resin (Delta-Cast Conformable, Depuy Orthopedics, Warsaw, IN) is
layered to focus the rigidity on certain regions, thereby decreasing the
need for multiple layers. Both plaster and synthetic bandages emit
heat as a by-product in the curing process. (Refer to Chapter 19 for
additional casting information.)
FIG. 15.29 A, Client with thumb extensor weakness is unable to grasp
a cup. B, Client with thumb short opponens orthosis is more able to
grasp a cup.
FIG. 15.30 SaeboFlex dynamic orthosis.
 FIG. 15.31 A, Using the SaeboFlex to assist with hand extension after
grasping ball. B, A SaeboGlove is best to use with mild spasticity. (B,
Courtesy of Saebo, Inc.)

Materials, Tools, and Equipment

Specialized casting tools include the following:

• Electric cast saw

• Hand cast spreader
• Bandage scissors

Casting program materials include the following:

• Plaster or fiberglass casting tape (2, 3, 4, 5 inch)

• Nylon or cotton stockinette (2, 3, 4, 5 inch)
• Rubber gloves (specialized casting gloves for fiberglass)
• Plastic water bucket
• Drop sheet to protect client
• Cast padding

Plaster Casting Procedures 28

1. Measure and record joint range of motion.

2. The client should be sitting or lying comfortably and should be
draped with sheets or towels to protect clothing and skin.
Explain the procedure to the client clearly and reassure as
needed. Some clients with brain injuries may be agitated
during the casting procedure. In such cases the therapist must
discuss the use of sedative agents with the referring physician
to accomplish the task.
3. Tubular stockinette is placed over the extremity to be casted,
extending it at either end 4 to 6 inches beyond where the cast
ends.
4. Determine the targeted position of the extremity. Direct
 another person (therapist or aide) how and where to hold the
extremity.
5. Strips of stick-on foam can be placed on either side of an area
that may be susceptible to skin breakdown.
6. Apply cast padding in a taut fashion around the extremity,
ending after three or four layers are applied. Extra padding or
felt may be added if needed over bony prominences. Padding
is applied 1 to 2 inches above the end of the stockinette.
7. Dip the plaster roll five to six times in warm water. Squeeze
excess moisture from the roll.
8. Apply plaster to the extremity in a spiral fashion, moving
proximally to distally.
9. Direct the person assisting to stretch the joint minimally as the
plaster is being applied. The casting assistant should not apply
direct pressure to the plaster as it is setting (breakdown or
ischemia inside the cast can occur from this loading point
effect). Rather, the assistant should stretch the joint above and
below the cast or apply pressure with the entire surface of the
hand to evenly distribute pressure.
10. Apply four to five layers of plaster. Smooth the plaster surface
in a circular fashion as the plaster sets. Pay special attention to
smoothing proximal and distal edges to prevent skin
breakdown.
11. Before applying the last layer, turn back the ends of stockinette
onto the cast. This gives a smooth finished surface to cast
edges. Apply the last layer of plaster below this edge.
12. Instruct the casting assistant to maintain stretch on the joint
until the plaster has set (3 to 8 minutes).
13 The plaster completely dries in 24 hours. Weight bearing on
the casted extremity should be avoided until then.
14. Clean any dripped plaster from the client’s skin, elevate the
extremity comfortably, and check both ends of the cast for
tightness. Check the client’s circulation regularly. Some
authors 17 recommend a post-casting management program of
bivalve casting to maintain increased range of motion and
 tone reduction.

Fiberglass Casting Procedures 28

1. Plastic gloves must be worn by anyone touching the fiberglass

material during fabrication. Initially and throughout the
procedure the plastic gloves are coated with petroleum jelly or
lotion. Fiberglass adheres to the skin or unlubricated gloves
and is difficult to remove. Prepare the limb with padding and
stockinette. Practice with the casting assistant to position the
joint correctly.
2. Submerge the fiberglass roll in cool water, and gently squeeze
it six to eight times. Remove the roll from the water, and apply
it dripping wet to the extremity to facilitate handling of the
material.
3. Fiberglass roll packages should be opened one at a time and
applied within minutes. Fiberglass hardens and does not bond
to itself when left exposed to air.
4. Fiberglass must overlap itself by half a tape width.
5. Blot the exterior of the cast with an open palm in a circular
fashion after all layers are applied. This facilitates maximum
bonding of all layers. Rubbing in a longitudinal fashion
disrupts the fiberglass bond.
6. If one layer of the cast is allowed to cure (harden), subsequent
layers will not bond well. All three to four layers are applied in
efficient succession.
7. During the first 2 minutes after immersion, the fiberglass is
molded while the extremity is maintained in the desired
position. The extremity is held stationary during the last few
minutes of the 5- to 7-minute setting time.
8. The cast is completely set in 7 to 10 minutes. Thereafter, the
cast may be removed using a cast saw. Cast saws should be
operated only by those individuals with training and
experience.
 The fiberglass cast can be made into a working bivalve in the
following manner 28 :

1. Using the cast saw, cut the cast into anterior and posterior
sections. Remove the cast with the cast spreader.
2. Remove the padding and stockinette from the extremity with
the cast scissors and discard.
3. Inspect both fiberglass shells for protrusions and rough edges.
Trim the edges of each shell and file smooth.
4. For soiled cast padding, use cotton padding to reline the shells,
taking care to rip padding edges off to provide a smooth inner
surface with no ripples. Reline with the same amount of
padding used to fabricate the original cast. Extend the padding
over all edges and sides of the shells.
5. Fold the padding over the edges of the shells, and secure with
adhesive tape.
6. Cut a length of the stockinette approximately 4 to 6 inches
longer than the length of the shell. Line each shell with
stockinette. Secure both ends with adhesive tape.
7. Fashion straps using wide webbing and buckles. These straps
can be taped or sewn onto stockinette covering the shell.
Bivalves can also be secured with Ace wraps.
8. Carefully wean the client into the bivalve, modifying and
adjusting as needed.

Review Questions
1. How do the biochemical and neurophysiological
approaches to hand orthotic provision differ?
2. Why would an orthosis that positions in submaximal range
be less beneficial and potentially harmful to a client with
evolving muscle tone?
3. What are the strengths and weaknesses of orthotic dorsal
 versus volar forearm platforms?
4. What is an appropriate rationale for orthotic design based
on a biomechanical rationale?
5. What is the difference between the elastic and contractile
properties of muscles, and what are the implications for
orthotic provision?
6. What are the material options for casting?
7. What are two major characteristics for each of the materials
below?
• Plaster bandage
• Fiberglass bandage
• Neoprene or Lycra
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Appendix 15.1 Case Studies
Case Study 15.1 a

Read the following scenario, and answer the questions based on information
in this chapter.
Rose is a 78-year-old client who is a resident of a long-term care
facility, and she experienced an ischemic cerebrovascular accident
(CVA) 2 months ago. She was admitted to the hospital for 12 days and
returned to the facility for short-term rehabilitation. Before the CVA,
Rose was independent in dressing and toileting, ambulatory using a
walker, and able to participate in recreational activities. After a 2-
week period of flaccidity, wrist and finger flexion spasticity emerged.
Outside of the therapy schedule, the hand rests in wrist flexion most
of the day. The dorsum of the hand is significantly edematous,
causing the fingers to assume the position of deformity with the
metacarpophalangeal (MCP) joints in slight hyperextension and the
interphalangeal joints partially flexed. Pain-free range of motion is
limited to 10 degrees of wrist extension. Composite finger extension
can only be accomplished pain-free with the wrist in 5 degrees of
extension. No active wrist motion is present, but reflexive digit flexion
is emerging. From a position of maximum wrist flexion, the stretch
reflex is elicited at −15 degrees of wrist extension until slightly past
neutral. The family is concerned about Rose’s hand becoming
deformed. The nursing plan of care has been to position the hand
elevated on a pillow resting on Rose’s lap. The palm and the web
spaces are moist, and a faint odor is detected along with slightly
macerated skin. Additionally, the thumb is tightly flexed across the
palm, thus causing skin irritation to the thumb web space.

1. Which of the following orthotic designs is most appropriate for

Rose? Explain your rationale.
a. A dorsal-based forearm platform with a volar hand
component that positions the wrist and fingers in
 tolerable composite extension
b. A volar finger spreader that positions the wrist and
fingers statically in maximum extension
c. A volar-based forearm platform and hard cone that
positions the wrist in submaximal extension and
fingers in partial flexion
d. A volar forearm-based hand immobilization
orthosis that stretches and positions the wrist and
the fingers in composite extension
e. A plaster cast that places the wrist in maximum
extension and the fingers in a current resting
position
2. The nursing staff reports that the orthosis is not applied
regularly because Rose’s edema worsens with wear.
Meanwhile, Rose’s hand at rest continues to be in the position
of deformity of MCP joint hyperextension and proximal
interphalangeal and distal interphalangeal joint flexion. How
would you modify the intervention approach?

Four weeks have passed, and Rose’s hand and arm function as well
as occupational performance are being assessed. Rose has been
wearing the orthosis consistently for several hours daily. The edema
has reduced significantly, the joints remain passively mobile, but the
spasticity is causing more muscle tightness. Rose is also getting more
active mass grasp and partial release of 20 degrees of composite finger
extension with effort—adequate to grasp and release a dish towel.
There is evidence that the wrist stabilizers are activating as grip on an
object can be sustained for a few seconds’ duration before the hand
fatigues. The thumb rests in an adducted and flexed position and is
not able to engage in gross grasp tasks. The first web space and the
thumb flexors are tight, but they can be passively positioned in
extension and palmar abduction.

3. Which of the following orthotic designs should be considered

for Rose at this time? Explain your answer.
 a. A finger spreader that positions the thumb in radial
abduction and does not incorporate the wrist
b. A hard cone that positions the thumb in opposition
and does not incorporate the wrist
c. A short (hand-based) opponens orthosis positioning
the thumb in abduction with partial
extension/opposition
d. An orally inflatable orthosis that positions the
wrist, fingers, and thumb in extension
e. A Neoprene thumb abduction and extension
orthosis that extends to the forearm radially
4. What specific suggestions would you offer the health care team
and the family to encourage increased functional hand skills
while Rose is wearing the orthosis?

Case Study 15.2 a

Brian is a 25-year-old who was recently admitted to an inpatient
rehabilitation unit after experiencing a traumatic brain injury
following a motor vehicle accident. He was admitted to the
emergency department, underwent a craniectomy, and was in the
intensive care unit for 10 days. He was then transferred to the acute
care floor for 2 weeks and was recently moved to inpatient
rehabilitation. Brian is emerging from his coma and is in a minimally
conscious state as evidenced by some automatic motor responses and
object localization when being assessed using the JFK Coma Recovery
Scale. Before the accident Brian was independent and working as an
analyst at a hedge fund. Brian is displaying spasticity throughout his
left upper limb, most specifically in the biceps, supinators, and wrist
and finger flexors. The therapist can passively range Brian’s arm.
However, pain-free range of motion is limited in elbow extension by
less than 10 degrees and wrist extension by 30 degrees, and composite
finger extension can only be accomplished pain-free with the wrist in
10 degrees of flexion. He has no active movement. The Modified
Ashworth Scale score is a 2 in his biceps and 3 in wrist and finger
flexors. Hand hygiene is becoming a concern. Positioning, modalities,
stretching, and weight bearing are proving beneficial during
intervention sessions. The rehabilitation team wants orthosis for night
use. Due to spasticity throughout his lower limb, serial bivalve casts
have been provided.

1. Which of the following orthotic designs is most appropriate for

Brian? Explain your rationale.
a. A dorsal-based forearm platform with a volar hand
component that positions the wrist and fingers in
tolerable composite extension
b. A volar finger spreader that positions the wrist and
fingers statically in maximum extension
c. A volar-based forearm platform and hard cone that
positions the wrist in submaximal extension and
fingers in partial flexion
d. A volar forearm-based hand immobilization
orthosis that stretches and positions the wrist and
the fingers in composite extension
e. A plaster cast that places the wrist in maximum
extension and the fingers in a current resting
position

Three weeks have passed, and Brian has become more aware and
engaging in therapy. He has 1 of 4 scores on shoulder movements
against gravity. He is initiating reach-to-grasp with his left arm;
however, his wrist and hand function is limited by spasticity. He can
use his tone to perform gross grasp but is unable to perform release
without passively moving his wrist into flexion. Modifications were
made to his existing orthosis for nighttime to meet his needs.

2. What is an appropriate approach to augment Brian’s therapy

for spasticity management? Explain your rationale.
a. A dynamic orthosis such as the SaeboFlex during
active reach to grasp
b. A static orthosis such as SaeboStretch during
weight bearing
c. A dorsal-based forearm platform with a volar hand
component that positions the wrist and fingers in
tolerable composite extension for pregrasp during
simulated reaching
Appendix 15.2 Laboratory Exercise
Laboratory Exercise 15.1
1. Practice fabricating a dorsal forearm based with volar hand
immobilization orthosis on a partner. Use a goniometer and an
acrylic cone to position the hand and wrist correctly.
2. After fitting the cone, use Form 15.1. This is a check-off sheet
for self-evaluation of the hard-cone wrist and hand orthosis.
Use Grading Sheet 15.1 as a classroom grading sheet.
Appendix 15.3 Form And Grading Sheet
Form 15.1 Dorsal Forearm Based With Volar
Hand Immobilization Orthosis
Grading Sheet 15.1 Dorsal Forearm Based
With Volar Hand Immobilization Orthosis
a See Appendix A for the answer key.
a See Appendix A for the answer key.
16
Orthotic Intervention for Older
Adults
Marlene A. Riley, and Helene L. Lohman

CHAPTER OBJECTIVES
1. Describe special considerations for orthotic intervention with
older adults in different environments.
2. Identify the complexity of age-related changes, medical
conditions, and medication side effects that may impact orthotic
provision.
3. Recognize how an older adult’s performance in occupations and
activities may influence orthotic use and design based on the
Occupational Therapy Practice Framework. 2,55
4. Select appropriate prefabricated off-the-shelf (OTS) orthoses.
5. Select appropriate materials to fabricate custom orthoses.
6. Describe factors that influence methods of instruction about safe
use and care of an orthosis for an older adult and/or care partner.

KEY TERMS
anticoagulants
arteriovenous (AV) fistula
ecchymosis
integumentary system
soft orthosis
working memory

Donald is a 75-year-old man who plays basketball at a county senior

center. He does not consider himself to be “old” and would not think of
going to a senior center except that his friend invited him to join the
indoor basketball team. He plays three times per week despite pain in his
thumbs. The senior center director referred him to a county health
department occupational therapist to explore options to minimize his
pain and enable him to continue participation with the team. During the
initial assessment, Donald said he had “his father’s hands” and was
interested in learning how to decrease his pain. The therapist
recommended bilateral prefabricated thumb carpometacarpal (CMC)
Push MetaGrip orthoses 39 because they would be appropriate for
someone with osteoarthritis who is active and requires small, yet durable
hand orthoses (Fig. 16.1).

Bonnie is a 78-year-old widow who lives alone. She just completed 5

months of chemotherapy for cancer and complains of weakness,
numbness, and cold intolerance in her hands. Her history is also
significant for flexor tenosynovitis in her dominant hand ring finger.
She is pleased that her cancer seems to be in remission, yet she feels very
despondent that she is not able to drive or prepare meals due to the
difficulty that she is experiencing with her hands. Her son accompanies
Bonnie to an outpatient rehabilitation setting. Part of the therapy
intervention for Bonnie includes an orthosis to restrict
metacarpophalangeal (MCP) flexion for trigger finger. 18 There are a
variety of trigger finger designs to choose from, including a lightweight
thermoplastic custom-fabricated type (Fig. 16.2A), a silver ring that
resembles jewelry 43 (see Fig. 16.2B), a soft prefabricated Neoprene
orthosis (see Fig. 16.2C), and a prefabricated off-the-shelf (OTS) molded
plastic orthosis (see Fig. 16.2D). Clinical reasoning to decide the most
appropriate orthotic includes consideration of the availability of
 materials, payment source, and client input. In addition to the trigger
finger orthosis, Bonnie may benefit from wearing a lightweight Showa
Atlas nitrile-coated garden glove 41 to reduce cold intolerance and aid
more secure grasping (Fig. 16.3).

Donald and Bonnie are both older adults who benefit from orthoses to
improve their ability to participate in daily activities. Although close in
age, their stories illustrate the broad range of knowledge and skills
necessary when making decisions about orthotic provision for older
adults. Donald is an active, independent older adult whose primary goal
is to decrease thumb pain from osteoarthritis. Bonnie has a complicated
medical history and requires ongoing therapy to address her decline in
function.

Note: This chapter includes content from previous contributions

from Serena M. Berger, MA, OTR; Maureen T. Cavanaugh, MS, OTR;
and Brenda M. Coppard, PhD, OTR/L, FAOTA.
Late adulthood spans from age 65 until the end of life. 13 According
to the U.S. Department of Health and Human Services Administration
for Community Living, almost 1 in every 7, or 14.9%; of the
population is an older American. 15 By 2040 the older adult population
is projected to represent 21.7% of the total population. 15 Only 3.1% of
the age 65 and older population in 2015 lived in institutional settings,
such as long-term care settings. However, the percentage increases
dramatically with age to 9% for persons 85 and older. The age 85+
population is projected to triple from 6.3 million in 2015 to 14.6
million in 2040. 15 The growth of the older adult population is a
significant reason that the Bureau of Labor Statistics projects
employment to grow by 21% for occupational therapists and 25% for
physical therapists between 2016 and 2026. 7
FIG. 16.1 Thumb carpometacarpal Push MetaGrip orthosis designed
in consultation with Judy Colditz, Hand Lab.
 FIG. 16.2 A, Custom lightweight thermoplastic orthosis to restrict
metacarpophalangeal flexion for trigger finger. B, Siris Silver Ring
Trigger Finger Splint for chronic recurring flexor tenosynovitis. C,
Neoprene Trigger Finger Solution (TFS). D, Oval-8 for trigger finger.
B Courtesy Silver Ring Splint Company, Charlottesville, Virginia. D
Courtesy 3-Point Products, 53 Stevensville, Maryland.
 FIG. 16.3 Showa Atlas lightweight nitrile-coated garden gloves worn
under an orthosis to reduce cold intolerance and assist with grasping.

According to the U.S. Census Bureau’s American Community Survey,

15 in 2013 over 30% of community-resident Medicare beneficiaries
ages 65 and up reported some limitation in function that prevented
them from being fully independent in performing one or more
activities of daily living (ADLs). An additional 12% reported
difficulties with instrumental activities of daily living (IADLs). 15
Hands are one of the most common locations for musculoskeletal
pain from osteoarthritis (OA). 14 The development of hand problems
in older adults significantly impacts global physical functioning. 52
According to McKee and Rivard, 27 an orthosis that includes the needs
of the client in the design process improves the ability to function by
“relieving pain, providing protection and joint stabilization and
enabling valued occupations.” 27 Therapists who work with the older
adult population need to have a strong foundation of interventions,
including orthotic provision, to improve functional abilities in ADLs
and IADLs.
Fundamental principles of clinical examination, design, and
fabrication of orthoses do not change as people age. Therapists do,
however, need to be aware of special considerations necessary to
accommodate the unique needs of older adults. When designing an
orthosis for an older adult, the therapist considers the specific needs of
the individual, the goals of the orthosis, and the orthotic materials
available. Clinical reasoning to determine the most effective orthosis
for an older adult should consider:

• Age-related changes in body functions

• Medical history, including current medications
• Least restrictive designs
• Choice of lightweight but supportive materials
• Choice of materials for maintenance of skin integrity
• Simple designs for donning and doffing
• Awareness of payer source and cost effectiveness (e.g.,
prefabricated versus custom)
• The environment
Treatment Settings and Orthotic
Designs
The older adult’s environment is an important consideration for
clinical decision making. Therapists provide interventions to older
adults in multiple settings. Table 16.1 presents considerations and
goals specific to different settings. The older adult’s living situation
(e.g., living at home, a long-term care setting, or an assisted living
center) is important when the therapist determines the most
appropriate orthosis. For example, an 80-year-old woman with OA
who performs self-care independently and requires the use of her
hands throughout the day may benefit from a thumb carpometacarpal
(CMC) immobilization orthosis to improve her daily function. In
contrast, a long-term care resident with multiple cerebrovascular
accidents (CVAs) may require an orthosis to maintain sufficient range
of motion (ROM) for assisted dressing and bathing. Hand ROM is
necessary to prevent skin maceration in the palm caused by sustained
full-finger flexion. A prefabricated resting orthosis that is easily
adjusted, such as the Comfy Hand Wrist Finger Orthosis (Fig. 16.4A)
or a custom thermoplastic cylindrically shaped orthosis (see Fig.
16.4B), can prevent secondary contractures that impede skin care.
Therapists who treat older adults during the acute stage of an illness
must be aware of risk factors to prevent secondary complications,
such as loss of passive range of motion (PROM), edema, and skin
breakdown.

TABLE 16.1

Considerations for Orthotic Design in Different Settings

ADL, Activity of daily living; IADL, instrumental activity of daily living; ICU, intensive care unit;
ROM, range of motion; SNF, skilled nursing facility.
Age-Related Changes and Medical
Conditions Impacting Orthotic
Intervention
In addition to typical age-related changes, older adults’ body systems
are vulnerable to chronic diseases. For instance, someone referred for
a hand orthosis following a CVA may have other health conditions
more prevalent with aging, such as type 2 diabetes and OA. Besides
obtaining a thorough medical history to determine the appropriate
goals of an orthosis, the therapist needs to be familiar with how
different medical conditions concurrently impact hand function.
Table 16.2 provides a summary of age-related changes and health
conditions that affect the design and approach to orthotic
intervention. The following client factors 2 are based on selected
classifications from the World Health Organization International
Classification of Functioning, Disability and Health 55 as related to
considerations for orthotic intervention.

Mental Functions
Therapists assess cognitive status to determine the older adult’s ability
to understand the orthosis’ purpose, wearing schedule, and
precautions. Working memory impairment may prevent the older
adult from recalling the orthosis’ storage location or application
procedure. Sometimes a therapist can ascertain memory problems by
noting how an older adult follows directions during orthotic
fabrication. If memory is a problem, the therapist establishes a routine
schedule for wear and care, fabricates a simple design, and labels the
orthosis for easy application.
If the older adult has significant cognitive impairments, the
therapist educates the care partner(s) about the orthosis’ purpose,
wearing schedule, care, correct application, and precautions.
Individuals with later-stage dementias often posture in flexed
positions and thus may require interventions to maintain skin
integrity. If there are cognitive impairments, the risks versus the
benefits of an orthosis must be carefully weighed against alternative
positioning, such as the use of pillows or dense foam wedges. In
addition, the therapist may consider using D-ring straps for more
secure positioning. Refer to Box 16.1 for a summary of general hints
for orthotic instructions with older adults.

FIG. 16.4 A, Comfy Hand Wrist Finger Orthosis is an example of an

adjustable prefabricated orthosis. B, A custom lightweight cylindrically
shaped orthosis assists with keeping fingers out of the palm.

TABLE 16.2

Summary of Age-Related Changes and Medical Conditions Impacting Orthotic

Interventions
AV, Arteriovenous; CMC, carpometacarpal; DIP, distal interphalangeal; MCP,
metacarpophalangeal; PIP, proximal interphalangeal.

Sensory Functions
Vision
Older adults are particularly vulnerable to conditions that affect the
visual system. Cataracts, glaucoma, age-related macular degeneration,
and diabetic neuropathy are the primary conditions of visual
impairment in older adults. According to a population-based study, 6
81% of people with visual impairment are older than 50 years of age.
Decreased vision may impact a client’s ability to adhere to orthotic
instructions. For example, some older adults may be unable to apply
their orthoses because of poor figure ground discrimination. Older
adults may have difficulty seeing how the straps attach and may be
unable to visually inspect their skin. Using thermoplastic material
with contrasting color straps may assist the older adult who has poor
visual discrimination. Bright colors may prevent the orthosis from
being easily lost in bed linens or mistakenly sent to the laundry in an
in-patient setting.
Older adults who have correctable vision should wear their glasses
when they are instructed in orthotic use. The therapist needs to ask
older adults to demonstrate proper orthotic application and removal.
Simple, large-print instructions are best for this population. High
contrast of ink and paper is helpful. The use of direct lighting and
magnification devices helps with reading instructions and with
performing skin inspections.
For older adults who have macular degeneration, glaucoma,
cataracts, or poor visual acuity, the therapist encourages the use of
compensatory techniques during application and removal of the
orthosis and skin inspections. Compensatory techniques include eye
scanning, head turning, and use of tactile labels to mark reference
points on the orthoses (Fig. 16.5).

Auditory System
According to the American Federation for Aging Research,
approximately 30% of older adults between 65 and 74 years of age and
50% of adults age 75 or older have hearing loss. 1 Hearing impairment
impedes health literacy. Sometimes hearing problems can be detected
during the initial interview or during orthotic fabrication. Therapists
should not rely solely on printed information to relay instructions,
because some older adults may be unable to read or have visual
impairments that also limit reading capabilities. The therapist needs to
use more tactile cues when positioning the person for orthotic
intervention. When talking to an older adult who is hearing impaired,
the therapist should use the guidelines outlined in Box 16.2.
BOX 16.1 General Hints for Orthotic Instructions

• Keep the orthotic design simple for easy donning and doffing.
Observe the client’s/care partner’s ability to don and doff the
orthosis.
• Label the orthosis with individual’s name, right or left extremity,
hand or foot, and additional landmarks to identify how to
properly position the orthosis.
• Provide written and oral instructions that include application,
wearing schedule, and precautions for discharge.
• Identify a consistent location to store the orthosis within easy
reach.
• Keep straps attached to the orthosis.
• Provide a picture of the orthosis on the extremity. Observe
privacy regulations, and avoid public posting of information
related to client’s care.
• A dark-colored orthosis provides better contrast with light-
colored bed linens.
 FIG. 16.5 Tactile label markers, such as the Spot ‘n Line Pen, can be
used to mark reference points on an orthosis for an older adult with
impaired vision.

Touch
A population-based study with community dwelling adults 57 to 85
years of age examined a potential common prevalence for global
sensory loss of the five senses (visual, smell, hearing, touch, and taste).
12 Impaired touch was identified in 70% of the subjects. Two-thirds of

the subjects had impairments in two or more senses. 12 Individuals

with one identified sensory impairment should be evaluated for
additional sensory deficits that may impact orthotic provision.
Somatosensory function of two-point discrimination declines with
age. 12 Because decline in somatosensory function is gradual over the
life cycle, older adults may not be aware of their diminished
sensibility. Vision is the primary sense used to compensate for
decreased tactile sensation. When both vision and touch sensory
functions decline, the older adult is at a greater risk for compromised
skin integrity.
Box 16-2 Guidelines for Talking to the Hearing
Impaired

• Seat or position the hearing-impaired person to see the face of the

person speaking.
• Whenever possible, face the person with impaired hearing on the
same level during verbal communication.
• Before talking, gain the older adult’s attention by using touch,
gesture, and eye contact.
• Use visual aids when possible. Take a photograph or draw a
diagram that shows correct orthotic application.
• Use demonstration as part of the instructions.
• Keep hands away from face while talking.
• If the person misses statements, rephrase the statements rather
than repeat the same words.
• Reduce background noises during verbal communication. When
possible, work with the person one-onone in a quiet room.
• Do not shout because doing so distorts voices. Talk in a normal
voice but at close range.
• Avoid chewing gum during verbal communication, because this
makes speech more difficult to understand.
• Be aware that people hear better if they are vertical rather than
horizontal. If a person is standing or sitting, sound waves are
directed into the ears. If a person is lying on a bed, sound waves
are dispersed over the head.
• Recognize that persons with hearing impairments may not hear
as well if they are tired or ill.
• If hearing is better in one ear, direct speech toward that ear.
Never shout directly into the ear.
• Ask client to repeat the instructions back to you.
Data from Lewis SC: Older adult care in occupational therapy, Thorofare,
NJ, 1989, Slack; Barlowe E, Siegal DL, Edwards F, et al: Vision,
hearing, and other sensory loss associated with aging. In Doress PB,
Siegal DL, editors: Ourselves, growing older, New York, 1987, Simon &
Schuster, pp. 365-379; Hills GA: The changing realm of the senses. In
Lewis BB, editor: Aging: the health care challenge, ed 4, Philadelphia,
2002, FA Davis.

Tactile sensation may become impaired secondary to poor

positioning of older adults with limited mobility. Decreased sensation
may contribute to compression neuropathies of the median or ulnar
nerves. Cubital tunnel syndrome, a compression of the ulnar nerve at
the elbow level, may result from constant pressure on flexed elbows
while sitting in a wheelchair or from prolonged bed confinement. A
padded elbow protector (Fig. 16.6) or a padded elbow orthosis to
restrict elbow flexion greater than 30 to 45 degrees (see Chapter 14)
prevents further pressure on the nerve. 37
Compression of the median nerve at the wrist or carpal tunnel
syndrome may be due to prolonged wrist flexion posturing or
secondary to an associated medical condition, such as rheumatoid
arthritis (RA) or diabetes. A prefabricated wrist orthosis in neutral
with D-ring straps is easier to don and can be used to prevent nerve
compression (Fig. 16.7; see Chapter 7).

Pain
Perception of pain is subjective and variable among individuals
regardless of age. A careful history, including documentation of
location and particular activities that cause pain using a valid and
reliable assessment such as the Patient-Rated Wrist Hand Evaluation
(PRWHE), is an important part of the initial assessment. 26,51 The
PRWHE is an example of an instrument that can be used for the self-
care G-code set to convert scores for a G-code modifier to document
percentage of impairment as required for Medicare B beneficiaries. 11
Once a baseline of pain and functional impairment is established,
reassessments with the same instrument can determine if goals are
met. It is important to assist the client in finding a balance between
resting joints in the orthosis and actively using his or her hand.

FIG. 16.6 Heelbo padded soft elbow sleeve protector to decrease

pressure on the ulnar nerve.

Neuromusculoskeletal and Movement-Related

Functions
Skeletal System
Several neurological and orthopedic problems are more common in
older adults. 25 The skeletal system is most affected by aging.
Osteoporosis and OA are common diagnoses that often require
orthotic intervention. The National Osteoporosis Foundation reports
that half of all women over 50 will break a bone due to osteoporosis
because the loss of bone density accelerates after menopause. 31 Some
older adults may sustain multiple fractures resulting from a fall (e.g.,
hip and distal radius fracture). Therapists may encounter such
patients in a variety of settings, inpatient or outpatient, depending on
the severity and healing progression.
The distal radius is especially vulnerable to fractures. A common
fracture of the distal radius, a Colles fracture, typically occurs after
falling on an outstretched arm. 32 Sustaining a Colles fracture can be
associated with functional declines in physical performance in hand
strength and walking speed. 32 A volar wrist orthosis is generally
indicated for immobilization after removal of an arm cast or external
fixator. As the fracture heals, the goal may change to one of
mobilization, which can be achieved by serial adjustments to a
thermoplastic orthosis to improve wrist extension (see Chapter 7).
When treating a Colles fracture or any upper extremity condition, it is
important to determine if there are other causes of upper extremity
impairments. For example, a thorough assessment of a client referred
with a wrist injury may reveal preexisting sensory loss in the
dermatome distribution of C6-C7 due to compression of cervical nerve
roots caused by OA. The sensory loss might otherwise have been
associated only with the wrist fracture. In older adults who have
multiple medical conditions, the source of decreased sensorimotor
function in the hand requires a careful differential diagnosis.
 FIG. 16.7 This D-ring orthosis has a circumferential design that holds
the orthosis in place during application.

In addition to OA of the cervical spine, hand joints are frequently

affected. OA typically becomes symptomatic in the 40s and 50s. 24
Primary OA is idiopathic or from known causes. Secondary OA
results from conditions that impact joint cartilage such as trauma,
congenital joint abnormalities, and endocrine and neuropathic
diseases. 24 Most older adults have evidence of some cartilage
damage. 36 Hand OA is characterized by enlarged nodules at the
distal interphalangeal (DIP) joints (Heberden nodes) and/or enlarged
proximal interphalangeal (PIP) joints (Bouchard nodes). 47 The
nodules typically cause more impairment in the index finger because
of the demands placed on the joint during pinch activities. An
immobilization orthosis (Fig. 16.8A) or compression sleeves (see Fig.
16.8B) for DIP joints are conservative options to decrease pain.
Surgical fusion may be warranted for more advanced degeneration if
pain persists.
OA of the thumb at the CMC joint is another common reason for an
orthotic referral. Initial conservative management usually requires a
hand-based thumb immobilization orthosis (see Chapter 8).
Individuals with CMC OA benefit from education on joint protection
techniques to break the pain cycle. As discussed in Chapter 8, there
are different approaches to orthotic intervention for arthritic hands.
An effective conservative approach includes fabrication of a
removable hand-based orthosis to immobilize only the CMC joint. 4
Chronic flexion of the thumb MCP joint or an adduction contracture
leads to a hyperextended interphalangeal (IP) joint. The
hyperextended joint can be conservatively treated with a figure-eight
orthosis to improve stability and function of the thumb (Fig. 16.9).

Neurological System
Central nervous system disorders are some of the most common
causes of disability in older adults. 3 Progression of cardiovascular
disorders may lead to CVAs resulting in abnormal tone on one side of
the body. When making an orthosis for an older adult with abnormal
tone, it is important to consider principles involved with orthotic
design related to a coexisting condition, such as OA of the thumb
CMC joint. Orthokinetic properties of materials should be cautiously
selected because they may adversely affect tone (see Chapter 15).
Some neurological conditions cause tremors, which are particularly
problematic for older adults. Tremors may be associated with
Parkinson’s disease, idiopathic essential tremors, or secondary to side
effects from medications. An orthotic may be used to construct a base
to hold assistive devices to improve self-care function in the presence
of tremors, or thermoplastic material may be used to adapt self-care
utensils, such as a spoon (Fig. 16.10A) or an electric razor (see Fig.
16.10B).
Peripheral neuropathies may be due to adverse effects of
chemotherapy. 45 One study found that approximately 64% of patients
treated with chemotherapy develop chemotherapy-induced
peripheral neuropathy (CIPN). 45 Most cancer diagnoses occur in
older adults, many of whom also have age-associated conditions. 29,42
Protocols for orthotic intervention of the particular nerve involved are
followed. The skin must be routinely monitored due to loss of
sensation.
FIG. 16.8 Enlarged distal interphalangeal joints from osteoarthritis
may become painful and benefit from (A) immobilization or (B) a
compression sleeve to decrease pain.
 FIG. 16.9 A, A tripoint figure-eight design stabilizes the thumb
interphalangeal (IP) joint to prevent hyperextension during pinch. B,
Siris Swan Neck splint on the IP joint of the thumb to prevent
hyperextension.
B Courtesy Silver Ring Splint Company.
FIG. 16.10 Examples of adapted activity of daily living devices using
thermoplastic materials. A, Eating utensils. B, Electric razor.
Cardiovascular and Hematological Functions
Many older adults have cardiovascular disease, which may be the
primary or secondary reason for referral. Older adults with
cardiovascular disease may have limited energy. The therapist
educates the older adult to store the orthosis in close proximity to
conserve energy.
Peripheral vascular disease is a common accompanying condition
for those who have cardiovascular disease. When fitting someone
with a lower extremity orthosis like a volar knee extension orthosis to
prevent flexion contractures post below-knee amputation (BKA),
precautions for peripheral vascular disease are observed. The
temperature of the thermoplastic material is carefully checked, and a
double layer of stockinette should be considered instead of applying
warm material directly to the skin. Older adults who have less ability
to dissipate heat are vulnerable to burns and skin tears. Older adults
with decreased cognition and thin skin may not be aware of the
potential for burns. Furthermore, poor circulation results in delayed
wound healing after skin breakdown. Footdrop orthoses should float
the heel to avoid pressure.

Digestive, Metabolic, and Endocrine Functions

Digestive System
Dehydration, substance abuse, chronic disease, or poor diet in older
adults may cause nutritional deficiencies. 56 Sensory testing is
carefully completed with individuals who have digestive disorders
and nutritional deficiencies because they may also present with
impaired nerve function. Poor wound healing may be the result of a
poor nutritional status. The condition of the skin and nails is observed
to determine appropriate materials and orthotic care. Review of
laboratory values gives therapists insight into nutritional status.

Endocrine System
Diabetes mellitus (DM), a disorder of the endocrine system, is a
common condition reported by the Centers for Disease Control and
Prevention, 8 which affects up to 25% of older adults. A chronic
disease such as type 2 diabetes, which is more prevalent in the older
adult population, is a source of hand impairment and activity
limitations. 35 Individuals with long-standing DM have an increased
incidence of other conditions that must be considered before an
orthosis is made.
A careful sensory evaluation determines whether there are
peripheral neuropathies in the hands or feet. 34 In the presence of
diminished sensation, pressure caused by an orthosis may not be
perceived by the older adult and may lead to skin breakdown. Straps
must never cause constriction, especially if there is associated
peripheral vascular disease. These considerations are particularly
important when someone with diabetes is referred for a footdrop
orthosis, a knee extension orthosis after a BKA, or a finger flexion
contracture secondary to a CVA.
Individuals with DM are at greater risk for associated conditions
that may require orthotic intervention for the upper extremity, such as
carpal tunnel syndrome, flexor tendon nodules, and flexion
contractures of the palmar fascia, which resemble Dupuytren disease.
21 Idiopathic Dupuytren disease (see Chapter 9) is most common in

men age 45 and older. 46 These individuals develop flexion

contractures of their fingers or thumbs with nodules at the palmar
base of the involved digits. An orthosis is contraindicated
preoperatively because the contracted palmar fibromatosis is caused
by fascia tissue, which does not respond to low-load prolonged stress.
Therefore, surgical intervention is necessary if the contracture is
limiting function. 22 Orthotic intervention with a hand immobilization
orthosis to regain extension of the digits 17 is appropriate only after a
surgical release of the fascia or injection of clostridial collagenase.
When stenosing tenosynovitis occurs at the first dorsal extensor
compartment on the radial aspect of the wrist, it is referred to as de
Quervain disease. Conservative management includes a thumb spica
orthosis (refer to Chapter 8). Orficast, a light, textile-like
thermoformable taping material, 33 makes a comfortable thumb spica
for an older adult with de Quervain disease (Fig. 16.11).

FIG. 16.11 Orficast thin and breathable thermoplastic fabric orthosis

for de Quervain tenosynovitis.

Genitourinary Functions
Kidneys are part of the urinary system and have an endocrine
function. When treating individuals with end-stage renal disease
(ESRD), it is important to identify the subcutaneous arteriovenous
(AV) fistula. Surgically created AV fistulas are typically located on
the forearm and used for vascular access for hemodialysis. Because of
the radial artery anastomoses with an adjacent vein, vascularity distal
to the AV fistula is compromised 20 and can result in edema and
peripheral neuropathies that affect sensorimotor hand function.
Orthoses should be used selectively because any source of pressure
could cause skin breakdown in an insensate hand with compromised
vascularity.
Nocturnal urination is a common cause of sleep disturbances in
older adults for a variety of reasons. The presence of comorbidities,
medication usage, and several factors more prevalent in older persons
influence the sleep-wake cycle.5. If an older adult needs to wear an
orthosis during sleep periods, the history includes urinary function
and a review of possible sleep-related disorders. With orthotic wear
during sleep, it is especially important that the orthosis is easily
donned and doffed for safe functional mobility and toileting.

Skin Functions
Aging of the integumentary system includes thinning of the
epidermis and dermis. 19 Older adults with little subcutaneous fat are
more susceptible to pressure sores. Fragile older adults are more likely
to have skin tears. A soft orthosis, padding to line the orthosis, or a
protective skin sleeve should be considered.
Medications and Side Effects
Many older adults take medications that cause side effects 9 that may
affect orthotic provision. More than 76% of older adults use two or
more prescribed medications, and 37% use five or more. 9 A list of
medications should be included in the history before an orthotic
decision is made. 23 Corticosteroids are commonly prescribed for
chronic conditions, such as rheumatic conditions and chronic
obstructive pulmonary disease (COPD). Long-term steroid use can
lead to ecchymosis (bruising), osteoporosis, and fragile skin that is
vulnerable to skin tears. Long-term steroid use can also lead to
delayed wound healing. Anticoagulants, such as heparin, are
prescribed for collagen vascular disorders. Side effects of
anticoagulants include increased risk of ecchymosis and edema from
minor soft-tissue trauma. 44 .
Antihistamines for respiratory conditions and psychotropic
medications for mental health conditions can cause tremors. When
designing orthoses for older adults who take these medications, the
additional risks of fragile skin, osteoporosis, bruising, edema, or
tremors are factored into the orthotic design. In older adults, sleep
medications may affect orthotic wear. For example, the person may
not notice problems if the orthosis becomes uncomfortable during the
night, thus increasing the possibility of skin breakdown. In addition,
the older adult may not be compliant with the wearing schedule and
not routinely perform skin checks.
Purposes of Orthoses for Older Adults
With the plethora of conditions that may affect older adults, the
purpose of orthotic intervention may include, but is not limited to, the
following:

• Prevent ROM loss

• Reduce pain
• Improve occupational performance
• Manage contractures
• Decrease edema
• Protect skin integrity
• Substitute for loss of sensorimotor function

Range of Motion
The design of an orthosis should always allow full ROM of
noninvolved joints. Serial mobilization orthotic intervention is
generally the preferred method to improve ROM for an older adult.
An orthosis that is serially adjusted to improve ROM is easier to
manage because the therapist has better control over the amount of
force applied. For example, a volar wrist extension immobilization
orthosis after a distal radius fracture may require several progressive
adjustments to improve wrist extension (see Chapter 7). 28

Pain Reduction
With acute and chronic conditions, one goal of orthotic intervention is
to reduce pain by providing support and resting the involved joints.
In addition to the design of the orthosis to rest specific joints, the
wearing schedule should provide the appropriate balance between
rest and activity. The hand-based thumb immobilization orthosis
worn for CMC OA is an example of an orthosis removed periodically
for ROM and reapplied during activities that otherwise cause pain
and stress to the joint.

Improvement of Occupational Performance

An orthosis may improve or maintain an older adult’s function. When
possible, it is preferable to use compensatory strategies rather than
restrict ROM in an orthosis. For example, rather than having an older
adult wear a wrist orthosis for use during shaving, the therapist
makes adaptations from thermoplastic material on an electric razor to
allow the older adult to remain independent (see Fig. 16.10B). If
adapting the task is not effective, then an orthosis may be indicated.

Contracture Management
Loss of mobility and neurological conditions place an older adult at
increased risk of developing contractures. 38 Changes in the older
adult’s connective tissue and cartilage increase the risk for
contractures, especially during inactivity. 38 Appropriate goals may be
to prevent further contracture, decrease pain, or enable better skin
care. Therapists determine whether to provide an orthosis by
weighing the risks of additional complications that may arise from
orthotic wear, such as contributing to skin breakdown.
If the orthosis is applied while PROM is still within normal limits, it
may be possible to prevent a contracture. If the loss of PROM is recent,
orthotic intervention may improve ROM and correct the contracture.
An example is a footdrop orthosis to gradually position the ankle at 90
degrees after loss of active ankle dorsiflexion. Therapists also
commonly use hand immobilization orthoses to prevent further
deformity when there is a loss of active hand or wrist ROM.

Edema Management
With loss of active range of motion (AROM) combined with
diminished circulation, edema can lead to secondary shortening of
soft tissue. It is important to prevent edema through techniques such
as elevation and AROM. The edematous hand is positioned in an
orthosis to counteract adaptive tissue shortening and residual
contractures. The position of deformity caused by edema in the hand
results in thumb adduction, MCP extension, and IP flexion. 48 To
prevent deformity the wrist is positioned in an intrinsic plus position.
The intrinsic plus position consists of approximately 20 to 30 degrees
of wrist extension, the thumb in palmar abduction to a level of
comfort, and the fingers in MCP flexion with the PIP and DIP joints in
extension (see Chapter 9). Adjunctive techniques may be necessary to
treat edema when there is limited AROM. Wearing a compression
glove concurrently with the orthosis may help control edema. If the
noninvolved side of an older adult also appears edematous, a
systemic cause, such as congestive heart failure (CHF), may be
present.

Protection of Skin Integrity

The combination of impaired cardiovascular function and changes
associated with aging, such as diminished sensation and thinning of
the dermis and epidermis, creates the risk for loss of skin integrity.
The heel is the most vulnerable area for skin breakdown in the lower
extremity. Use of a densely padded positioning orthosis or footdrop
orthosis with the heel elevated from the orthotic surface may prevent
pressure sores from developing. Older adults who hold their hands in
a fisted position or continually flex their elbows, knees, and hips
create an environment conducive to skin breakdown.
The accumulation of perspiration within the skin folds allows
bacteria to grow. 40 This constant posturing and the resulting bacteria
growth may cause joint contractures, skin maceration, and possible
infection. A thermoplastic orthosis, a hand roll, or a palm protector
positions the involved joints in submaximum extension, allowing
adequate hygiene of the hand. To accomplish goals, consider the
following guidelines:

• An orthosis should not impede function unnecessarily. For

example, the orthosis should not prevent an older adult from
 safely grasping an ambulation device or interfere with
wheelchair propulsion.
• An orthosis should not exacerbate a preexisting condition. For
example, an older adult who demonstrates a flexor-synergy
pattern may wear a functional position orthosis at night for
pain and contracture management. If the older adult also has
OA in the thumb with joint deformities, consideration must be
made not to aggravate the thumb CMC, MCP, and IP joints.
• An orthosis should not limit the use of uninvolved joints.

Substitution for Loss of Sensorimotor

Function
When there is a nerve compression severe enough to cause loss of
motor function, an orthosis may substitute for the lost function. In the
case of median nerve compression, an orthosis can position the thumb
in opposition to the index finger. If the ulnar nerve is affected, the
fourth and fifth MCP joints are blocked in slight flexion to prevent a
claw deformity with MCP hyperextension and IP flexion of the fourth
and fifth digits. See Chapter 14 for more information on orthotic
intervention for nerve conditions. 18 In the case of damage to the
peroneal nerve, an ankle-foot orthosis can substitute for loss of ankle
dorsiflexion (see Chapter 18).
Orthotic Intervention Process for an
Older Adult
Assessment
During an initial assessment the therapist completes a comprehensive
rehabilitative evaluation to determine whether orthotic intervention is
indicated. It is important to recognize that interactions with older
adults require considerations such as those outlined by the National
Institute on Aging in Understanding Older Patients 30 (Box 16.3).
All components of a therapy evaluation are essential for
determining effective intervention strategies. (See Chapter 5 for a
discussion of a hand examination.) The therapist pays special
attention to the cognitive, sensory, physical, and ADL status of the
older adult to determine the usefulness of orthotic intervention as part
of the plan of care. The results of the assessment are used to develop a
list of problems to be addressed. Typical goals include those listed in
the section “Purposes of Orthoses for Older Adults.” The therapist
also documents functional goals based on orthotic usage.
During the initial assessment the therapist notes any current use of
adaptive devices and techniques. For example, an older adult may
already have an orthosis for a chronic condition, such as OA. The
therapist evaluates the orthosis for its functional purpose, proper fit,
and wearing schedule.

BOX 16.3 Considerations for Interactions With

30
Older Adults

• Use proper form of address.

• Make older patients comfortable.
• Take a few moments to establish rapport.
 • Try not to rush.
• Avoid interrupting.
• Use active listening skills.
• Write down take-away points.
• Demonstrate empathy.
• Avoid jargon.
• Reduce barriers to communication.
• Be careful about language.
• Ensure understanding.
• Compensate for hearing deficits.
• Compensate for vision deficits.

From National Institute on Aging: Understanding older patients.

(website) https://www.nia.nih.gov/health/understanding-older-
patients#address.

Observation during the assessment is vital to determining the

purpose and orthotic design. It is important to observe and assess
movement of the extremities in relation to the trunk. For example, an
older adult who has hemiplegia with a spastic upper extremity may
rest the hand on the chest, and provision of an orthosis may cause
pressure.

Material Selection, Instruction, and Follow-Up

Care
The choice of thermoplastic material, straps, and padding varies and
is based on the older adult’s needs.

Material Selection
Depending on client considerations and the goal(s) of the orthosis, the
optimal material may be rigid, lightweight, multiperforated, less rigid
thermoplastic material, or soft fabrics and dense foams. Selection of a
low-temperature thermoplastic material is determined by the
following:

• Extent to which an older adult’s joint can assume and maintain

a gravity-assisted position
• Size of the orthosis
• Performance requirements of the orthosis
• The padding requirements
• Weight of the orthotic material
• Therapist’s skill level
• Environment

If the older adult is physically and cognitively able to hold the limb
in the desired position, the therapist uses a material with high
drapability and conformability to ensure an intimate fit. The therapist
positions the extremity to ensure that gravity assists the material to
more easily drape. Material with a high degree of conformability
allows for a precise fit, thus increasing comfort and decreasing the risk
of migration and friction over bony prominences.
Some older adults cannot assume positions that allow gravity to
assist during molding. Clients may be anxious and respond to the
stretch applied during orthotic fabrication by exhibiting increased
tone. In such situations, or during the fabrication of large orthoses,
materials with resistance to stretch are helpful. A material that lightly
sticks to the stockinette placed on the older adult facilitates antigravity
orthotic intervention (see Chapter 3). Preshaping techniques are
helpful when fabricating an orthosis for an older adult with
diminished cognition or abnormal tone.
Thinner thermoplastic materials (e.g., 3⁄32 or 1⁄16 inch) are less rigid.
The therapist selects the thinnest material that can perform effectively.
Minimizing the weight of an orthosis increases comfort and enhances
adherence. Strength increases with more contouring to the underlying
body part. Older adults usually appreciate lightweight orthoses
because they are more comfortable. Orficast is a textile-like
thermoformable taping material that is an alternative to traditional
low-temperature plastics. It is a very lightweight knitted hybrid fabric
and well suited for finger and/or thumb orthoses. 33

Strapping material
Wide, soft, foam-like strapping material distributes pressure over
more surface area than thin, firm straps. Soft strapping accommodates
slight fluctuations of edema and can be fringed to decrease pressure
against the skin. To prolong the durability of soft strapping material, it
is beneficial to cut the material to the width of skin contact and weave
a standard 1-inch loop strap through slits to keep the longer-lasting
standard loop in contact with the adhesive hook on the thermoplastic
material (see Fig. 16.12B). The loop strap should completely cover the
hook portion on the orthosis’ surface. This prevents skin abrasion or
catching the orthosis on clothing and blankets. The use of presewn,
self-adhesive straps can be an alternative to reduce the chance of
losing straps.
There are advantages and disadvantages of using D-ring straps. An
advantage is that D-ring straps provide mechanical leverage to
effectively adjust the strap. Similarly, D-ring straps are useful for
clients with dementia who may tend to spontaneously remove the
orthosis. To minimize difficulty threading straps through D-rings,
double over the ends to keep them loosely in position.

Padding selection
The two basic types of padding are open-cell foam (absorbent) and
closed-cell foam (nonabsorbent). Open-cell padding absorbs moisture,
is more difficult to keep clean, and can become a breeding ground for
bacteria. Padding should be bonded with the thermoplastic material
before molding to ensure a proper fit to accommodate the thickness of
the padding. A composite thermoplastic material (i.e., with attached
padding) can be placed in a resealable plastic bag before being
immersed in heated water to keep it dry during fabrication (Fig.
16.12A). An alternative method is to first mold a removable padded
liner. Plastazote, 57 a closed-cell foam available in a variety of
thicknesses, is heated in a hot air oven at 285°F for 10 seconds for each
1 mm of thickness. The selected thickness of foam is softened to a
pliable state and can then be molded directly on the extremity or over
stockinette. The thinner widths can be used to mold a liner for an
orthosis (see Fig. 16.12B), and the thicker widths can be used to
fabricate an entire soft orthosis. Padding may also be molded on the
outside of an orthosis if cushioning is needed when an orthosis rests
against another body part. For example, an older adult who has
hemiplegia and a flexed upper extremity may rest the orthosis against
the rib cage, or a right ankle orthosis may press against the left leg
when the older adult is side lying.
 FIG. 16.12 A, A composite thermoplastic material put in a resealable
plastic bag before placement in heated water keeps the padding dry. B,
Foam, such as Plastazote, may be custom molded to line an orthotic if
skin integrity is a concern.
A Courtesy North Coast Medical.

Choosing the correct strapping, padding, and thermoplastic

materials is important. Clinical judgment and the ability to make
adaptations is beneficial for older adult clients because they are most
prone to contractures and pressure sores with illness. 49 Orthoses
should fit well, achieve their goal(s), and be acceptable to the older
adults and their care partners.

Technical tips
Therapists acquire technical skills through practice. With orthotic
provision to older adults, one or more of the following technical tips
may be helpful:

• Choose materials that have a slightly longer working time. For

example, when fabricating a hand immobilization orthosis
(see Chapter 9), partially preshape the hand portion of the
resting pan for a similar-size hand before applying it to the
older adult.
• During the molding process, use latex-free resistance bands or
an elastic bandage to temporarily secure the forearm trough.
This technique permits more attention to contouring of the
hand and wrist.
• Prepad bony prominences using circular pieces of adhesive-
backed foam or gel padding over stockinette. Mold the
orthosis over the padding, then reverse the adhesive side to
position inside the orthosis and ensure congruous contact.
• Apply a stockinette to the extremity.
• Use uncoated and self-bonding material for orthoses if darts or
tucks are necessary. Therapists often use this type of design
for ankle, knee, and elbow orthoses.
• Use a coated material for thumb immobilization orthoses.
 Often the thumb IP joint is enlarged or deformed, thus making
application and removal of a closed circumferential orthosis
difficult. Use of a coated material allows circumferential
wrapping around the thumb. After cooling the overlapping
material pops open to allow for easier removal. If self-bonding
materials are preferred, use a wet paper towel or tissue paper
between the overlapping surfaces to prevent bonding.
• For serial repositioning, select a material that has a high
resistance to stretch and memory.
• For a painful or deformed extremity, make the pattern on the
opposite extremity, cut it out of the thermoplastic and then
reverse it during fitting.
• To ease the fabrication process when working among multiple
settings, create orthotic boxes or travel kits containing all
necessary supplies. 50

Older Adult and Care Partner Instructions for

Follow-Through
Clear client and care partner instructions and consistent follow-
through are important for successful orthotic intervention. Many
factors influence adherence to an orthotic wearing schedule. The
person responsible for the orthotic wearing schedule and care is the
older adult or care partner(s). See Box 16.4 for information on
adherence issues.

Instructions With Care Partners

Older adults unable to care for themselves will need assistance. Care
partners are often family members or staff members from an agency
or facility. When fitting an orthosis to an older adult, the therapist
must provide thorough instructions. Instructions include information
regarding (1) the orthosis’ purpose, (2) wearing schedule, (3) orthotic
care, and (4) precautions or safety factors. The therapist informs care
partners about who and when to contact if a problem occurs. For
example, for a client who has fluctuating edema, tone, and PROM, the
responsible individuals are instructed in how to adjust the straps.

BOX 16.4 Factors That Influence Adherence to

Orthotic Care and Wear Schedule
Older Adult Who Is Capable of Self-Management
or Care Partner (Family and/or Staff)
• Explain the purpose and goals of the orthosis to the older adult
and caregiver.
• Provide simple written and oral instructions with pictures.
• Use positive reinforcement for correct follow-through.
• Listen to the adult’s complaints, and make adjustments as
necessary.
• Use repetition with instructions as needed.
• Consider using analogies for instructions (e.g., “This is just like
cleaning your dentures.”)
• Ensure older adults wear their glasses and hearing aids.
• Label the orthosis for easy application when necessary.
• Ask if the patient/care partner has any questions about the
orthotic wearing schedule and care instructions.
• Demonstrate proper orthotic application and removal.
• Encourage the patient or care partner to demonstrate the correct
procedure several times.
• In an institutional setting, ensure that the orthotic-wearing
schedule and hand hygiene are part of the older adult’s care plan.
• Educate about precautions and safety. Provide contact
information to report problems if they arise.

The therapist provides oral and written instructions, demonstrates

application of the orthosis, and observes for correct repeat of the
demonstration until it is mastered.
The therapist labels parts of the orthosis for easier application (e.g.,
right/left, thumb/wrist/forearm). When possible, the therapist
provides photographs of proper orthotic position in addition to a
written wearing schedule. The therapist should include a list of
precautions, safety factors, and maintenance information.
The therapist includes instructions in the medical record to ensure
staff follow-through. All staff members involved with an older adult’s
care must receive instructions about the wearing schedule,
precautions, and safety factors, particularly for those older adults who
wear orthoses for only a portion of the day or evening. The wearing
schedule may require modification to fit the staff schedule.
When appropriate, the therapist instructs care partners about the
use of inhibition techniques to facilitate proper orthotic application.
The therapist also provides instruction about the importance of
intermittent PROM and active-assisted ROM to immobilized joints
when appropriate. 16

Skin care
Maintenance of skin integrity is important for older adults who need
long-term orthotic intervention. The orthosis must be clean for
application. A good cleaning method involves the use of isopropyl
alcohol. Chlorine is appropriate for removal of stains. After removal
of the orthosis, instruct to thoroughly wash and dry the hand. To
manage moisture, have the older adult wear a stockinette under the
orthosis.

a
Self-Quiz 16.1
For the following questions, circle either true (T) or false (F).

1. T F Observing the older adult’s skin condition is important

when the therapist is making orthotic intervention decisions.
2. T F The therapist should apply closed-cell foam only after the
 formation of an orthosis.
3. T F For an older adult who has spasticity, to ensure intimate
contour, the therapist should use a material with high
drapability.
4. T F The therapist should use wide straps on an orthosis for an
older adult who has fragile skin.
5. T F A functional position orthosis is always appropriate to
position the arthritic hand.
6. T F Older adults are more prone to joint contractures than
younger persons who have similar diagnoses.
7. T F After orthotic completion for an older adult in a long-term
care facility, there is little follow-up needed by the therapist.
8. T F Orthotic materials may be used to adapt ADL devices.
9. T F Medication use does not affect orthotic design.
10. T F It is always important to initially evaluate the entire upper
extremity for an older adult with any injury.
11. T F Older adults with diabetes are at greater risk of associated
conditions that may require orthotic intervention.
12. T F Poor positioning of older adults with limited mobility may
contribute to neuropathies of the median and ulnar nerves.
13. T F When fitting an orthosis on an older adult with
cardiovascular disease, the therapist should consider
precautions for peripheral vascular disease.

a
See Appendix A for the answer key.

Wearing schedule
To determine the wearing schedule, the therapist considers the goals
of the orthosis. The goals establish whether a daytime, nighttime, or
an intermittent wearing schedule is the most beneficial. For example,
an intermittent wearing schedule allows air to reach the skin. A
nighttime wearing schedule may be more appropriate if the older
adult is able to use the extremity for functional assistance during the
day.
Cost and Payment Issues
Medicare is the primary insurance payer for older adults. Medicare
Part A covers in-patient hospitalization, skilled nursing, and home
health episodes of care. Medicare Part A services are typically paid
under a bundled payment structure. Medicare Part B covers a
percentage of outpatient rehabilitation and durable medical
equipment (DME). The outpatient facility must be a DME supplier
with Medicare to submit a bill with an L code for reimbursement for
prefabricated off-the-shelf (OTS) or custom-fitted orthotics. 10 OTS
orthotics are defined by the Centers for Medicare and Medicaid
Services (CMS) as orthotics that require “minimal self-adjustment for
appropriate use and do not require expertise in trimming, bending,
molding, assembling, or customizing to fit to the individual.” 10 When
the orthotic does require

a
Self-Quiz 16.2
Critical Thinking Case Scenarios

1. You are fabricating a volar hand immobilization orthosis for an

older adult who is unable to actively supinate the forearm.
Should you choose a material that has high drapability? Is this
the best choice? Why?
2. You are treating an 86-year-old woman one year after a CVA.
Since that time, she has held her left hand in a fisted position.
Gentle passive extension is painful. The palm is macerated
from perspiration. She does not have active motion in the left
hand and does not use the hand for functional assistance
during ADLs. Which type(s) of positioning device(s) would be
appropriate?
3. An older adult who has RA complains of pain in the wrists and
 metacarpophalangeal joints. What problems would you
anticipate if the therapist provides hand immobilization
orthoses to rest all of the joints of the wrist and hands at night?
4. You fabricate a functional position hand immobilization orthosis
for an older adult who has spasticity and hemiplegia and is in a
flexor-synergy pattern. The older adult wears the orthosis at
night for pain relief and contracture management. When the
older adult is in bed, the orthosis is positioned against the rib
cage. What can you do to relieve the pressure?
5. You fabricated a hand immobilization orthosis for an older adult
with hemiplegia and congestive heart failure (CHF). You are
concerned about the fluctuating edema noted in the hemiplegic
hand. How would you modify the orthosis and straps?

a
See Appendix A for the answer key.

a
Self-Quiz 16.3
Matching
Match the intervention option with the problem that it would address.

1. _________ Silver ring orthotic

2. _________ Orficast custom orthotic
3. _________ Plastazote molded splint padding
4. _________ Nitrile-coated gloves under orthotic
5. _________ Soft, foam straps with fringed edges
a. Cold intolerance such as side effect from chemotherapy
b. Finger joint with chronic instability
c. Fragile skin or peripheral vascular disease
d. Need for lightweight breathable material
e. Edema
a
See Appendix A for the answer key.

specialized fitting, the custom-fitting L code should be applied. The L-

code payment structure covers the expertise required to provide an
evaluation that is relative to provision of the orthotic. Follow up
orthotic checks or training with an orthotic does not require the
therapist to be a DME supplier. Medicare requires the use of timed
Current Procedural Terminology (CPT) codes to bill for orthotic
training and management during initial encounters and a separate
code for subsequent encounters. Transmittals regarding codes,
payment caps, and procedures frequently change. Therapists are
encouraged to follow up-to-date information from their national and
state level professional practice organizations as well as the CMS
website. For additional details on cost and payment issues, see
Chapter 6.

Review Questions
1. What are the accommodations that a therapist can make
for each of the following problems: edema, ecchymosis,
fragile skin, contracture, diminished cognition, sensory
loss, and motivation?
2. What are four possible goals of orthotic intervention with
older adults?
3. Why are older adults prone to developing contractures?
4. What are five medical conditions more prevalent in older
adults? What are the implications for orthotic
intervention?
5. What are three common medication side effects that older
adults typically experience? How might the side effects
 impact orthotic intervention?
6. How do instructions and selection of orthotic materials
vary with an individual living independently in the
community versus an individual in an inpatient setting?
7. What are three specific orthotic adaptations for older
adults who have impaired cognition, sensory function, and
poor adherence?
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Appendix 16.1 Case Studies
Case Study 16.1 a

Ruby is a 90-year-old right-hand–dominant woman who lives in an

assisted living center. She was referred to occupational therapy to be
evaluated and treated for an orthosis and activity of daily living
(ADL) interventions. She underwent a trigger finger release of the
right middle finger 2 years ago and has right thumb carpometacarpal
(CMC) osteoarthritis (OA). Ruby no longer experiences triggering of
the middle finger. However, she does have some loss of active
metacarpophalangeal (MCP) extension. Ruby reports enjoying
crocheting, but she finds that she has progressively crocheted less due
to pain in her thumb. Upon observation of self-care performance, due
to loss of active MCP extension of the middle finger, Ruby is noted to
use only index-to-thumb opposition for activities that require pinch.

1. The therapist needs to consider which of the following to

determine the most appropriate orthosis?
a. Postoperative trigger finger protocols
b. Grip strength
c. Advantages and disadvantages of prefabricated and
custom-fitted orthoses
d. Prefabricated orthoses for trigger finger
2. The orthotic design should incorporate a combination of which
of the following? Circle all that apply.
a. Thumb CMC immobilization
b. Thumb CMC mobilization
c. Middle finger extension assist
d. Middle finger MCP flexion block
3. Goals for the orthosis should include which of the following?
Circle all that apply.
a. Thumb mobilization
b. Improved occupational performance
 c. Pain reduction
d. Substitute for loss of motor function
4. To promote occupational performance, which of the following
is least significant?
a. Self-care function
b. Leisure interest
c. Location and degree of pain
d. Age

Case Study 16.2 a

Edward is a 74-year-old man who lives with his wife on a farm in a
rural setting. He was recently discharged from an inpatient
rehabilitation facility to his home. Edward receives home care services
that include physical therapy, occupational therapy, and nursing. His
referring diagnosis is left cerebrovascular accident (CVA) with right
hemiparesis. Medical history is significant for congestive heart failure
(CHF) and chronic obstructive pulmonary disorder. Edward’s chief
complaints are limited endurance and decreased use of his right
upper extremity.
Upon evaluation, Edward presents with bilateral upper extremity
(UE) tremors, good return of right UE function at the shoulder and
elbow, minimal active wrist extension, finger and right-hand
(dorsum) edema, and enlarged distal interphalangeal (DIP) finger
joints. Although he is referred for orthotic intervention at this time, he
was not fitted with an orthosis during his inpatient stay, because he
was showing signs of motor return and was receiving daily treatment
to prevent loss of motion.

1. Goals for the orthosis should include which of the following?

Circle all that apply.
a. Prevent loss of range of motion (ROM)
b. Substitute for loss of sensorimotor function
c. Decrease pain
d. Decrease edema
2. What orthosis do you recommend?
a. Wrist immobilization orthosis with D-ring straps
b. Thumb immobilization orthosis
c. Soft Neoprene prefabricated orthosis
d. Prefabricated adjustable wrist-hand-finger orthosis
3. What type of straps would you choose?
a. Long, soft, wide straps
b. Thin loop straps
c. D-ring straps cut to the exact size
d. Wide hook straps
4. What wearing schedule would you suggest?
a. Wear orthosis at all times
b. Remove orthosis only for hygiene
c. Wear orthosis only during the day
d. Wear orthosis at night and periodically during the
day when resting
5. What is the most likely cause of the enlarged DIP joints?
a. Rheumatoid arthritis (RA)
b. Osteoporosis
c. Osteoarthritis
d. Peripheral vascular disease
Appendix 16.2 Laboratory Exercise
Laboratory Exercise 16.1 a

1. What problems are identified in the orthosis made for someone

with thumb carpometacarpal (CMC) osteoarthritis (OA)?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
 2. How would the orthosis shown in the figure be modified for
someone with hyperextension of the thumb interphalangeal
(IP) joint?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

a See Appendix A for the answer key.

a See Appendix A for the answer key.
17
Orthoses for the Pediatric
Population
Yvette A. Elias

CHAPTER OBJECTIVES
1. Identify common diagnoses affecting the pediatric upper
extremity.
2. Examine the impact of upper extremity orthoses on child
development.
3. Describe common surgical procedures for select diagnoses and
the postsurgical orthoses.
4. Describe orthoses fabricated specifically for the pediatric upper
extremity.
5. Identify when thermoplastic versus soft orthotics are appropriate.
6. Describe challenges of orthotic fabrication for the pediatric
population.
7. Describe wearing schedules and precautions for pediatric
orthoses.
8. Discuss the importance and role of family members and other
caregivers in orthotic intervention for children.
9. Assess and critique correct orthotic fitting.
10. Identify safety issues of orthotic intervention for children.
11. Identify resources for the purchase of prefabricated pediatric
soft orthoses.
12. Examine current evidence for pediatric orthotic intervention.
13. Apply knowledge of pediatric orthotic intervention to a case
 study.

KEY TERMS
arthrogryposis
brachial plexus palsy
camptodactyly
centralization
cerebral palsy (CP)
clasped thumb
clinodactyly
congenital hand anomalies
Erb palsy
hypoplasia
pediatric trigger thumb
radialization
radial longitudinal deficiency
spasticity
syndactyly
tone
ulnarization

Johnny is an 18-month-old boy who presents with right hemiparesis

resulting from an intrauterine stroke. He has full passive range of
motion in his right upper extremity and mild flexor tone, causing him to
posture his elbow in slight flexion, forearm in pronation, wrist in
flexion, thumb flexed into palm, and digits fisted. Active motion is
limited at the end ranges of shoulder flexion/abduction, elbow extension,
 forearm supination, and wrist extension. Although Johnny can actively
extend his right-hand digits, he has difficulty grasping objects in his
right hand because he approaches objects with his wrist flexed and has
trouble abducting his thumb out of his palm most of the time. When his
therapist stabilizes his wrist in extension, he can use a modified radial
digital grasp on objects with more success but then has difficulty
releasing objects from his hand and requires increased time for release
tasks. Johnny’s flexor tone causes him to have difficulty coordinating
active wrist and digital extension simultaneously during grasping tasks
(Fig. 17.1).

The therapist considers the following questions: In what ways might

orthoses assist Johnny’s function or prevent loss of function? Which
orthoses are appropriate interventions for Johnny? What other
interventions might enhance Johnny’s volitional grasp and release, and
how might orthoses be required with concurrent interventions?

This chapter introduces the most common conditions that affect the
pediatric population and may require upper extremity orthotic
intervention. A short description of each diagnosis is offered only as
an overview. It is beyond the scope of this chapter to describe every
pediatric hand condition. More detailed information is found in the
cited references and in texts and journals. Orthotic fabrication is a
therapeutic intervention used for children with orthopedic conditions
and/or with developmental disabilities. 24 Surgical interventions for
congenital hand anomalies are described with the postsurgical
orthoses commonly required. General orthotic fabrication principles
discussed in previous chapters apply to the pediatric population, but
there are differences inherent in fabrication. This chapter addresses
proper selection of orthotic materials, orthotic design, steps of orthotic
fabrication, and tips for working with children and their caregivers.
Typical orthoses fabricated for the pediatric population include elbow,
forearm rotation, resting hand, wrist, and thumb orthoses. Children
may benefit from commercially available orthoses. The measurements
for and recommendations of a variety of commercial orthoses are
described. The purpose of this chapter is to guide the novice therapist
in applying knowledge of orthotic fabrication to the special needs of
children with injuries, congenital hand anomalies, and/or
developmental disabilities.

FIG. 17.1 Child with cerebral palsy (CP).

Purpose of Orthoses for Pediatrics
The intents of pediatric orthoses are protective, preventive, or
enhancement to the child’s upper extremity function and skill
development. Similar to orthotic provision for adults, pediatric
orthoses may address issues at single or multiple joints. Orthoses may
be applied in a variety of locations (e.g., shoulder to the distal
interphalangeal [DIP] joints).
The different orthoses presented in this chapter are one small part
of a comprehensive intervention program. A comprehensive
intervention plan is developed beginning with an assessment of the
child and incorporating all elements of the Occupational Therapy
Practice Framework. 3 Using the Practice Framework as a guide
ensures that the delivery of occupational therapy services is client
centered and focused on occupations of importance to the child, the
role within the family, and the performance of play and learning,
especially within the contexts of home and school environments. One
quick method to apply the Practice Framework is to incorporate the
following areas during evaluation:

• Areas of occupation: Make clinical observations of the child

participating in activities. Does the use of an orthosis limit or
improve function? What skill(s) does the child need to
develop that might be enhanced with an orthosis?
• Client factors: Assess the child’s muscle tone, range of motion
(ROM), strength, and contractures. Will an orthosis improve
or prevent further loss of any of these components?
• Performance skills: Evaluate the child’s ability to reach, grasp,
bear weight on the affected limb(s), and stabilize and
manipulate objects. What are the child’s sensory status, visual
capabilities, and cognitive level? Will the use of an orthosis
affect such systems?
• Context: Note the child’s home and school environments. How
does the use of an orthosis affect performance in these
settings?
Goals
The goals of orthotic intervention for children are similar to those for
adults. Goals may include:

• Support the upper extremity

• Protect during healing
• Position for improved function
• Assist weaker muscle groups to improve function
• Facilitate or maintain tissue length and joint alignment
• Prevent deformity

However, orthotic fabrication for children involves more than

simply making smaller-size orthoses.
Previous chapters discussed mechanical principles and orthotic
fabrication techniques that apply to children. Orthotic fabrication for a
child is different from orthotic fabrication for an adult in several key
areas, including the following:

1. Different proportions between the palm and length of fingers

in the growing hand versus the adult hand exist. 25
2. Children are constantly growing and therefore require more
frequent orthotic adjustments and/or new orthoses to
accommodate for growth.
3. In many cases the parents or teachers are responsible for
applying and removing the orthosis. They must understand
the importance of the orthosis, wear and care schedule, and
precautions.
4. Foundational movement patterns are set during the first 2 to 3
years of life. Interventions with orthoses assist the child with
developing more typical movement patterns.
5. Children may be fearful about getting an orthosis and will
typically not remain still while a custom orthosis is fabricated
 on their hand.
6. Children may remove their orthosis, and compliance with
orthosis wear may be challenging.
Development
Working with children requires a thorough understanding of normal
and abnormal child development, knowledge of the specific pediatric
conditions, and current evidence-based intervention practices,
including orthoses. The parent or caregiver must be included in the
orthotic process from the beginning to ensure adherence to the
intervention plan. The parent should have a good understanding as to
the purpose of each orthosis so that adherence to the wear schedule is
optimal. The therapist should also consider the parent’s specific goals
and expectations for his or her child.

Normal Hand Development

Understanding normal hand development is required before orthotic
fabrication. The upper extremity begins as a small outgrowth of tissue
on the lateral body wall of the fetus, beginning on day 26 of gestation,
even before growth of the lower extremity. 28 This small area contains
all of the necessary information to form the limb. Development of the
upper extremity proceeds proximally to distally. By the 31st day, the
area of the hand is present. Fingers are evident by days 36 to 41. Bone,
joint, muscle, and vascular development follows. Formation of the
upper extremity is completed by the eighth week of fetal
development. 28

Abnormal Hand Development

Abnormal hand development may be affected by intrinsic factors (e.g.,
chromosomal abnormalities or mutant genes), extrinsic (i.e.,
environmental) factors, or a combination of the two. These factors
contribute to the arrest of development of the forming limb or to the
destruction of structures already formed.

Fine Motor Skill Development

A detailed description of hand and fine motor skill development is
beyond the scope of this chapter. However, the therapist fabricating
an orthosis considers the infant or child’s current level of fine motor
skills and thinks about how the orthotic intervention impacts future
hand skill development. Through sensory exploration and play,
children learn about their environments. Wearing an orthosis
interferes to some degree with the ability to explore and play. The
therapist provides appropriate scheduling of orthotic wear to ensure
ample opportunities for play and development of grasp and release
patterns. Table 17.1 is a guide to the development of gross and fine
motor skills during the first year. Children develop these skills in a
predictable manner. Proper orthotic selection takes this progression
into account.

Atypical Upper Extremity Motor Development

Atypical upper extremity development occurs when the infant or
child develops patterns of movement that compensate for weakness,
spasticity, contractures, deformity, tightness, and/or sensory
abnormalities. For example, if a child has an adducted thumb, grasp
may result in using the ulnar fingers. Ulnar deviation and wrist
flexion are reinforced with this pattern, whereas radial musculature
may be overstretched and weakened through nonuse. This topic is
discussed later in this chapter in the Cerebral Palsy section.

TABLE 17.1

Gross and Fine Motor Skill Development

Approximate
Gross and Fine Motor Skill
Age
Birth to 2 Physiological flexion
months
2 months Grasp reflex

3 months Hands together in supine

4 months Objects held in midline, bears weight on forearm

5 months Two-handed approach to objects, extended-arm weight bearing, displays some

supination of forearm
 6 months Weight shifts on extended arms in prone, sits with straight back, elbows fully
extend
7 months Purposeful release, may pull to stand

8 months Creeps on hands and knees

9 months Reaches with active supination

10 months Pokes with index finger

12 months One hand stabilizes while one hand manipulates

15 months Develops release with precision

Modified from Hogan, L., Uditsky, T. (1998). Pediatric splinting:

Selection, fabrication, and clinical application of upper extremity splints. San
Antonio, TX: Therapy Skill Builders.
Common Pediatric Upper Extremity
Conditions
Children born with congenital hand anomalies require special
consideration and a team approach. Intervention involves family
members, therapists, surgeons, and teachers. The most common
congenital anomalies include:

1. Common congenital hand anomalies

a. Radial longitudinal deficiency/radial clubhand
b. Hypoplastic thumb
c. Pediatric trigger thumb
d. Syndactyly
e. Camptodactyly
f. Clinodactyly
g. Clasped thumb
2. Brachial plexus palsy
3. Arthrogryposis
4. Juvenile idiopathic arthritis
5. Cerebral palsy

Common Congenital Hand Anomalies

Radial Longitudinal Deficiency/Radial Clubhand
Radial longitudinal deficiency, also referred to as radial clubhand
(Fig. 17.2), is the most common congenital longitudinal deficiency in
the upper extremity. 15 The term describes congenital hand anomalies
that present as a result of absent or abnormally developed or
underdeveloped tissue on the radial aspect of the upper limb. 28 There
is typically an absent or hypoplastic thumb with abnormalities seen in
the other digits. The radial digits are usually stiff, while the more
ulnar digits are more mobile. 43 There is no bony support on the radial
side with carpal and musculotendinous abnormalities. 43 The
combination of a stiff elbow, short forearm, radially deviated hand,
and underdeveloped or absent thumb significantly impairs hand
function. 43 The degree of severity determines the need for surgical
intervention.

FIG. 17.2 Radial clubhand.

Radial deficiency conditions may occur in isolation but commonly

occur to some degree in association with each other and in the
presence of other syndromes. 1
Passive stretching to all affected joints and fabrication of
appropriate orthotics should be initiated soon after birth to distract
and lengthen the tight radial structures at the wrist. 44 The
implementation of passive stretching and use of orthotics is essential
to preventing progressive contractures and to providing a supportive
base for hand use. These approaches facilitate the best functional
outcome postoperatively should they require a centralization
procedure in the future, as is the case with more severe deficiencies.
(Centralization is a surgical procedure to move the carpus to a central
position on the ulnar to correct radial deviation and wrist
subluxation.) Initially the radial gutter type of wrist orthosis (Fig. 17.3)
(see Chapter 7) is molded on the radial border of the forearm and
places the hand in a central position relative to the forearm, or as close
to the center as passively possible. The orthosis is worn full-time and
should allow the digits to be free for play and for hand to mouth
exploration. Padding over bony prominences and lining the orthosis
with moleskin is important for protecting the skin and promoting
maximal comfort. Soft straps are better tolerated on the skin. If there is
stiffness in the elbow, a posterior long arm orthosis can be fabricated
for overnight use in the child’s submaximal available passive flexion
for prolonged stretching (see Chapter 10). This posterior long arm
orthosis is serially modified into increased flexion as ROM improves.
Full arm casting may be used to correct the positioning of the hand,
wrist, and elbow. 36
 FIG. 17.3 Radial clubhand with orthosis.

There are new surgical approaches being implemented to manage

radial longitudinal deficiencies, but the most common procedure
performed currently is soft tissue distraction followed by a wrist
realignment procedure such as a centralization, radialization, or
ulnarization. 32 (Radialization is a surgical procedure to move the
hand closer to the radial border of the forearm. Ulnarization is a
surgical procedure to move the hand closer to the ulnar border of the
forearm.) A large retrospective review of 446 patients, including 137
patients managed nonsurgically and 309 patients managed with either
a centralization or radialization procedure, found that those managed
surgically had improvement in appearance and function, including
improved alignment, ROM, and strength. 32
Banskota and colleagues 5 recommend surgery for the wrist before 2
years of age because children quickly acquire adaptive functional
skills. A delayed surgery may interfere with normal hand skill
development. During the first phase of the surgery an external fixator
is applied for soft tissue distraction. During this time the therapist
may need to fabricate a protective orthosis over the external fixator to
protect the pins and prevent injury to the child. This orthosis may
need to be circumferential and may need to include the elbow for
improved stability, especially if there is no thumb for anchoring the
distal portion of the orthosis. Applying straps strategically can help
prevent the orthosis from migrating. When strapping a short arm
radial gutter orthosis, one strap can be used in a figure-eight pattern
to best secure the orthosis, or one long strap can be applied to secure
orthosis. A figure-eight pattern can also be applied to a long arm
orthosis with wide straps crossing over the anterior elbow. A benefit
to orthotic use is that, unlike casts, orthoses can easily be removed by
the surgeon to perform weekly distractions. The therapist must then
modify the orthosis as needed to accommodate to the increased
alignment of the wrist. The next phase is a formal centralization
procedure, requiring the use of a forearm orthosis (see Chapter 7)
throughout the 12-week postoperative period; which is removed for
hygiene only. Again, if there is an absent thumb and there is difficulty
in maintaining the orthosis in place, a long arm orthosis may be a
better option to lessen chances of the orthosis being easily removed.
This long arm orthosis is weaned to overnight use at around 12 weeks
post surgery and is typically worn overnight until skeletal maturity. 28
Children with mild deformities are advised to follow the same
overnight wearing schedule, with daytime use as needed.

TABLE 17.2

Hypoplasia/Aplasia of the Thumb

Type Findings Treatment
I Minor generalized hypoplasia Augmentation
 II Absence of intrinsic thenar muscles Opponensplasty
First web space narrowing First web release
UCL insufficiency UCL reconstruction
III Similar findings as type II plus: A: Reconstruction
Extrinsic muscle and tendon abnormalities B: Pollicization
Skeletal deficiency
A: Stable CMC joint
B: Unstable CMC joint
IV Pouce flottant or floating thumb Pollicization

V Absence Pollicization

CMC, Carpometacarpal; UCL, ulnar collateral ligament.

Serial-static and static-progressive mobilization orthoses stabilize

and position the wrist. These orthoses (and passive motion) align the
wrist in a more neutral position and maximize function. Alternatively,
children may benefit from nighttime resting hand orthoses (see
Chapter 9) once full passive motion is achieved. Resting hand orthoses
maintain digital alignment and prevent flexion contractures of the
digits. A wrist support often improves functional grasp of the digits.
With growth, children may require multiple surgeries and need
frequent orthotic adjustments.
A number of challenges exist when fabricating an orthosis for a
child with radial deficiency. These include:

• The child may easily remove the orthosis.

• Lack of a thumb to hook the thermoplastic material around
during fabrication and wear.
• Tendency of the orthosis to migrate proximally and/or distally.
• Frequent serial adjustments of the orthosis are necessary with
gains in passive ROM (PROM).
• The elbow may need to be included in the orthosis for leverage
and mechanical length.

Hypoplastic Thumb
A thumb with some degree of deficiency in any of its anatomical parts
—osseous, musculotendinous, or ectodermal—is referred to as a
hypoplastic thumb. 28 The popular Blauth system classifies
hypoplastic thumbs into five types (Table 17.2). 28

FIG. 17.4 Hypoplastic thumb.

Children with congenital thumb aplasia (total absence of the thumb)

or hypoplasia (Fig. 17.4) are severely impaired with function. 28 These
children lack an active thumb, which plays a key component in hand
function. Surgical procedures vary from thumb reconstructions,
including tendon transfers to enhance thumb function (for mild cases
of thumb hypoplasia), to pollicization, creating a thumb from the
index finger when the thumb is absent. 14
Box 17.1 lists the indications for thumb hypoplasia orthotic
intervention. Thumb orthoses (Fig. 17.5) for children with thumb
hypoplasia include the carpometacarpal (CMC), metacarpal (MP), and
interphalangeal (IP) joints, as needed. Such orthoses maintain an
adequate first web space, hold the thumb in a functional position, and
correct or prevent deformity. The appropriate thickness of
thermoplastic material is based on the size of the child’s hand. For
small children and infants, even 1⁄16-inch thick thermoplastic material
may be too heavy. A commercially available soft thumb orthosis, a
ribbon, or a thin Neoprene strap in the web space may work best.

Pediatric Trigger Thumb

Pediatric trigger thumb generally presents early in childhood, but not
at birth. 8 Most commonly the thumb is locked in flexion at the IP
joint. There is a palpable nodule at the volar aspect of the
metacarpophalangeal joint flexion crease, known as a Notta nodule. 8
A recent ultrasound study of children with trigger thumbs
demonstrated no abnormalities of the flexor pollicis longus (FPL)
tendon or the A1 pulley. Rather, it is simply a size mismatch between
the cross-sectional area of the tendon compared with that of the
pulley. 8 There is some controversy as to whether pediatric trigger
finger is an acquired deformity or a congenital anomaly. 8 In either
case, orthotic intervention and stretching exercises can be successful.
The evidence for the protocol includes full-time hyperextension
orthotic intervention for 6 to 12 weeks followed by nighttime wear.
Shiozawa and colleagues 42 recommended an immobilization orthosis
at the first physician evaluation. A forearm-based orthosis is applied
with the wrist in mild extension, the thumb in radial abduction, and
the IP joint in as much IP extension as passively available (Fig. 17.6). A
forearm orthosis is best suited for children, as small digitally based
orthoses will typically slip off easily or will be removed by the child.
These authors found that wearing an orthosis significantly reduced
the need for further surgical intervention. Surgical release of the A1
pulley may be needed when there is no resolution after 1 year of
conservative management. 31 Koh and colleagues 31 reported on the
results of nonsurgical management of locked trigger thumbs
specifically. They found that 92% of those treated with nighttime use
of an orthosis resolved completely at an average of 22 months after
presentation, whereas 60% who were simply observed resolved
completely at an average of 59 months. 31
Box 17.1 Indications for Orthotic Fabrication for
Thumb Hypoplasia

Preoperatively Postoperatively
Orthoses to preserve and/or increase the Orthoses to protect the tendon transfers during
first web space healing
Orthoses to protect pollicization of the index finger
(in its new position)

FIG. 17.5 Thumb orthosis.

 FIG. 17.6 A forearm-based orthosis is applied with the wrist in mild
extension, thumb in radial abduction, and the IP joint in as much
extension as passively available.

Trigger Finger
Pediatric trigger fingers often present in children with underlying
conditions. 8 In contrast to trigger thumbs, trigger fingers more often
present with classic triggering symptoms rather than fixed or locked
in flexion posture. 8 Success has recently been reported in the
nonsurgical management of idiopathic pediatric trigger finger. A
recent comparative study of orthosis versus observation of pediatric
trigger fingers found that 30% resolved in the observation group,
whereas 67% resolved in the orthosis group. 8

Syndactyly
Syndactyly (Fig. 17.7A) refers to the webbing of fingers. Syndactyly is
classified as complete (full length of the fingers) or incomplete.
Syndactyly may involve the skin only (simple syndactyly), or it may
involve fusion of the bones (complex syndactyly). 27 Syndactyly is
treated by surgical release for functional and cosmetic improvement.
Surgery is typically performed before prehension patterns are
established. 14
For postsurgical syndactyly release, a web spacer or finger
separator is formed from silicone or elastomer putty to maintain
pressure on the surgically corrected interdigital web space. Highly
conforming thermoplastic material is used. Web creep or the repeated
fusion of the skin between the released digits may reoccur and is a
significant complication that may require an additional surgical
release. 27 The type of orthoses used in the treatment of syndactyly
may include a resting hand orthosis (Fig. 17.8) with finger separators
made from pellets of thermoplastic material or elastomer. A foam-
padded dorsal piece of thermoplastic material can be clamshelled to
the volar orthosis at the distal end to decrease existing PIP flexion
contractures as well as to prevent the child from easily sliding fingers
out of the orthosis. Coban can also be wrapped lightly around affected
digits to aid in preserving webs and for scar remodeling purposes.
Once the wounds are healed, some therapists measure the child’s
hand for compression gloves with slant inserts to preserve the web
spaces and facilitate the development of a soft, flat, and mobile scar
throughout the scar maturation period of 1 year (see Fig. 17.7B). It is
recommended that the gloves be worn 23 hours a day for best
outcome. The therapist has the option of lining a daytime glove with
silicone within the webs and over the digital scars for 12-hour daytime
wear and then alternating these with nighttime compression gloves
without silicone lining for a total of 23-hour daily wear between both
gloves. Parents should be instructed to perform scar massage
frequently throughout the day and to monitor the child’s skin for any
signs of skin irritation or skin maceration. Those children with
residual digital flexion contractures should continue to wear a static
extension orthosis overnight.
 FIG. 17.7 A, Syndactyly. B, Compression glove to preserve webs
after syndactyly release.

Camptodactyly
Camptodactyly is a nontraumatic, flexion contracture of the proximal
interphalangeal (PIP) joint that typically affects the little finger. 39
There are three basic types of camptodactyly:

• Type I appears in infancy and is present in both males and

females. Type I affects the little fingers on both hands and
may involve the ring and long fingers.
• Type II presents in adolescence and is more common among
females. Type II worsens during growth spurts.
• Type III is a more severe form of camptodactyly and may
involve multiple digits of both hands. Type III is associated
with additional congenital anomalies.
 FIG. 17.8 Resting hand for infant.
Courtesy Orfit Industries.

Intervention for camptodactyly, both operative and nonoperative,

remains controversial and may depend on the severity of the
deformity. 14 Nonoperative intervention with orthotics may
sometimes be the only form of treatment needed for camptodactyly.
Surgery is not the sole definitive treatment. Hand therapy plays a
substantial role in achieving postoperative results and may also play a
role in nonsurgical patients. Hand therapy must be individualized via
clinical examination to decipher the best orthotic intervention to use.
39 Surgery is usually considered only when PIP skeletal changes are

noted radiographically and the deformity is progressively worsening

and interfering with function. 39 Types of orthoses for camptodactyly
are PIP extension orthoses, including immobilization, mobilization,
and/or static-progressive orthoses. Orthosis position is based on the
clinical evaluation of the hand. 39 If the PIP joint remains flexed while
the MP joint is flexed, the orthosis positions the hand in full MP joint
and PIP joint extension. 39 If the PIP joint is flexed only when the MP
joint is extended, the orthosis positions the hand in an intrinsic plus
position with the MP joint flexed and the PIP joint extended (see
Chapter 9 for a description of intrinsic plus position). 39 In young
patients, excessive pressure to the skin and the joint may cause the
DIP joint to be placed in excessive hyperextension, and this should be
avoided. 39 It is preferable for young children to wear their orthoses
during the night so that their hands are free to explore and develop
appropriate developmental skills during the day. There is some
evidence for the success of continuous orthotic wear to correct simple
camptodactyly in young children. 28
Orthoses are typically worn full-time at night until skeletal maturity
is reached. Serial casting (see Chapter 19) and/or static-progressive
orthoses may be more effective for rigid deformities. 12 Most if not all
children require a forearm-based orthosis to prevent orthotic removal.
Fabricating a circumferential orthosis or clamshelling the volar
orthosis with a dorsal padded component distally helps prevent the
child from sliding his or her fingers out of the orthosis and keeps the
fingers as straight as possible. The fingertips should be visible for
parents to monitor for any signs of discoloration.
 Challenges providing orthoses for camptodactyly include difficulty
keeping orthoses on the child’s little finger only. Frequent orthotic
adjustments are required during periods of growth. The best results
occur when orthotic intervention is initiated early.

Clinodactyly
Clinodactyly refers to radioulnar deviation of the finger. Minor
angulation, especially of the little finger, is so common that it is
considered a normal variant. Pathological clinodactyly is usually
described as greater than 10 or 15 degrees. Clinodactyly is usually
present bilaterally and is caused by an abnormally shaped middle
phalanx. For those whose function is impaired, an indication to
operate can exist. 27

Clasped Thumb
Clasped thumb refers to a classification of thumb anomalies that
range from mild deficiencies of the thumb extensor mechanism to
severe abnormalities of the thenar muscles, web space, and soft
tissues. 33 A classification system was proposed by McCarroll and
expanded by Mih. 33 A type I clasped thumb is supple, and the
extensor mechanism is either absent or hypoplastic. Type II clasped
thumbs are complex with additional findings of joint contracture,
collateral ligament abnormality, first web space contracture, and
thenar muscle abnormality. A type III clasped thumb is associated
with arthrogryposis or its associated syndromes, in which case the
extensor mechanism has minimal or no abnormality. 33 An extensor
lag is usually observed at the MP joint as a result of a hypoplastic
extensor pollicis brevis muscle tendon unit (Fig. 17.9A). A
concomitant lag at the IP joint implies a deficiency of the extensor
pollicis longus tendon as well. A thumb that postures in adduction
may imply a deficiency of the abductor pollicis longus. 33
Initial treatment of the type I clasped thumb is an orthosis for the
affected joint in extension to prevent additional attenuation of the
hypoplastic extensor mechanism and to allow hypertrophy over time.
33 A soft Neoprene thumb abduction orthosis is well tolerated by most
infants (see Fig. 17.9B). In past studies, full-time orthotic wear for 2 to
6 months has been shown to be most effective when performed within
12 months of birth and less effective between the ages of 1 and 2 years.
33 Surgery is considered for children who have not responded to an

orthotic regimen or who present after 2 years of age. 33 However, this

all depends on the degree of impairment and its overall effect on hand
function. 33 For example, a mild extensor lag at the MP joint usually
does not affect hand function significantly.

FIG. 17.9 A, Child with clasped thumb. B, A soft Neoprene thumb

abduction orthosis is well tolerated by most infants with clasped
thumbs.

Brachial Plexus Palsy at Birth

Brachial plexus palsy is an injury that occurs at birth. The typical
posture of a child with brachial plexus palsy includes a shoulder that
is adducted and internally rotated, an extended elbow, a pronated
forearm, and a flexed wrist and digits. The thumb may be flexed in the
palm. Most babies born with brachial plexus palsy recover
spontaneously within the first 2 months. Those who do not recover
the antigravity biceps by 5 to 6 months of age are considered for
microsurgical reconstruction to facilitate a more functional outcome.
17 If recovery is not achieved by 3 months, there will be permanent

ROM deficits, decreased strength, and a smaller upper extremity. 17

Typically the injury affects the C5 and C6 roots of the brachial
plexus (Erb palsy). The palsy can affect the C7 root or even C8 and T1
(global brachial plexus palsy). Initial intervention is PROM to all
joints. More recently a new Sup-ER orthosis has been used by some
therapists early on after initial injury to position the shoulder in a
functional position and prevent the shoulder from resting in an
internally rotated posture, which positions the glenohumeral joint at
risk for contractures, glenohumeral deformities, and posterior
dislocations. 46 The Sup-ER orthosis protocol was implemented on 18
children with brachial plexus palsy during their study period. At a 2-
year follow-up, those children who wore the orthosis performed
better on the active movement scale than those who were treated
without the orthosis.
The Sup-ER orthosis positions the shoulder in external rotation, the
elbow in extension, and the forearm in supination (Fig. 17.10). The
therapist fabricates a long arm elbow orthosis extending to the wrist.
Two D-rings are riveted onto the upper medial aspect of the orthosis
where two straps are applied. The long arm orthosis is kept in place
circumferentially by a soft fabrifoam wrap. The therapist then
manually rotates the shoulder into external rotation while keeping the
arm fully adducted by the trunk. While this position is maintained,
the two medial straps on the orthosis aspect are applied to the back
side of a Neoprene diaper to maintain the position. The orthosis is
worn 22 hours per day during the first month of its use. Then the
orthotic wear is weaned to nighttime wear only. Full video
instructions on the fabrication and application of the Sup-ER orthosis
can be viewed online at https://bcchr.ca/brachial-
plexus/treatment/splint. Further intervention depends on the severity
of the paralysis. Children may have limitations in ROM at every joint
and may develop contractures of the shoulder, elbow, forearm, and
wrist. Orthoses (Fig. 17.11) are used for positioning, preventing elbow
flexion contractures, and enhancing function.
Early intervention is the key to maximizing development of motor
patterns. If an infant shows signs of muscle weakness or limited active
range of movement, soft elastic orthoses are recommended. Signs of
contracture development at the elbow, forearm, wrist, thumb, or
digits indicate the need for immobilization or static-progressive
orthoses.
Orthotic intervention for brachial plexus palsy includes
immobilization orthoses (e.g., elbow positioning, wrist extension,
forearm supination, thumb positioning, and nighttime resting
orthoses). Static-progressive and/or mobilization orthoses may be
used to lengthen tight structures and release joint contractures. Soft
elastic orthoses that supinate the forearm and promote thumb
opposition are used to improve functional skills (Fig. 17.10). A
challenge in fabricating orthoses for brachial plexus palsy includes
providing constant orthotic adjustments as the child grows.
Adjustments ensure that the orthosis does not interfere with function.
FIG. 17.10 Infant wearing Sup-ER orthosis for functional positioning.
 FIG. 17.11 Older child with brachial plexus injury wearing static elbow
orthosis.

Surgical Options for Brachial Plexus Palsy

There are multiple surgical procedures for children who do not
spontaneously recover full upper extremity motion. Early surgery
may include neurolysis, nerve grafts, or nerve transfers. Secondary
surgeries typically occur between 2 and 10 years of age. These may
include tendon transfers, free muscle transfers, arthrodesis,
osteotomies, and others. Postoperative care requires protective
orthoses, depending on the specific surgical procedure. 41 Creative use
of dynamic orthotics can facilitate specific movements, enhance
function, and improve bimanual play skills.

Arthrogryposis/Arthrogryposis Multiplex
Congenita
Classic arthrogryposis or arthrogryposis multiplex congenita (Fig.
17.12) typically involves all four extremities. A pronounced lack of
muscle mass and flexion creases is apparent. Joints have decreased
ROM with an inelastic end range. Typical posturing includes
internally rotated and adducted shoulders, extended elbows, pronated
forearms, flexed and ulnarly deviated wrists, partially flexed fingers,
and adducted thumbs. 47 Children who are born with amyoplasia, a
form of arthrogryposis, also lack elbow flexor muscles and are born
with elbow extension contractures. 35 These deficits significantly
impact the child’s ability to play and perform basic self-care tasks
without assistance. 35 It is essential that physical and occupational
therapy interventions begin at birth and include stretching, orthotics,
positioning, and parent education on compensatory techniques to
facilitate maximal independence with developmentally appropriate
activities of daily living. 35 Orthotics are often needed to address
contractures of the elbow, forearm, wrist, and hand. Often, bimanual
patterns of upper extremity function are used due to lack of muscle
strength. Children without passive elbow flexion are particularly
compromised with an inability to self-feed. When passive elbow
flexion is present, children can use mobilization elbow flexion
orthoses or other strategies (e.g., tabletop propping or trunk swaying)
to assist in self-feeding (see Chapter 10 and Fig. 17.13).
 FIG 17.12 Child with arthrogryposis.

Multiple surgical procedures may be considered for children with

arthrogryposis, including tendon transfers, posterior elbow
capsulotomy, wrist arthrodesis or carpectomy, and thumb procedures.
Orthotic intervention before surgery to increase passive joint ROM or
to stretch tight contractures may be necessary. Postsurgical therapy
and protective and positioning orthoses are an integral part of
facilitating functional independence.

FIG. 17.13 Child with amyoplasia, a type of arthrogryposis, using

dynamic elbow orthoses for feeding.
 The intervention goal determines which type of orthotic
intervention is appropriate for children with arthrogryposis. Soft
elastic and/or thermoplastic immobilization orthoses for elbow,
forearm, wrist, fingers, and thumb may be used to maintain or
increase ROM. Orthotic intervention may improve the span of reach,
quality and strength of grasp, and weight bearing. The orthoses
protect the joint post surgery.
The challenges of fabricating orthoses for children with
arthrogryposis include providing orthoses that allow maximal
function while trying to preserve joint positioning. These children
often require multiple surgeries and orthotic adjustments. Serial-static
and static-progressive orthoses are fabricated for maximal passive
stretching of tight joints and contractures. Bilateral use of
immobilization orthoses may severely impair function; therefore
consider wearing schedules carefully. Resting hand orthoses worn at
night may be used to preserve and maintain joint motion and
positioning.

Juvenile Idiopathic Arthritis

The term juvenile idiopathic arthritis (JIA) is the newer term for what
used to be called juvenile rheumatoid arthritis. JIA encompasses
different subsets of the disease. 40 Common to all subsets is the onset
before 16 years of age and episodes lasting at least 6 weeks. 40 The
disease is more prominent in females than males. JIA is a chronic,
potentially lifelong disease causing joint inflammation. The goals of
physical and occupational therapy are to enable children to participate
in activities of everyday life. Goals of orthotic intervention are to
preserve normal joint function and to prevent deformity and
disability. Orthotic intervention should accompany joint protection
techniques. Well-designed prefabricated orthoses are less expensive
than custom-made orthoses and are typically better accepted by teens
when long-term use is required. Usually orthoses are needed only
during flare-ups. 34 Immobilizing orthoses are offered during periods
of increased joint pain and inflammation to support and position
joints. Mobilization orthoses are offered to enhance function in weak
joints. Studies of adults with rheumatoid arthritis showed that
patients using functional wrist orthoses reported decreased pain and
improved function with orthotic use. 18,29
Types of orthoses fabricated for children with JIA may include
immobilization orthoses for the elbow, forearm, wrist (dorsal or volar
based), fingers, and thumb. These orthoses:

• Protect the joints during flare-ups

• Prevent further deformity
• Support weak and inflamed joints
• Improve function of grasp and reach

Cerebral Palsy
Cerebral palsy (CP) (Fig. 17.14) is a lifelong disorder of sensory-motor
development that originates from insult to the developing brain. CP is
characterized by impaired ability to move and maintain posture and
balance. Eighty-five percent of CP etiology is congenital, originating in
utero or at the time of labor and delivery. The remaining 15% is
acquired during early childhood from injury, poisoning, illness, and
other causes. 13 CP ranges from mild to severe and can affect
development of movement in one or all of the limbs, including the
head and trunk. Spasticity, fluctuating muscle tone, muscle weakness,
and/or reflex-dominated movement patterns are the hallmarks of
impaired movement quality. These symptoms relate to where the
initial brain damage occurred. 26 Co-occurring conditions (such as
seizures, cognitive deficits, attention deficits, and visual, auditory, and
other sensory disorders) are frequent and affect motor development.

Atypical Motor Development

A deep understanding of the development of movement is essential
when providing intervention for CP and is beyond the chapter’s
scope. Key to appropriate and timely intervention is the notion that
“Compensatory movement patterns develop and often become more
extreme as the child ages because new functional sensorimotor
patterns often are built on inefficient or inadequate foundations.” 13
At birth, spastic CP of the upper extremities usually pre-sents as
weakness with a prolonged period of fisting. Atypical and immature
patterns of weight bearing, limited active movement, and weakness
contribute to both excessive and diminished ROM in infants. For
example, by 5 months typically developing infants push up into
forearm prop. As infants tip from side to side, weight is transferred to
the ulnar forearm and functionality moves from the ulnar to the radial
side of the hand. 2 In a child with CP, if forearm prop is delayed (due
to trunk and arm weakness), persistence of grasp typical of a 4-month-
old is seen (i.e., adducted thumb and grasp attempts with the ulnar
fingers only). 11 Infants with CP may attempt to grasp using atypical
and immature patterns. Such patterns fail to serve as building blocks
for more refined grasp development. 20 Likewise, limited experience
in upper extremity weight bearing and unequal muscle strength
between agonist and antagonist muscles leads to an inability to fully
elongate shoulder flexors and elbow extensors. Inexperience in
forearm prop leads to locking in pronation for stability and
nondevelopment or limited development of supination. 11 Full
elongation of the wrist and finger flexors is present in typically
developing children when they prop on extended arms, creep, and
engage the thumb in grasp. With CP, children’s inexperience with
these milestones leads to underdeveloped range in wrist and finger
extensors. Problems at the wrist are compounded if the child is
allowed to creep while bearing weight on the dorsum of the hand.
This destructive movement pattern overstretches and further weakens
the already weak wrist extensors. Intervention of these movement
patterns when first emerging improves the course of the child’s motor
development.
 FIG. 17.14 Older child with cerebral palsy (CP).
From Burke, S. L., Higgins, J., McClinton, M. A., et al. (2006). Hand
and upper extremity rehabilitation: A practical guide (3rd ed). St. Louis:
Elsevier Churchill Livingstone.

When evaluating for potential orthotic intervention for a child with

CP, view the whole child and observe movement patterns during a
typical day within the context of overall development. Therapists
should:

• Observe the infant during supine, prone, and sitting positions

for patterns of mobility, weight bearing, reach, and grasp.
• Watch toddlers play and note patterns of weight bearing,
reach, and grasp, but also transitional patterns of movement
(i.e., sitting to creeping or lying to standing). These
observations give a clear understanding of whether the
orthosis being considered will facilitate or inhibit function.
• Observe preschoolers and older children during play, school-
related tasks, and self-care activities. If children are able to
verbalize, ask them what they can do with their arms and
hands. Note what types of activities they struggle to perform.
 Specific upper extremity function observations should include:

• Any limitations or hypermobility in ROM at the shoulder,

elbow, forearm rotators, wrist, thumb, and fingers
• Components of movement that appear to be diminished or
absent during reach and weight bearing
• How the hand is incorporated into activities (e.g., hand used
to stabilize a toy, hand neglect, sensation, volitional control of
hand/digits, bilateral use, type of grasp pattern)

Orthotic Intervention for Children With Cerebral Palsy

Individuals with CP usually benefit from orthoses throughout their
lives. Orthoses address issues of weakness and spasticity (Fig. 17.15),
muscle fiber and connective tissue shortening, and maladaptive
compensatory movement patterns. Orthoses address poorly aligned
or subluxed joints and hygiene and skin integrity. All of these
concerns are addressed through a comprehensive program of
stretching, muscle strengthening, antispasticity medications, dynamic
garments, and orthoses. Constraint-induced movement therapy,
botulinum toxin type A (Botox), and electrical stimulation are
emergent therapies used in conjunction with orthoses. Surgical
interventions are used when less invasive techniques are inadequate.
Orthoses are often an important component of presurgical and
postsurgical intervention.

Types of Orthoses Used for Children With Cerebral Palsy

The intent of orthotic intervention determines the appropriate orthosis
for children with CP. Orthoses may be fabricated for different
purposes. Orthoses assist children with developing more typical
movement patterns (see Fig. 17.16). Elastic soft orthoses augment
movement in weaker muscle groups. 10,37 These orthoses are made of
Lycra, Neoprene, or similar elastic material and are worn during
active play. Soft orthoses include shoulder-based rotation straps,
flexible elbow extension orthoses (to assist with weight bearing and
reach), forearm rotation straps, Neoprene thumb orthoses, and
Neoprene wrist-hand orthoses. In a study that examined hand
movements while performing functional tests, the children (who had
CP) with the aid of a wrist extension and thumb abduction orthosis
(Fig. 17.17 A & B) that was made of Neoprene and thermoplastic
showed more improvement in overall hand function than those
without the orthosis. 7

FIG. 17.15 Individuals with CP usually benefit from orthoses

throughout their lives to address issues of weakness and spasticity.
 FIG. 17.16 Grasping with thumb orthosis with supinator strap.

Other orthoses block abnormal, nonproductive movement patterns,

such as excessive wrist flexion, ulnar deviation, or thumb adduction.
Rigid or semirigid stays may be added to soft elastic orthoses.
Examples of these orthoses include Neoprene thumb orthosis with
web stay, Neoprene wrist-hand orthosis with wrist stay and ulnar
hand trough (see Fig. 17.17A), and Neoprene elbow band with an
extension stay along the flexor surface of the elbow.
Functional thermoplastic orthoses block unwanted motion while
allowing function. Examples include a dorsal wrist immobilization
orthosis and a thumb abduction orthosis. These orthoses optimally
position joints for function.
Orthoses reduce contractures, maintain ROM, and protect skin
integrity. Orthoses that completely immobilize the joint and restrict
function are best worn when the child is resting or napping.
Immobilization orthoses include resting hand, elbow extension,
thermoplastic thumb, and cone orthoses.
Orthoses assist in increasing ROM over time. Serial-static and static-
progressive orthoses are fabricated for a stiff elbow, wrist, fingers, or
thumb and may be used in combination with other interventions (see
Chapter 13).
Postsurgical orthoses immobilize and protect joints, muscles, and
soft tissues. Physicians typically determine the specifications for the
orthosis and wearing schedule.
Finally, custom orthoses assist with specific skills to increase the
child’s functional repertoire, such as a pointer orthosis (Fig. 17.18).
The bases for such custom orthoses are common orthotic patterns,
such as a wrist immobilization orthosis that has a component added
for the assist of function.
The challenges of orthotic fabrication for children with CP include
the need to make adjustments as the child grows and develops.
Implementing weight-bearing orthoses in a timely manner may be a
difficult task. Therapists must be aware of the child’s tone and how it
affects function. Muscle tone may increase when a child is fearful, ill,
cold, irritable, or when experiencing a growth spurt. In a small hand
the weight and bulkiness of the orthotic material may present a
barrier to movement. Therefore the therapist needs to use thin
thermoplastic materials (1⁄16 inch to 1⁄12 inch) or soft orthoses during
function for the very young. In children with CP the wrist and long
finger flexor muscles dominate over the extensor muscles. Over time
the muscles may shorten in length if not positioned in a resting hand
orthosis (see Fig. 17.8).
Because ulnar muscles dominate over radial muscles, wrist
extension orthoses are designed to block excessive ulnar deviation.
Due to the strength of the proximal muscles, there is a higher
probability over time for hyperextension and subluxation at the
thumb MCP joint.
When fabricating orthoses for children, it is always crucial that the
parent and/or caregiver understand the reasons for the orthosis and be
able to follow through with the wearing schedule. The child may need
multiple orthoses. The therapist plans an appropriate wearing
schedule to prioritize and accommodate the child’s needs. For
example, many children with CP need soft orthoses during the day to
assist with function. But because soft orthoses do not maintain stretch
on the wrist and long finger extensors, children also need resting hand
orthoses at night to maintain ROM in the extensors.

FIG. 17.17 A, Neoprene wrist hand orthosis with ulnar stay. B,

Neoprene and thermoplastic wrist extension thumb abduction splint.
A, Courtesy Orfit Industries.
 FIG. 17.18 A and B, Orthosis with pointer.

Hints for Orthotic Fabrication for Children With

Increased Tone
Fabricating an orthosis on a child who has increased tone is
challenging. With experience, therapists gain insight into methods
that optimize the process. The following are hints for the novice
therapist who is fabricating an orthosis for a child with increased tone:

• Choose a quiet location, and minimize other activity.

• Be conscious of lighting and room temperature.
• Invite parents/caregivers to assist if they can calmly help.
• Position the child in a comfortable position so that muscle tone
 is as close to normal as possible.
• Speak calmly and slowly, and handle the child’s extremity
gently.
• For a calming effect, use soft music, sing, or read a story.
• Do not use toys to distract the child because they can cause
overexcitement, resulting in a crossover effect and increase
tone.
• Prevent any sudden quick movements.
• Have parents assist in keeping the arm and specifically the
elbow stable on the surface.
• Avoid touching the palm of the hand. First abduct the thumb
out of the palm, and flex the wrist to normalize tone as much
as possible. Then try extending the wrist while avoiding the
palm as much as possible.

Cerebral Palsy and Botox Injections

Recent studies examined the benefits of a combined intervention
strategy incorporating injections of Botox with orthotic fabrication for
treatment of spastic muscles in the upper and lower extremities. This
Botox injection causes a temporary weakening of the spastic muscles.
One study demonstrated significant results following injections and
the use of static nighttime upper extremity orthoses for children with
spasticity. 30 Botox injections cause muscle relaxation, reductions in
spasticity, and increased joint ROM. These results led to improved
functional skills and fine motor function.

Cerebral Palsy and Surgery

Surgical procedures considered for children with CP include
arthrodesis, contracture and joint release, tendon transfers, and
muscle-lengthening procedures. Postoperative care requires a variety
of protective orthoses depending on the specific surgical procedure.
General Principles for Orthotic
Fabrication
After a thorough initial evaluation and interview with the child and
parents or caregivers, the key to successful orthotic fabrication is
prioritizing the needs of the child.

• Create a list of the abilities and deficits.

Box 17.2 Goals of Pediatric Orthoses

• Prioritize the needs in accordance with age and ability to

perform.
• Incorporate the family’s stated outcomes and the child’s stated
outcomes.
• Fabricate an orthosis that first addresses one or two primary
needs.
• Fabricate other orthoses to meet additional needs, and
schedule alternate wear among the various orthoses.
• Reassess the fit of each orthosis and need for it frequently.

Consider the goal(s) for the orthosis (Box 17.2). Positioning orthoses
mobilize joints, reduce contractures, provide stability, rest the
extremity, and provide proper joint alignment. Functional orthoses
enable continuation or improvement of existing function and can
substitute for weak or absent muscles. Improvement or prevention of
hygiene problems is assisted with orthotic intervention. Protective
orthoses keep the child safe or prevent undesired behaviors. 25
Always use a problem-based approach for orthotic intervention.
Although a diagnosis helps predict probable outcomes with a given
orthotic intervention, applying critical analysis allows for creative
interventions.

Approaches to Pediatric Orthotic Fabrication

Several approaches are used for pediatric orthotic fabrication:

• To encourage motivation and acceptance of the orthosis,

engage the child in design and color selections.
• Monitor the orthosis frequently due to growth. Consider not
only the physical growth, but also psychomotor and mental
growth.
• Children have unique hands that require custom designs and
individualized intervention plans.
• It is essential that family/caregivers are invested.

Safety Tips and Precautions

When working with children, be mindful of safety. Consider the
location of tools and equipment and the positioning of the child. The
following safety guidelines are important:

• Place sharp tools and scissors out of reach.

• Do not leave scissors or other equipment unattended on the
counter or table.
• When using hot water for orthotic fabrication, avoid splashing.
Always cover the hydrocollator or fry pan when in use.
• Children’s skin may be sensitive to heat and may react to
thermoplastic materials. Allow the material to cool adequately
before placing on the skin.
• Sharp edges on the orthosis’ corners can scratch or cut skin.
 Smooth sharp edges and round corners on the orthosis and
strapping materials. Securely attach straps and other small
pieces to the orthosis so that they cannot be pulled off and
swallowed.
• Verify that the thermoplastic material does not contain toxic
ingredients.
• Use latex-free Neoprene.

Steps for Orthotic Fabrication

Once the goals are established, the orthotic fabrication process is
initiated. The child and environment are prepared. The therapist
designs the orthosis, selects the orthotic material, and makes the
pattern. All three aspects are considered together. The orthotic design
takes into account the child’s unique hand shape and size, its purpose,
intended wearing schedule, and the most effective material.

Prepare the Child

Position the child so that the effects of abnormal tone and postural
reflexes on the arm and hand are at a minimum. This position
depends on the assessment results of the child and may differ from
how the child is typically positioned. It is important to provide
external stability through equipment or handling for children who
have not acquired internal stability of proximal joints. This stability
may involve a seating system or other adaptive equipment. For the
infant or young child, it may be possible for the parent to hold the
child and provide external stability with the therapist’s instructions.
It is important to reduce the child’s fearfulness and maximize
adherence. If the therapist does not already have a relationship with
the child, spend time to allow the child to warm up. Even if the child
knows the therapist, a brief time is provided to allow the child to
acclimate to the equipment and setup for orthotic intervention. The
therapist has toys, music, books, stickers, or other materials to
establish a reciprocal interaction with the child before starting the
fabrication process. With an infant the therapist talks in a soothing
voice and touches the child in a playful manner before fabrication.
With an older child the therapist shows the child what to expect by
first fabricating an “orthosis” on a doll or stuffed animal or by making
“thermoplastic jewelry” or other play objects.
When appropriate, the child is given the opportunity to touch and
feel the material while it is warm and soft and again after it becomes
cool and hard. The child’s response to tactile stimuli is noted, and if
signs of tactile defensiveness occur, the therapist follows sensory
processing guidelines for improving sensory system modulation. If
colored thermoplastic material is available, the child is encouraged to
select a color. For some children, decorating the orthosis with stickers
or leather stamps encourages acceptance.
Giving children a role to play in the fabrication process may
increase adherence. The child’s role may include keeping time by
counting, holding the end of the Ace wrap, or any other task the
therapist invents to keep the child involved. However, if associated
reactions are present, it is best for the child to be involved without
exerting effort because this may increase tone. Although preparing the
child takes a few extra minutes at the beginning of a session, it can
save hours of frustration in having to reschedule or remake an
orthosis because of lack of adherence.

Prepare the Environment

Thoughtful preparation is especially important for orthotic
intervention of children because of short attention spans. In addition
to having orthotic and play materials close at hand, it is recommended
that the therapist plan to have a second pair of adult hands to help
with the fabrication. 4 This additional person might be a parent,
teacher, paraprofessional, or another therapist. Extra help is especially
important if the child has increased tone, is not able to follow verbal
instructions, or is likely to be uncooperative. The therapist clearly
explains the helper’s role so that efforts assist the process and do not
hinder it. This usually involves maintaining the child’s overall
position, calming or entertaining the child, holding the arm just
proximal to the joint being positioned, or stabilizing the material once
in place and while it is cooling.

Design
Orthoses can be fabricated on the volar, dorsal, ulnar, or radial
borders, or circumferentially. Circumferential orthoses do not tend to
migrate distally, especially when fabricated from a highly conforming
material. Circumferential orthoses, which cover both the dorsal and
volar surfaces, are more comfortable to take on and off than clamshell
orthoses. Circumferential designs are strong and supportive. The
number of joints included in the orthosis is considered. Although it is
not usually recommended to include uninvolved joints in the typical
adult orthosis, when working with the pediatric population,
uninvolved joints might be included to maintain the position and
keep the orthosis in place. When the therapist is creating a soft elastic
orthosis, the elastic quality of the orthosis must cross the joint and pull
in the same direction as the muscles do if the orthosis is intended to
assist the weaker muscles.

Selection of Orthotic Materials

Pediatric orthoses are made of many different types of materials,
depending on the purpose of the orthosis and the age and needs of the
child. Thermoplastic materials are commonly used for the fabrication
of static orthoses or those that require restricting motion at certain
joints. Soft orthoses are commonly made of materials such as
Neoprene. Soft orthoses may not totally immobilize a joint, but they
provide support and allow greater freedom of movement. Children
with athetosis or involuntary flailing movements should be protected
from possible harm from the orthosis by selection of a soft material or
by covering a thermoplastic material with a mitt or sock.
When working with Neoprene, take thickness into account.
Although 3.0 mm is commonly used, consider 1.5-mm thickness
because it is less bulky in a small hand. Check the stretch because the
elastic quality is more prominent in one direction. It is possible to find
Neoprene with one side smooth nylon and the other a Velcro-
receptive material. Such material eliminates the need to sew on a
Velcro loop where it is intended to adhere.
With Neoprene be alert to the possibility of skin irritation or rash.
According to Stern and colleagues, 44 “skin contact with Neoprene
poses two dermatological risks: allergic contact dermatitis (ACD) and
miliaria rubra (i.e., prickly heat).” Although Neoprene
hypersensitivity is rare, the authors recommend that therapists screen
patients for a history of dermatological reactions; instruct clients to
discontinue use and inform the therapist if a rash, itching, or skin
eruptions occur. Cases of adverse skin reactions are reported to the
manufacturer of the Neoprene material. The authors recommend that
therapists limit their own exposure to Neoprene and Neoprene glue
because exposure to thiourea compounds may contribute to allergic
reactions.
Thermoplastic materials range in conformability, thickness, stretch,
and rigidity. For an orthosis designed to stretch a tight web space, use
a highly conforming material. Otherwise the skin may break down
from the high resistance and unyielding shape. Generally,
thermoplastic materials with a high plastic content have more
conformability, whereas materials with high rubber content have less
stretch but are less likely to be indented with fingerprints during
fabrication. When making an orthosis that counteracts the forces of
spasticity, it is especially important to select a thermoplastic material
that resists stretch (i.e., one with high rubber content) because it is
necessary to apply considerable pressure to obtain the desired
position of the wrist, thumb, and fingers. 4 For children with spasticity
or larger limbs, a ⅛-inch thick thermoplastic material might be the
best selection. Smaller hands require thinner thermoplastic materials
of 1⁄12 inch and 1⁄16 inch.
Some products combine the properties of plastic and rubber.
Usually rubber-like (or combination) thermoplastic material is
necessary when one is working against spasticity, even though it is
less rigid than the plastic type. If necessary, a reinforcement
component is added to the orthosis. Selecting a material with a high
degree of memory is helpful when one is working with a child whose
movements may be unpredictable and require the therapist to start
over (sometimes more than once!). These plastics are elastic-like and
self-adhere easily. Self-adherence can be problematic. One way to
reduce the stickiness of the thermoplastic material is adding a
tablespoon of liquid soap or shampoo to the hot water. 18 Ultimately
with all these suggestions for thermoplastic materials, the therapist’s
experience and preferences affect the choice. (See Chapter 3 for a
review of orthotic material.)

Pattern Making
Pattern making for a pediatric orthosis may be challenging, and
intervention approaches are based on the child’s developmental level.
Older children can be encouraged to participate in the process by
having them trace their own hands on the paper. Infants and toddlers
might best be approached while napping or feeding. Younger children
can be enticed to play a game where their hands are placed on the
table. Making a photocopy of the child’s hand may be helpful. A
pattern drawn on a larger-size hand can be reduced by a photocopier
to obtain the correct size. 25
Using flexible material (such as paper towels or aluminum foil) to
create the pattern allows the therapist to easily check the pattern on
the child. Sometimes it is not possible to make an accurate pattern.
Children with abnormal tone may be unable to lay their hands on a
table surface for an accurate tracing. In this case the pattern must be
held under the extremity in whatever position is least stressful. The
therapist may consider using an uninvolved contralateral side to start
a pattern, given that there is some symmetry of anatomy. Another
approach is for the therapist to best estimate the design and sizing. It
may be helpful to plan on extending the thermoplastic material
beyond that of the finished product to give leverage to help hold joints
in position. The extra thermoplastic material is cut away when the
essential part of the orthosis is finished and hardened. 22 For patterns
that tear, masking tape is used for repairs or to reinforce contours.

Heating the Thermoplastic Material

The therapist heats the water to the temperature range recommended
by the manufacturer. After cutting out the orthosis, it may be
necessary to reheat the plastic to obtain the desired degree of pliability
before the molding process. Before placing the plastic on a child’s
extremity, the therapist dries off the hot water and makes sure the
plastic is not too hot. Check the material’s temperature by placing it
against one’s face or anterior portion of the forearm. Checking the
material’s temperature is especially important when spot heating with
a heat gun because this method tends to result in higher surface
temperatures.
Some children may be hypersensitive to temperature and react
negatively, even though the temperature does not feel hot to the
therapist. Because many children cannot communicate that the plastic
feels too hot, the therapist watches the child’s facial expressions and
listens for vocalizations that indicate discomfort. The child’s arm and
hand can be moistened with cold water before molding. Another
option is placing a wet piece of paper towel over the extremity, or
waiting longer for the plastic to cool. Some therapists use a stockinette
to protect the extremity. However, care must be taken that it does not
wrinkle under the plastic during fabrication.

Hastening the Process

Time is of the essence when one is working with a moving target, a
rebellious little one, or a difficult-to-position extremity. Rubber-based
plastics, which are necessary to resist stretch, are somewhat slower to
harden. Once the plastic is in place on the extremity, an ice pack can
be rubbed on the orthosis to hasten the setting process. A rubber glove
filled with ice chips can easily serve the purpose. After being partially
hardened, the orthosis is carefully removed and put into a pan of ice
water or placed under a faucet of cold running water. A TheraBand
roll cooled in a freezer helps form the orthosis, which accelerates the
cooling process.
A spray coolant may be used, but only with great care to spray after
the orthosis is off the child. The spray is directed away from the child.
The use of coolant spray is avoided with children who are unable to
keep their heads turned away from the direction of the spray and
those who have frequent respiratory problems.
An Ace wrap is useful to hold an orthosis in place while the
therapist works on other portions of the orthosis—although this
maintains heat and may increase setting time. The therapist should
not apply the wrap or TheraBand too tightly and should flare the
edges of the forearm trough away from the skin after formation of the
orthosis.

Padding
Padding, or some form of pressure relief, may be necessary over bony
areas to prevent skin problems. Padding does not compensate for
pressure resulting from a poorly made orthosis. Padding takes up
space, a factor the therapist considers before formation. Otherwise, the
amount of pressure against the skin may increase. A variety of
paddings exist, including closed- and open-cell foam and gel
products. Pressure-relief padding with a gel insert is useful in
protecting bony areas for children with little subcutaneous fat.
To ensure proper fit, the therapist lays the padding on the child’s
extremity before molding the plastic or places it on the thermoplastic
material before molding the orthosis. When the therapist is molding
with padding, the stretch of the thermoplastic material and the
contourability may be compromised. Therefore the therapist adds
padding only if necessary. In addition, padding becomes soiled and
needs to be replaced. For more information on padding, see Chapter 3.
Another way to create pressure relief around a bony prominence
without using padding is to cover the prominence with a small
amount of firm therapy putty before forming the orthosis. The putty
creates a built-in bubble and is removed from the orthosis after
cooling. 25 Thin forms of padding are used to create friction and
reduce migration or shifting of orthoses or for covering edges.
Microfoam tape is useful for this purpose, especially on small
orthoses.

Strapping
Many creative strapping solutions exist to keep orthoses on children
(Fig. 17.19). The therapist considers strength, durability, elasticity, and
texture when the strap is against the skin. Strapping with sharp edges
is avoided with younger children and those with sensitive skin. The
wider the strap, the more force is dispersed if the entire strap width is
in full contact with the skin. Strap material may need to be cut
narrower, especially around the wrist and fingers, to be proportionate
to the size of the child’s hand.

FIG. 17.19 Extra Velcro strap for closure.

Courtesy Orfit Industries.

D-ring straps are often used to increase the likelihood of

nonremoval. Fasteners that require a two-handed release prevent easy
removal. Swivel snaps, rings, and/or metal C-rings from hardware
stores can be incorporated into strapping mechanisms.
Straps can be secured at each end with Velcro hook, which is
attached to the orthosis. Velcro hook allows straps to be easily
replaced when they become soiled, which is important if the child
drools or mouths the orthosis. However, loose straps easily become
lost and many times are not placed on the orthosis at the correct angle
or location. An alternative is to secure the strap at one end with a rivet
or strong contact adhesive. Another option is to create an extra
attachment with Velcro hook that allows the child to open the
orthosis. When soiled, straps are removed, and a new strap is
attached. (See Chapter 3 for more detailed information about
attaching straps.)
Increasing the likelihood that the child will not remove straps or the
orthosis requires knowledge of child development and creativity. For
infants and toddlers, consider the use of an Ace or Coban wrap to
secure the orthosis. Children at certain ages (2- and 3-year-olds) are in
the developmental stage of asserting their autonomy and may resist
the parent’s choice of clothing, food, or orthotic application. In this
case, using principles of behavior analysis (such as shaping or
rewarding successive approximations, finding times during the day
when the child is most likely to be compliant, and contingent use of
praise and attention) are helpful. Actively involving the child in
choosing colors and decorations may increase the child’s willingness
to wear the orthosis (Fig. 17.20). Strap critter patterns are provided by
Armstrong, 4 along with suggestions for using decorative ribbon,
fabric paints, or shoelace charms. Armstrong suggests describing the
orthosis as something cool to wear and providing the child with
language to explain to peers, such as, “This is my shield or my
princess glove.”
If positive methods to prevent orthotic removal do not work,
therapists use creativity to keep the little “Houdinis” in their orthoses,
especially young children who do not understand cause and effect.
Some child-proof methods include using shoelaces, buttons (Fig.
17.21), buckles, or socks/stockinette/puppets. Lacing is done by
punching holes along the lateral edges of the orthosis and lacing with
wide decorative shoelaces. The therapist places padding under the
laces and against the skin. To secure the laces, the therapist uses a
“bow biter” (a plastic device available in children’s shoe departments)
to hold the laces in place. 16 Depending on the function of the orthosis,
a sock puppet worn over the orthosis may be used as camouflage (see
Fig. 17.8). Care must be taken not to provide any attachment that the
child could bite off and swallow.

FIG. 17.20 Decorated Neoprene orthoses.

Courtesy Orfit Industries.
 FIG. 17.21 Buttons on dorsum of orthosis.
Courtesy Orfit Industries.

Providing Instruction for Orthotic Application

Those responsible for applying the child’s orthosis (e.g., teachers,
nursing staff, or parents) should be part of the assessment process and
provide input on the orthotic design and agree with the need for the
orthosis. They must understand the orthosis’ purpose, rationale,
precautions, and risks of incorrect usage. The correct application of
the orthosis may not be obvious to those unfamiliar with orthotic
intervention.
 FIG. 17.22 Orthoses can be covered with a hand puppet.

The more complex the orthosis, the more detailed and explicit the
instructions are. This is especially true when there are multiple care
providers. The therapist provides written instructions along with a
phone number and/or email address to contact for questions or
concerns. A demonstration of the steps involved in donning the
orthosis is provided, followed by an opportunity for the caretaker to
practice applying the orthosis under supervision. A photograph of the
child with the orthosis in the correct position is often an effective
teaching tool if it does not conflict with policies regarding
confidentiality.
Correct placement of straps is facilitated by writing a number or
placing a small design on the strap end and a corresponding number
or design on the orthosis. The therapist does everything possible to
take the guesswork out of putting on the orthosis. Instruct caregivers
to inspect the skin every time the orthosis is removed to assess for
signs of excessive pressure.

Wearing Schedules
Wearing schedules vary according to the purpose of the orthosis, the
child’s tolerance, musculoskeletal status, occupations, and daily
routines. Orthoses may be worn for long or short intervals during the
day, at night, during functional activities, or a combination. It is
necessary to gradually increase the wearing time initially to build up
the child’s tolerance for the orthosis and to make any modifications
that become apparent with use.
When the purpose of the orthosis is to increase functional use,
wearing the orthosis should occur during times when the child is
engaged in occupations. If the purpose is tone reduction, the orthosis
is worn before activities or occupations. When the purpose of the
orthosis is to prevent a contracture, the orthosis is worn when the
child is not engaged in occupations. Finally, if the orthosis is used to
treat an existing contracture, it is necessary to wear it for prolonged
periods of time.
 The total time spent wearing the orthosis during a 24-hour period
appears to be more important than whether it is worn continuously or
intermittently. 25 The length of time an orthosis can be worn is affected
by how much force is applied to achieve the desired position, which
causes stress on the joints, muscles, and skin. Ultimately, wearing
schedule decisions are based on developing and maintaining clinical
competence, clinical reasoning, and collaborating with the child
and/or family members or care providers.
The wearing schedule works only if the orthosis is placed on the
child during the recommended times. Incorporating the orthotic
schedule into the child’s regular routine may increase adherence
because it becomes less of a special chore for the parent, teacher,
caregiver, or nursing staff. The therapist documents the agreed-upon
wearing schedule and provides written copies to parents, caregivers,
teachers, nurses, and child care providers. As the child’s
developmental or ROM status changes, the therapist evaluates the
wearing schedule and possibly the orthotic design to make
modifications.

Precautions
The skin is inspected frequently during the initial wearing phase. A
distinct red area or generalized redness that does not disappear within
15 to 20 minutes after removal indicates excessive pressure and the
need for revision. 23,25 During periods of monitoring the therapist
should be aware of any problems associated with joint compression,
pressure on nerves, compromised circulation, and dermatological
reactions. Children’s growth spurts often come without obvious
signals, and during those times therapists and caregivers should be
extra vigilant.

Evaluation of the Orthosis

A plan is made to reassess the orthosis on a regular basis to ensure
proper fit and function. When possible, the therapist has the child don
the orthosis 1 hour before the reassessment. This allows observation of
how the orthosis is donned and whether the orthosis migrates. A
poorly fitting orthosis can do more harm than good.

Special Pediatric Orthoses

Resting Hand Orthosis
The purpose of a resting hand orthosis is to prevent a contracture or
deformity, to prevent an existing deformity from becoming worse, or
to gradually improve or reduce a deformity (deformity-reduction
orthosis). Children who are at the greatest risk of developing a
contracture are those with moderately to severely increased tone or
those with severely decreased tone who have no active movement.
For children with severely increased muscle tone and tightly fisted
hands, an additional purpose may be maintenance of skin hygiene.

Features
The components of a resting hand orthosis for a child are the same as
those described in Chapter 9, except for the shape of the thumb trough
and C bar. Components include a forearm trough, a pan for the
fingers, a thumb trough, and a C bar. If spasticity is present in the
thenar muscles, the thumb is positioned in partial radial abduction to
elongate the opponens muscle. Sustained stretch of tight thenar
muscles may inhibit tone in the hand. 39
For children with moderately to severely increased tone, the ideal
position of the wrist, fingers, and thumb may not be possible. Because
its purpose is to prevent or reduce joint deformity, the orthosis
provides as much elongation of the tight muscles as possible without
causing excessive stress. The child should be able to tolerate wearing
the orthosis for several hours to obtain the maximum benefit.
If the orthosis places the hand into the maximum range of passive
motion, the forces generated may compromise circulation, cause skin
breakdown, elicit pain, or reduce the length of time the child tolerates
wearing the orthosis. Therefore the orthosis places the wrist joint in
submaximal range, 21,23 which is a position especially important at the
wrist to allow for finger extension. Low-load prolonged stretch
provided by casts or orthoses is the best conservative way of
increasing PROM. 19 When flexor spasticity is severe, using a serial-
static orthosis may be necessary. 19,21
The therapist determines the best orthotic position by handling the
child’s extremity and feeling the amount of passive resistance. After
achieving the desired position manually, the therapist notes the angles
of the joints involved and where pressure is applied to obtain this
position. Handling the joints and feeling the resistance from muscles
determines the most therapeutic position and the location of force
application during orthotic fabrication and strap application.

Process to fabricate a resting hand orthosis

Thermoplastic material selection
When making an orthosis that counteracts the forces of spasticity, the
therapist selects a low-temperature thermoplastic material that resists
stretch. A considerable amount of pressure is applied on the material
to obtain the desired position of the wrist, thumb, and fingers. This
pressure can indent and inadvertently stretch materials that have
conformability. Usually a thermoplastic material containing a high
rubber content has the desired working characteristics (see the Steps
for Orthotic Fabrication section).

Pattern
The pattern includes the measurements and markings of landmarks
(see Chapter 9). Because the thumb position is different from the
traditional resting hand orthosis, the thumb trough and C bar are
shaped differently. After the pattern is drawn and cut out, it is fitted
to the child for further modifications. While making the pattern and
molding the orthosis, position the child to minimize the effects of
abnormal tone and postural reflexes on the body and the extremities.

Padding
Before forming the orthosis the therapist considers the need for
padding to allow the additional space necessary. Because padding
places some restrictions on forming the orthosis and keeping it clean,
it should not be used unless the assessment shows risk for skin
problems. Creating bubbled-out areas over bony areas may be
sufficient to avoid skin problems.

Forming the orthosis

Before placing the plastic on the child’s extremity, the therapist
prestretches the edge of the orthosis that forms the C bar. The
therapist then places the soft plastic on the web space of the thumb. If
available, an assistant stands beside the child and secures the forearm
trough. The therapist forms the orthosis into the palmar arches and
around the wrist and thumb. To obtain the desired contour and fit, the
therapist needs to be aggressive when molding into the palm and
around the thenar eminence—especially if working against spasticity.
The therapist forms the orthosis so that the bulk of pressure
positioning the thumb is directed below the thumb
metacarpophalangeal (MCP) joint and distributed along the thenar
eminence. This formation is necessary to avoid hyperextension and
possibly dislocation of the thumb MCP joint. 21 The thumb trough
cradles the thumb and extends approximately ½ inch beyond the end
of the thumb. The IP joint of the thumb is slightly flexed, and the C
bar fits snugly into the web space and contours against the radial side
of the index finger.

Forearm trough
After completing the wrist, palm, and thumb portion, the therapist
completes the forearm trough. (See Chapter 9 for guidelines on
securing the forearm in the trough and avoiding pressure points.) If
the edges of the trough are too high, the straps bridge (i.e., the straps
are raised from the skin’s surface and do not follow the contour of the
forearm, thus losing contact with the skin surface). To keep the
forearm securely in place, the straps have maximum surface contact. If
not secure, the forearm may rotate in the trough or the orthosis may
shift distally, and the position of the wrist, fingers, and thumb are
compromised.

Pan
Finally, the therapist forms the finger pan to position the fingers. The
pan may require reheating because controlling all joints at the same
time is difficult. (See Chapter 9 for the correct width and height of the
pan.) In addition, the distal portion of the pan extends approximately
½ inch beyond the fingertips to allow for growth and for safety
purposes. When forming the curve of the pan, contour into the
proximal and distal transverse arches.

Straps
The correct placement of straps is as important as correct formation of
the orthosis, especially when the orthosis is positioning joints against
increased muscle tone. The straps and orthosis work together to create
the necessary leverage and distribute pressure. If the forearm, palm,
fingers, and thumb do not stay in the correct position, the benefit of
the orthosis is greatly reduced. The optimum location and angle of
each strap is determined in relation to the forces being applied by
abnormal muscle tone.
The forearm trough requires two straps for an older child.
However, for a smaller child or an infant, one wide strap across the
forearm may be sufficient. Stability is provided at the proximal and
distal areas of the forearm. If considerable wrist flexion is present, two
straps are necessary to provide three points of pressure to secure the
wrist.
One strap extends directly across the wrist distal to the ulnar
styloid, and a second strap is angled from the thumb web space across
the dorsum of the hand and secured proximal to the MCP joints on
the ulnar side. Otherwise, one strap across the dorsum of the hand
may be sufficient. If there is considerable finger flexion, straps may be
needed across each of the three phalanges. Finally, the therapist adds
a strap between the MP and IP joints of the thumb. When making a
small orthosis for a young child, cut the straps narrower.

Adaptations
The resting hand orthosis provides a basic form for positioning the
child in good alignment and serves as an inhibitor of hypertonicity.
However, often the therapist deviates from the basic form to truly
meet the needs of the child. One way the orthosis is adapted is the
addition of finger separators (also described in Chapter 9) to abduct
the fingers and assist in tone reduction. Separators are created by
bubbling the material between digits or attaching a roll of
thermoplastic material between the digits. Finger separators are also
fabricated from thermoplastic pellets or elastomer.
Pellets are softened in hot water and kneaded together to the shape
and size required. The pellets have 100% memory and are attached in
the same way as any other thermoplastic material. Because of the
putty-like consistency, pellets work well for individualized finger
separators—such as for children who have arthrogryposis and
different deformities in each finger. 25
Elastomer is a silicone-based putty that is used in pediatric orthoses
for thumb positioning or finger spacers. Pellets and elastomers are
available from many product catalogs. The putty types of elastomers
“with a gel catalyst or the 50/50 mix are probably the easiest to work
with because they can be mixed in the hand and varied in stiffness by
adding more or less catalyst.” 4 Another option for modeling is
Permagum, a silicone rubber dental-impression material. 6 Elastomers
and pellets may also be used to maintain the palmer arches or as a
base for a small hand orthosis. 16
The therapist may choose to use a dorsal-based resting orthosis 4,45
as an alternative to the palmar-based orthosis already described. This
design is illustrated in Chapter 9. The dorsal-based orthosis avoids
sensory input to the forearm flexors, although it is somewhat more
difficult to fabricate. For a child with very tight wrist flexors, donning
the dorsal-based resting orthosis is easier than the palmar-based
orthosis. The child’s fingers are placed into the finger slot (with the
fingers sufficiently positioned through the slot to support the MCP
joints), pressure is placed across the wrist flexors, and slowly the
forearm trough can be levered down onto the dorsum of the forearm.
Armstrong 4 is a good source of information on fabricating this
orthosis.
Infants with congenital finger contractures often need resting hand
orthoses. However, when all digits are not affected, the orthosis is
altered to free nonaffected digits to engage in movement and sensory
experiences. Resting hand orthoses may be made with alternative
materials, especially for infants. The therapist selects a semirigid
pliable material for neonatal orthoses because it is less likely to cause
abrasions. Bell and Graham 6 describe the use of Permagum, a silicone
rubber dental-impression material, for neonatal orthoses. Several
layers of adhesive cloth tape may also be an effective semirigid
support.

Precautions
For orthotic provision against increased muscle tone, the therapist
considers biomechanical principles of force distribution. The therapist
monitors for any undesired lateral forces on the fingers or wrist that
may result in poor anatomical alignment, dislocation, or deformity.
The therapist is aware of any circulation compromise or pressure on
nerves. The therapist’s observations elicit important information from
the child, parent, or caregiver—especially when assessing very young
children or those with communication dysfunction.
Follow the same precautions for this orthosis as with any other
orthosis. (See Chapter 6 for guidance in determining problems with
skin, bone, or muscles.) For a child who has increased tone, the
therapist shortens the initial wearing time to 15- to 20-minute intervals
on the first day. The therapist carefully inspects the skin. A distinct
red area or generalized redness on the skin that does not disappear
within 15 to 20 minutes after orthotic removal indicates excessive
pressure and the need for revision. 23,25 If no pressure areas are
present, the therapist increases the wearing time to 30-minute
intervals. The therapist then increases the wearing time by adding 15
to 30 minutes until the maximum wearing period is reached.
An additional precaution when making a resting hand orthosis for a
child who has moderately to severely increased tone is maintaining
the integrity of the MCP joint of the thumb. The therapist directs
pressure below the MCP joint of the thumb. Exner 21 cautions that
distal force to the spastic thumb can result in hyperextension and
dislocation of the MCP joint.

Wearing schedule
The wearing schedule is determined on an individual basis, as are all
other aspects of the intervention plan. In general, the more serious the
threat of deformity, the longer the orthosis is worn over 24 hours. If
tone continues to increase at night, extend the wearing schedule
unless it interferes with the child’s sleep or presses against another
part of the body. During the day the orthosis is removed for periods of
passive ranging, active movement, and opportunities for sensory
experiences.
McClure and colleagues 38 provide a flow chart or algorithm for
making clinical decisions regarding wearing schedules. They describe
the biological basis for limitations in joint ROM and for increasing
ROM. This information is especially applicable with existing
contractures. According to the authors, “the primary basis for using
[orthoses] to increase ROM is that by holding the joint at or near its
end-range over time, therapeutic tensile stress is applied to the
restricted periarticular connective tissues (PCTs) and muscles. This
tensile stress induces remodeling of the tissues to a new, longer
length, which allows increased ROM.” 38 McClure and colleagues 38
defined remodeling as “a biological phenomenon that occurs over
long periods of time rather than a mechanically induced change that
occurs within minutes.”
The child benefits from participating in occupations immediately
after removal of the resting hand orthosis to capitalize on increased
hand expansion and elongation of tight muscles. If developing or
improving functional hand skills is a primary goal, the orthosis is
removed more frequently or for longer periods of time.

Instructions for orthotic application

Applying the child’s orthosis correctly is important. Caregivers
should understand the purpose of the orthosis, precautions, risks of
incorrect use, and how to reach the therapist with questions or
concerns.

Procedure for Fabrication of a Dorsal

Wrist Immobilization Orthosis
When selecting thermoplastic material for the wrist immobilization
orthosis, use highly conforming material. For children who have
wrist flexor spasticity, use rigid material. For smaller children, use
1⁄12-inch thick thermoplastic material, whereas for larger children,
use ⅛-inch thick material.

1. Position the child’s hand palm down on a piece of paper. Make

an outline of the child’s hand from the fingertips to the
forearm. The wrist is neutral with respect to radial and ulnar
deviation. The fingers are in a natural resting position (not flat)
and slightly abducted. Draw an outline of the fingers, hand,
and forearm to the elbow.
2. While the child’s hand is still on the paper, mark A at the MCP
joint of the index finger, and mark B at the MCP joint of the
little finger. Mark a C for the first web space. Mark a D for the
ulnar border of the hand between the distal palmar crease and
the wrist crease. Mark two-thirds the length of the forearm on
each side with an X. Place another X on each side of the pattern
approximately 1 inch outside and parallel to the two previous
X markings for the approximate width of the orthosis. These
markings are to accommodate for the side of the forearm
trough.
3. Remove the child’s hand from the pattern. Draw a line
connecting the A and B markings of the MCP joints. Now,
draw a new line 1 inch proximal to this line. This should match
the child’s distal palmar crease and marks the distal edge of the
orthosis. Make sure that this line is angled toward the ulnar
side of the hand.
 4. Draw a kidney bean shape over the palmar area of the hand,
leaving at least 1¼-inch border on each side and from the distal
edge. This kidney bean shape matches with the first web space
marked C on the radial side, and mark D on the ulnar side of
the hand. This kidney bean–shaped area will be cut out.
Redraw all borders of the orthosis pattern, and cut it out.
5. Trace the pattern onto the sheet of thermoplastic material.
6. Heat the thermoplastic material.
7. Cut the pattern out of the thermoplastic material. Carefully cut
out the kidney bean–shaped opening in the palm. Reheat the
thermoplastic material until fully activated.
8. Mold the orthosis onto the child’s hand. To fit the orthosis on
the child, have the child’s elbow rest on a pad on the table with
the forearm in a pronated position.
9. Slip the child’s four fingers through the distal cut out, and pull
the material over the dorsum of the hand and wrist. Make sure
to stop midway over the back of the hand, halfway down the
length of the MPs.
10. Fold over the dorsal material at the level of the wrist to provide
extra support for extension.
11. Flare the material away from a prominent ulnar styloid and at
the proximal edge of the forearm. Make other adjustments to
the orthosis as needed.
12. Position the child’s wrist in extension as the material cools and
hardens. Use your thumb to mold the palmar arch. Make sure
the wrist remains correctly positioned as the thermoplastic
material hardens.
13. Cut the Velcro hook adhesive into two 2-inch oval-shaped
pieces for the proximal edge of the orthosis. Heat the adhesive
with a heat gun to encourage adherence before putting the
Velcro pieces on the orthosis. If the material has a coating, use a
solvent on the thermoplastic material or scratch the surface to
remove some of the nonstick coating to increase adherence of
the Velcro pieces.
14. The Velcro loop strap is placed at the proximal border of the
 orthosis. Depending on the child’s size, it can be either a 1-inch
or 2-inch wide strap. The strap should secure the orthosis
snugly to the forearm.
15. Check the final fit of the orthosis. Make sure the orthosis is
dorsally based and does not cover the volar surface of the
forearm or wrist. Check the edges to ensure that they are not
impinging on the skin or pressing on the bony prominences.
Smooth all edges, and round all corners.

Evaluation of the orthosis

The self-evaluation described in Chapter 9 is used to evaluate the
finished orthosis. The orthotic fit is reviewed at regular intervals. The
orthosis’ effectiveness in accomplishing stated goals and outcomes is
reevaluated on an ongoing basis.

Dorsal Wrist Immobilization Orthosis

A dorsal-based wrist immobilization orthosis offers excellent wrist
support while allowing the palmar surface of the hand to be free for
sensory input and play. Remember that children gain information
from the world through exploration with their hands and fingers.
Even while the child is crawling, the dorsal-based wrist
immobilization orthosis supports the wrist in extension for weight
bearing. Using an appropriate thermoplastic material and slightly
altering the pattern make weight bearing easier while wearing the
orthosis. Blocking the entire palmar surface in a weight-bearing
orthosis may not be appropriate for all children. During crawling and
weight-bearing activities, ensure that the child’s fingers are not
hyperflexed, but rather extended.
 FIG. 17.23 Instructions for dorsal wrist cock-up orthosis.
Courtesy Orfit Industries.

Instructions for fabricating a dorsal wrist immobilization

orthosis
The steps for fabricating a dorsal wrist immobilization orthosis can be
found in the following procedure (Fig. 17.23).

Soft Thumb Orthosis

A soft thumb orthosis with a thumb loop is often used with children
who have mild spasticity or increased tone. The orthosis positions the
thumb out of the palm. The material used for the wrist band and
thumb loop is made from Neoprene. The strap forming the thumb
loop is wide enough to support the thumb but not so wide that it
buckles or wrinkles in the thumb web space. The strap forming the
wrist band is wide enough to secure the thumb loop, remain in place
on the wrist, and distribute pressure. The wrist band strap length is
long enough to form an adequate overlap to secure the Velcro.
Determine the specific dimensions by placing strap material on the
child’s arm and hand to measure lengths and widths to determine the
desired angle of pull. Steps to fabricate a soft thumb orthosis can be
found in the following procedure.

Rotation Strap
The rotation strap facilitates forearm supination or pronation, and it
can be used to facilitate or augment shoulder rotation. The rotation
strap is always coupled with a thumb or wrist orthosis. If used for
shoulder motion, the strap must attach either to a therapeutic garment
or strapping system at the trunk. A rotation strap is appropriate for
children with flexor tone that pulls the forearm into pronation or
shoulder internal rotation. The strap can also be used for positioning
the forearm after surgeries.
To make the strap, use colorful soft Velfoam, Beta Pile, or Neoprene.
To augment a weaker movement, use Neoprene because it is more
elastic. Strap width varies from ¾ inch for infants to 1½ to 2 inches for
older children and adolescents. Wider straps have greater elasticity
than narrower straps. The length of the strap is approximately three to
four times the length of the forearm (for forearm rotation) or three
times the length of the arm for shoulder rotation (Fig. 17.24).
 FIG. 17.24 Forearm rotation strap.

Procedure for Fabrication of a Soft

Thumb Orthosis
To make the pattern, the wrist band overlaps on the volar side of the
wrist. The length of the thumb loop is the distance from the proximal
edge of the wrist band, around the thumb, and back around to the
point of origin.
The materials and tools needed for fabrication of the soft thumb
orthosis include:

• Neoprene
• Hook-and-loop Velcro
• Needle and thread and/or Neoprene tape
• Tape measure
• Scissors or roller cutter
• Straightedge ruler
1. Measure the child’s thumb IP circumference with accuracy to
the 1⁄16 inch. This measurement is used to create the pattern.
When measuring an infant or toddler, it may be simplest to
knot one end of a piece thread, wrap the thread snugly—not
tightly—around the child’s IP, and mark where the thread and
knot intersect. Then straighten the thread, and align it to a
ruler’s edge to obtain an accurate circumference measure.
2. Trace or photocopy the palm side of the child’s hand with
fingers and thumb outstretched. If tracing, mark points on the
outline to indicate the four corners of the palm where the palm
intersects the wrist and the index and little fingers. Mark the
two points where the line of the thumb IP intersects the outline
of the thumb. As accurately as possible, draw a line for the
 distal palmar crease on the hand tracing.
3. From the photocopy or tracing determine the following
measurements:
• Measurement A: From the web space, just below the
distal palmar crease to the edge of the palm. Add 1 to
2 inches to this measurement.
• Measurement B: Half the distance of the web space
from the thumb IP to the index finger MCP.
• Measurement C: Half of the thumb IP circumference.
Add 1⁄16 inch if using 1.5-mm Neoprene. Add 1⁄8 inch
is using 3.0-mm Neoprene.
• Measurement D: Thumb IP to proximal edge of the
thumb MCP joint.
• Measurement E: Distance along the wrist crease from
the ulnar to radial side of the wrist. Add 1 to 2 inches
to this measurement.
4. Create the pattern using measurements A through E. Cut out
the pattern, and trace it onto the Neoprene. Next cut the pattern
from the Neoprene using either the scissors or roller cutter.
Trace and cut a second pattern from the Neoprene. (Note: If the
Neoprene has back and front sides, cut out mirror images.)
5. To assemble the orthosis, abut the two pieces of Neoprene side
D to side D. Sew this seam by machine using a wide zigzag
stitch. You may alternatively apply Neoprene tape or sew these
two pieces together by hand. If sewing by hand, follow the
directions for sewing by hand in #6.
6. Tape or sew by hand side B to side B. Neoprene heat-sensitive
tape can be used to bond the two pieces together because the
thickness makes it difficult to sew together. If sewing by hand,
use a single thread, and embed the knot in the foam rubber
within the seam. Use a running stitch to sew fabric to the fabric
on the outside of the orthosis. Turn the orthosis inside out,
pierce the needle through, and use a running stitch to sew
fabric to fabric. This method avoids compressing the Neoprene
at the joint and thereby does not reduce the strength of the
 abutted joint. Using a single strand of thread reduces the
possibility of creating irritation along the web of the child’s
hand.
7. Adjust volar and dorsal portions of the orthosis to achieve
desired amount of thumb abduction, and cut excess
accordingly (dorsal portion overlaps volar portion by 1 inch for
hook-and-loop closure).
8. Sew hook-and-loop fastener onto thumb sleeve, loop side down
on dorsal portion and hook side up on volar portion. The fit
should be snug but not constricting.
9. Attach hook-and-loop Velcro to each end of the wrist band that
is designed to overlap on the volar side of the forearm. To form
the thumb loop, attach one end of the thumb loop to the dorsal
portion of the wrist band. Then attach the loop Velcro to the
free end of the thumb loop and hook Velcro to the dorsal
portion of the wrist band (partially covering the origin of the
thumb loop).
10. The thumb loop is directed up across the web space, around
the thenar eminence, and pulled diagonally to attach to the
dorsal portion of the wrist band. The amount of tension on the
thumb loop and the attachment location of the free end to the
wrist band influence the amount of radial and palmar
abduction of the thumb. If the wrist band does not fit snugly,
the orthosis shifts distally on the wrist, thus reducing the
amount of tension on the thumb loop. The wrist band must
avoid circulatory restrictions (see Fig. 17.25 A & B).
 FIG. 17.25 A, Radial view soft thumb orthosis with loop. B, Volar view
soft thumb orthosis with loop.
Courtesy Orfit Industries.

Instructions for a rotation strap

Construction of a forearm rotation strap is simple. If cutting from a
Neoprene bolt, use a roller cutter against a plastic ruler for accuracy.
Before attaching the distal Velcro hook strip, trim the distal corners of
the strap in a “V” to reduce bulk where the strap attaches to the hand
or thumb orthosis. The proximal Velcro hook does not need to be
sewn.
To apply the strap, attach to the hand thumb orthosis on the dorsal
surface if promoting wrist extension. Likewise, attach to the palm side
if promoting wrist flexion. Attaching the strap on the palm side and
pulling through the web space may add unnecessary bulk to the
orthosis and reduce hand function. Do not attach the strap ulnarly
from the midline of the hand because it promotes ulnar deviation. The
strap is always attached near the thumb. To fabricate the orthosis,
position the child in a comfortable end range of desired rotation.
For a rotation strap that promotes supination, wrap the strap from
the thumb side to ulnar side while spiraling up the forearm (Fig.
17.26). Likewise, for an orthosis that promotes pronation, wrap the
strap from the thumb side to the radial side while spiraling up the
forearm (Fig. 17.27).
Attach the strap to itself above the elbow with Velcro hook. You can
assist in blocking elbow flexion if the strap is wrapped behind the
elbow joint before securing it. This is a great addition to a thumb- or
hand-based orthosis. The strap can sometimes provide enough
assistance with wrist extension to promote weight bearing on the
palm.

Anti–Swan Neck Orthosis

The goal of an anti–swan neck orthosis (Fig. 17.28) is to prevent
hyperextension or swan neck deformity of the PIP joint of the finger.

FIG. 17.26 Supination strapping.

 FIG. 17.27 Pronation strapping.

FIG. 17.28 Anti–swan neck orthosis.

Courtesy Orfit Industries.
Fabrication of an anti–swan neck orthosis
The steps for fabricating an anti–swan neck orthosis can be found in
the following procedure.

Procedure for Fabrication of an Anti–

Swan Neck Orthosis
The orthosis is fabricated from thin strips of 1⁄12-inch coated
thermoplastic material.

1. Position the child’s finger in PIP joint flexion. Construct a

thermoplastic oval shape over the proximal phalanx and
middle phalanx. Overlap the ends and let harden.
2. Place another strip of thermoplastic material directly under the
PIP joint so that it overlaps onto the oval. Let harden. Carefully
remove both strips and bond together with the use of a heat
gun. Immediately dip into cold water to facilitate the bond and
prevent overstretching of the material.
3. Ease the orthosis over the finger while it is flexed. The orthosis
should allow for full finger flexion but prevent hyperextension
or “swanning” of the PIP joint.

Commercial Orthoses
Sometimes the most cost-effective option for orthotic provision is a
commercial orthosis. Therapists select a product and measure for
correct sizing. The following companies specialize in prefabricated
pediatric orthoses:

1. Bamboo Brace (elbow extension orthosis): The Bamboo Brace is

a flexible pediatric arm brace (orthosis) placed around the
elbow joint for children with CP and other developmental
challenges. The Bamboo Brace assists children in maintaining a
more extended elbow position to enable development of gross
 and fine motor skills.
2. Benik Orthoses (http://www.benik.com/): Benik sells custom
Neoprene products, such as elbow, wrist, and thumb supports
for adults and children. Measurement instructions are
available online.
3. Comfy Splints (http://www.comfysplints.com/): These are
prefabricated orthoses designed by occupational therapists
and physicians. Their easy adjustability at multiple joints
allows them to be used for many indications and deformities.
They feature multilayers for softness and new drirelease with
FreshGuard terry cloth covers. They are available in sizes for
infants to large adults. The company sells a large selection of
immobilization and mobilization orthoses.
4. The Joe Cool Company (http://www.joecoolco.com/): The Joe
Cool thumb abduction orthosis maintains thumb abduction
with minimal interference with grasp and sensation. Joe Cool
thumb abduction orthoses are made of soft, flexible Neoprene
and have an adjustable hook-and-loop closure system. They
are latex-free and can be hand washed.
5. McKie Splints, LLC (www.mckiesplints.com): Dissatisfied with
the bulkiness of commercially made thumb abduction orthoses
for the 0 to 3-year-old population, Ann McKie, an occupational
therapist, designed and patented the McKie thumb orthosis.
Made from 1.5-mm Velcro-receptive Neoprene, the orthosis
dynamically draws the thumb into opposition. The Velcro
strap attaches at the head of the thumb MP to block
hyperextension at the MCP joint. McKie Splints manufactures
latex-free Neoprene thumb orthoses, supinator straps, and
custom wrist-hand orthoses. All products are sized for
premature infants, infants, children, teens, and adults and are
available in a variety of colors. Low-temperature thermoplastic
stays are available on custom orthoses.
Evidence for Orthotic Intervention for
Children
Table 17.3 summarizes evidence addressing the effectiveness of
orthoses for children with a variety of diagnoses.

TABLE 17.3

Evidence-Based Practice About Orthotic Provision for the Pediatric Population

ADL, Activity of daily living; AHA, Assisting Hand Assessment; COPM, Canadian
Occupational Performance Measure; CP, cerebral palsy; FIM, Functional Independence
Measure; GAS, Goal Attainment Scale; ICF, International Classification of Functioning,
Disability and Health; IP, interphalangeal; OT, occupational therapy; PT, physical therapy;
RCT, randomized controlled trial; ROM, range of motion; TMC, trapeziometacarpal; VAS,
visual analog scale.
Contributed by Whitney Henderson.
Summary
This chapter addressed the use of several types of orthoses for the
management of children with a variety of conditions. Orthotic designs
for a child differ from many of the adult designs. In addition to the
dynamics of development, children differ from adults in the types of
environments in which they live, learn, work, and play. Published
case reports and research studies are needed to determine the
effectiveness of pediatric orthotic designs and optimal wearing
schedules. Such outcomes will allow therapists to make decisions
based on clinical reasoning and evidence.

Review Questions
1. How is orthotic intervention different with the pediatric
population as compared to the adult population?
2. How would you prepare the room and the child to
increase the probability of a successful orthotic fabrication
session?
3. What factors should be considered when determining a
wearing schedule for any pediatric orthosis?
4. What are the differences among the Bamboo Brace, Benik,
Comfy Splints, Joe Cool, and McKie Splints commercial
orthoses?
5. What are the pros and cons of using a soft orthosis versus
thermoplastic material when providing an orthosis for a
child?
6. What methods are appropriate for providing instructions
to parents, teachers, and other caregivers to maximize
correct application and use of an orthosis?
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Appendix 17.1 Case Studies
Case Study 17.1 a

Read the following scenario, and use your clinical reasoning skills to answer
the questions based on information in this chapter.
Matthew is an 8-month-old boy with arthrogryposis multiplex
congenita. He lives with his mom and is cared for by a caretaker
during the day, when his mom attends school. He has a supportive
extended family. Matthew’s shoulders rest in internal rotation, his
elbows rest in extension, forearms rest in pronation, and wrists rest in
flexion with thumbs adducted and digits partially flexed. Passive
motion is limited and painful for end ranges of all shoulder motions,
elbow flexion past 30 degrees, supination past 45 degrees, and wrist
extension past 0 degrees. Active shoulder flexion is limited to 90
degrees. Matthew has only 30 degrees of active elbow flexion. There is
no observable active wrist extension, and there is active finger flexion
and extension. Matthew has difficulty grasping most toys. To
compensate, he uses both hands during play and when attempting to
grasp toys. He cannot hold a bottle or bring his hands to his mouth.
You have just completed Matthew’s evaluation. Among the team
goals are increasing his opportunities for play, increasing functional
reaching and grasping skills, and increasing active participation in
age-appropriate activities of daily living (ADLs). Specific objectives
include increasing Matthew’s ability to grasp and sustain hold on toys
and improving functional reach and use of hands for play. You have
selected the biomechanical frame of reference.
Orthotic intervention has never been used. You consider all of
Matthew’s limitations, and you are quite overwhelmed because you
understand that it will be a challenge, but you are up for the task and
decide to tackle it one step at a time. Which of the following treatment
interventions would you select and why?

1. Option A: Educate his mom on passive range-of-motion

 exercises for both upper extremities, and inform his mom that
once the child is able to tolerate passive motion without pain,
you will implement the use of orthoses in your treatment plan.
2. Option B: Fabricate bilateral circumferential wrist orthoses in
submaximal passive wrist extension for daytime wear.
Fabricate bilateral posterior elbow orthoses for night use in
submaximal passive elbow flexion.
3. Option C: Fabricate bilateral resting hand orthoses for daytime
wear and bilateral posterior elbow orthoses for night wear in
submaximal passive elbow flexion.
4. Option D: Fabricate bilateral circumferential wrist orthoses for
daytime use, but remove orthoses during play activities.
Fabricate bilateral resting hand orthoses for overnight wear.

Case Study 17.2 a

Read the following scenario, and use your clinical reasoning skills to answer
the question based on information in this chapter.
Luke is a 7-month-old boy who was referred to occupational
therapy for indwelling thumb posture in his right hand. Mom is very
concerned, explaining that Luke cannot bring his thumb out of his
palm when attempting to grasp objects in his right hand. She reports
that he keeps his thumb flexed in his palm when holding his bottle as
well. You observe that Luke postures his right thumb metacarpal joint
in flexion and that there is no active metacarpal extension during your
evaluation. Luke has full active range of motion in bilateral upper
extremities, with the exception of his right thumb. He has full passive
right thumb metacarpal (MP) and interphalangeal (IP) flexion and
extension, and this is interfering with the development of his fine
motor skills. Which of the following orthotic interventions would you
initiate now?

1. Option A: Fabricate a thermoplastic thumb spica for daytime

use to facilitate improved functional positioning.
2. Option B: Fabricate resting hand orthoses for both hands and a
 thermoplastic material thumb orthosis for the right hand.
Recommend wearing both resting hand orthoses at night and
the left orthosis periodically during the day (depending on
status of range of motion [ROM]). Recommend wearing the
right thumb orthosis during functional grasp activities.
3. Option C: Fabricate resting hand orthoses for both upper
extremities. Recommend that they be worn at night and
during the day except during scheduled activities involving
reach, grasp, and release.
4. Option D: Fabricate resting hand orthoses for both upper
extremities. Because you are unsure if the orthoses would be
put on correctly at home, recommend that they be worn only
during the day at school. Both orthoses will be removed
during scheduled activities involving reach, grasp, and release.
Appendix 17.2 Laboratory Exercises
Laboratory Exercise 17.1 a Recognizing
Problems in Orthotic Fabrication No. 1
What problems in orthotic fabrication are present in the following
picture?

Laboratory Exercise 17.2 a Recognizing

Problems in Orthotic Fabrication No. 2
What problems in orthotic fabrication are present in the following
picture?
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
UNIT THREE
Topics Related to Orthosis
OUTLINE

18. Lower Extremity Orthotics

19. Casting
20. Upper Extremity Prosthetics
21. Professional Development in Upper Extremity Rehabilitation
Supplement for 13. Mobilization Orthoses: Serial-Static,
Dynamic, and Static-Progressive Orthoses
18
Lower Extremity Orthotics
Christopher Robinson, Stefania Fatone, and Brittany Stryker

CHAPTER OBJECTIVES
1. Recognize the meaning of basic terminology used in lower
extremity (LE) orthotic prescriptions.
2. Outline the role of the occupational therapist in the LE orthotic
intervention program.
3. Recognize the importance of an interdisciplinary team approach
to LE orthotic provision.
4. Describe the general purposes and basic functions of LE
orthoses.
5. Describe the biomechanical principles of LE orthoses.
6. Describe the basic design principles of LE orthoses.
7. Describe various components and materials commonly used in
the fabrication of LE orthoses.
8. Identify the basic components of normal and pathological gait.
9. Recognize commonly prescribed LE orthoses.

KEY TERMS
biomechanical principles
clinical considerations
normal gait
orthotic design principles
pathological gait

The International Organization for Standardization (ISO 8549-1:1989)

defines an orthosis as an externally applied device used to modify the
structural and functional characteristics of the neuromuscular and
skeletal systems. 3,4 Orthoses are categorized based on the anatomical
segments and joints encompassed (ISO 8549-3:1989) 4 with standard
abbreviations for lower extremity (LE) orthoses listed in Table 18.1.
Consistency in terminology ensures effective communication within the
rehabilitation team.

Evidence of orthotic applications has been found as early as 2750 BC 2 in

excavation sites where mummies have been uncovered with various
orthoses still intact. Wars and battles have always dramatically
increased the number of people in need of assistive devices. However, it
was the polio epidemics of the 1950s and the introduction of
thermoplastics in the 1970s that spurred increased interest and
development in the field of orthotics in the United States. 6 Today,
continued advancements in technology promote the development of new
orthotic designs, materials, and components.

NOTE: This chapter includes content from previous contributions

from Deanna Fish, MS, CPO; Michael Lohman, MEd, OTR/L, CO;
Dulcey Lima, OTR/L, CO; and Karyn Kessler, OTR/L.
Role of the Occupational Therapist
In upper extremity orthotic practice, occupational therapists (OTs)
typically provide comprehensive management, including the design,
fabrication, fitting, and functional training of the client with the
orthosis. With increased emphasis on interdisciplinary care, OTs are
increasingly engaged in the care of clients who use LE orthoses.
However, in these cases, certified orthotists (COs) are responsible for
the design, fabrication, and fit of the LE orthoses, often working in
concert with physical therapists in the provision of training in their
use. OTs collaborate to ensure that LE orthoses are designed to
facilitate successful occupational performance at each stage in the
rehabilitation process. Common concerns addressed by OTs include
acting as a client advocate, donning and doffing the orthosis,
education regarding skin inspection for clients with insensate limbs,
and integration of the orthosis into everyday use.
LE orthoses address specific biomechanical goals, such as providing
knee stability during ambulation. In that case, it may require the OT to
help the client learn how to perform mobility tasks with a locked
knee. It is the OT’s role to anticipate performance issues that may
occur when wearing LE orthoses and collaborate with the orthotist to
ensure that these issues are considered during the design and
fabrication processes. The potential of a LE orthosis to address
biomechanical and gait impairments is irrelevant if it is rejected
because it is too difficult to don or doff or impedes activities of daily
living (ADLs).

TABLE 18.1

Standard Abbreviations for Lower Limb Orthoses

Abbreviation Name
FO Foot orthosis

AFO Ankle-foot orthosis

KO Knee orthosis
KAFO Knee-ankle-foot orthosis
HO Hip orthosis

HKAFO Hip-knee-ankle-foot orthosis

From Condie, D. (2008). International Organization for

Standardization (ISO) terminology. In J. Hsu, J. Michael, & J. Fisk,
AAOS atlas of orthoses and assistive devices (pp. 3–7). Philadelphia, PA:
Mosby.

With pediatric clients, LE orthoses affect occupational performance

differently from adults. LE orthoses may focus, for example, on the
development of balance and equilibrium as a foundation for skill
development and motor milestone acquisition. LE orthosis designed
to hold the hips in relatively extended and abducted position may
provide a stable base of support to facilitate independent eating,
playing, or writing skills but also impede crawling and transitional
movements unless it is designed to avoid such problems.
An OT involved as part of the clinical team making decisions about
LE orthotic management must have a working knowledge of
terminology and basic biomechanical and orthotic design principles
pertaining to LE orthoses. This chapter provides a basic
understanding of LE orthotics but is not intended to be definitive or
comprehensive in nature. Those with an interest in developing further
expertise in this area should invest in additional training and
reference texts, such as the AAOS Atlas of Orthoses and Assistive
Devices. 17
Interdisciplinary Approach
Although this chapter focuses primarily on the roles of the OT and the
CO, all members of the interdisciplinary team contribute the expertise
needed to facilitate a client’s progression through a comprehensive
rehabilitation program involving LE orthoses. The suggestion to
provide a LE orthosis can come from any member of the
interdisciplinary team with effective collaboration required to ensure
the best possible clinical outcome. Consideration must be given to the
client’s sensory, motor, and occupational performance. Skin integrity
and sensation influences the choice of material for interface
components. The client’s strength is considered in relation to the
weight and forces required to use the orthosis. Fine motor strength
and coordination also influence the design of the strapping system.
ADLs are considered with regard to donning and doffing of the
device. The client’s physical and cognitive capabilities are also
considered for successful use of the device.
Upper extremity orthoses made by OTs are typically fabricated
from low-temperature thermoplastic materials and are intended for
interim use with a typical life span of 3 to 6 months. The properties of
low-temperature thermoplastic materials are described in Chapter 3 of
this text. Limitations in material properties, such as lack of sufficient
rigidity, preclude use of low-temperature thermoplastics in most LE
orthotic applications. Orthotists must access a much wider variety of
materials to successfully fabricate LE orthoses that may be worn for
months or even years while being able to withstand forces such as
weight-bearing activity. With the proper tools and skills, LE orthoses
can be adapted to address the client’s changing clinical presentation as
the client progresses through rehabilitation.

BOX 18.1 Clinical Objectives of Lower Extremity

Orthotic Treatment
 • Relieve pain
• Manage deformities
• Prevent excessive range of joint motion
• Increase the range of joint motion
• Compensate for abnormalities of segment length and shape
• Manage abnormal neuromuscular function (e.g., weakness or
hyperactivity)
• Protect tissues
• Promote healing
• Provide other effects (e.g., placebo, warmth, postural feedback)

From Condie D. (2008). International Organization for

Standardization (ISO) terminology. In J. Hsu, J. Michael, & J. Fisk,
AAOS atlas of orthoses and assistive devices (pp. 3–7). Philadelphia, PA:
Mosby.
Orthotic Design Principles
General Concepts
When providing a client with LE orthoses, all involved must have a
fundamental understanding of key biomechanical principles, clinical
assessment, orthotic components, and material science to develop an
orthotic intervention plan. Box 18.1 details the goals commonly
addressed by LE orthoses. This intervention plan is created with input
from the entire interdisciplinary team to ensure that it provides the
client with the best possible outcome.

Biomechanical Principles
The orthotist’s foundation for clinical decision making is based upon
three fundamental biomechanical principles: three-point force
systems, total contact, and kinaesthetic reminders. Although each of
these principles may be used individually, they are often used in
combination to achieve the best possible clinical outcome. These
principles are summarized below in the context of LE applications.

Three-Point Force Systems

A three-point force system (Fig. 18.1) is used to change the alignment
of a joint through the application of two forces working in opposition
to a counterforce (or fulcrum). The counterforce is positioned on the
convex side of the joint deviation, close to the joint requiring the
angular change. The opposite two forces are positioned proximally
and distally to the counterforce, on the side of the joint concavity. The
greater the linear distance between opposing forces, the less force is
required to achieve/maintain the angular correction.
 FIG. 18.1 Three-point force system to correct genu valgum. Pictured
is a three-point force system applied in the coronal plane to effect an
angular change at the knee joint (i.e., resistance to genu valgum).

Total Contact
Total contact is used to distribute forces from the orthosis more evenly
over the client’s body. The equation demonstrates that
for the same force; an increasing area results in a relative decrease in
pressure. It is important that pressures are kept at reasonable
magnitudes; otherwise, the client is placed at risk for the development
of skin breakdown. Breakdown could result in the inability to use the
orthosis or infection if soft tissues are damaged and become a portal
for bacteria. Some clinical presentations require relatively higher
magnitudes of force from the orthosis to achieve biomechanical goals.
The application of higher magnitudes of force requires increasing the
surface area over which forces are applied, ensuring that tolerable and
safe pressures are experienced by the soft tissues.

Kinaesthetic Reminder
A kinaesthetic reminder does not rely on the mechanical properties of
an orthosis to achieve the intended function, but rather the sensation
of wearing an orthosis. The sensation of being in physical contact with
the orthosis may in some cases be sufficient to cue the client to alter
movement patterns in a beneficial manner. For example, a child
diagnosed with Down syndrome may present with excessive ankle
dorsiflexion during the stance phase of gait (typically referred to as
“crouch” gait) and can be provided a supramalleolar orthosis (SMO),
which has elastic straps that circumferentially wrap just proximal to
the malleoli. Although the elastic straps do not have the material
properties required to mechanically limit excessive dorsiflexion and
forward progression of the child’s tibia during gait, the sensation of
the strap across the tibial crest cues the child to volitionally limit
movements of the ankle joint.

Clinical Assessment for Lower Extremity Orthotic

Management
The ultimate design of any orthosis should explicitly address the
intervention goals identified for each individual client. Clinical
objectives of orthotic treatment as identified by ISO 8551:2003 are
listed in Box 18.1. Fabricating an orthosis without specific intervention
goals identified will likely result in a less than optimal clinical
outcome and decreased client acceptance of the orthosis. Making the
client part of the clinical decision process is important because a single
clinical presentation can be managed in many different ways.
Defining appropriate orthotic intervention goals requires a thorough
clinical assessment (Box 18.2). Physical examination includes both LEs
to fully understand the client’s current and potential function. LE
orthoses may have intervention goals other than improving gait. Gait
constitutes a large part of what LE orthoses address or compromise by
their use. Hence it is important to understand gait when dealing with
LE orthoses. An overview of both normal and pathological gait
biomechanics is discussed.

BOX 18.2 Assessment for Lower Extremity

Orthotic Intervention

• Personal history (e.g., initial presentation of disease, trauma, or

problem; course of disease to date)
• Medical background (e.g., current medications, previous
interventions)
• Comorbid conditions that affect orthotic management (e.g.,
diabetes, neurological impairment, hand dysfunction, and so on)
• Current and previous orthotic use
• Current exercise/therapy program
• Individual goals and expectations
• Daily activity level (current and anticipated)
• Sitting and standing posture and balance
• Description of body size and habitus (e.g., weight, height)
• Skin integrity
• Presence of edema
• Areas of pain/discomfort
• Neurological profile
• Sensation (e.g., light pressure, deep touch)
• Proprioception
• Range of available joint motion(s)
 • Spasticity/tone
• Muscle strength
• Cognitive abilities (e.g., follow through with education and
instructions regarding the orthosis)
• Static and dynamic alignment of joints
• Transfers and self-care tasks
• Observational gait assessment
• Functional testing to identify specific functional challenges
(impact of condition on current functional status)

Data from Fish, D., Kosta, C., et al. (1997). Functional walking: An EPIC
approach. Oregon Orthotic System course manual; Magee, D. (1987).
Orthopedic physical assessment. Philadelphia, PA: WB Saunders; Uustal,
H. (2008). The orthotic prescription. In J. Hsu, J. Michael, & J. Fisk.
(2008). AAOS atlas of orthoses and assistive devices (pp. 9–14).
Philadelphia, PA: Mosby.

Having a strong working knowledge of the major joints and

structures that contribute to LE movement and how to assess them
enables informed clinical decisions. The key joints and structures
contributing to lower limb movement are the oblique midtarsal
(Chopart), subtalar, ankle, knee, and hip joints (Fig. 18.2). When in
contact with the ground, these joints work in concert to facilitate
efficient movement patterns. When a single joint is deficient in
strength or motion to perform a functional task, adjacent joint
segments are often affected as well. For example, normal walking
requires a person to have approximately 10 degrees of ankle
dorsiflexion in order to allow the body to progress forward over the
stance limb. 38 With a client who presents with a fixed plantar flexion
contracture of 5 degrees at the ankle, tibial advancement is hindered.
As a result, adjacent joints, including the oblique midtarsal joint and
knee, may exhibit excessive motion so as to allow the tibia to continue
to advance in the sagittal plane. The midtarsal joints may dorsiflex,
and the knee may hyperextend, getting progressively worse over time
as the client’s body mass continues to progress forward with each
step. This example describes movement in only a single plane. An
orthosis aimed at addressing these impairments also accounts for
coronal and transverse plane movements and the interplay that occurs
between the joints, muscle groups, and motor control strategies
needed to facilitate movement.
 FIG. 18.2 Key joints and structures contributing to lower limb
movement.

Once the orthotist has identified the specific joints, segments, and
movements to address with the orthosis, the decision is made to
control the joint directly or indirectly. 1 Direct control requires that the
orthosis physically surrounds the segment or joint selected. Indirect
control occurs when the orthosis attempts to modify the external
forces acting on a joint beyond its physical boundaries. For example,
an orthosis can address weak knee extensors using either direct or
indirect control. The direct approach would involve fabricating an
orthosis that physically surrounds the knee joint (e.g., a knee orthosis
[KO] or knee-ankle-foot orthosis [KAFO]). Hinges that lock when the
knee is fully extended act to stabilize the knee. An indirect approach
would use an orthosis that encapsulates the foot, ankle, and calf
musculature but terminates distal to the knee (i.e., an ankle-foot
orthosis [AFO]). The AFO would rigidly hold the ankle joint in a fixed
position, eliminating the ability of the tibia to advance over the foot
during the stance phase of walking. Limiting ankle dorsiflexion in this
way encourages the knee to remain extended during walking and
standing without having an orthosis that physically surrounds the
knee.

TABLE 18.2

Control Options for Modification of Joint Motion by an Orthosis

Terminology Description
Free Permit unencumbered motion in a plane or direction (e.g., free motion about the
knee would allow flexion and extension of the knee through the full arc of motion).
Stop To limit motion in a particular direction or plane (e.g., a plantar flexion stop
mechanically blocks plantar flexion of the ankle but does not impede dorsiflexion).
Hold To limit motion of a joint in both directions of a single plane of motion (e.g., a rigid
orthosis preventing any motion at the ankle joint would be considered a hold).
Hold- To limit motion of a joint in both directions of a single plane of motion without the
variable joint being fixed (e.g., an orthosis made from a thin strut of flexible plastic posterior
to the ankle can limit both plantar flexion and dorsiflexion without completely
blocking all movement).
Assist To encourage or facilitate motion in a specific direction for a plane of motion. Note
assisting a motion will resist the opposing motion (e.g., a dorsiflexion-assist joint
assists dorsiflexion movement while resisting plantar flexion movement).
 A helpful tool in the orthotic clinical decision-making process is the
technical analysis form (TAF). 26 The TAF allows orthotists to identify
specific motion constraints to impart at each joint and in each plane.
Classifications for joint motion constraints are shown in Table 18.2.
Among other decisions the orthotist decides whether to provide a
prefabricated or custom-fabricated orthosis. Prefabricated devices are
also referred to as custom-fit because they still require a skilled
orthotist to adjust and modify the device to ensure that it achieves the
desired intervention goals. Custom-fit orthoses are beneficial in that
they are potentially less costly than a custom-fabricated device, and
they allow for immediate fitting so long as the desired orthosis is in
inventory. The dilemma with custom-fit orthoses is that they are
designed for a broad range of individuals and typically available in
limited sizes that may not match the anatomy of the particular client.
The severity of the pathology being treated may necessitate the use of
a custom orthosis. For example, triplanar deformities often require a
custom intervention because the affected segments lack the normal
anatomical shape/alignment required to fit a prefabricated
intervention. Custom-fabricated orthoses require additional time and
skill, but they offer an intervention that is customized, allowing the
orthotist to choose the most optimal combination of materials and
components to address a particular client’s needs. The criteria that is
most important to the selection of a custom-fit versus a custom-
fabricated intervention is the anatomical shape of the limb segments
and the number of planes of motion.

Orthotic Components
Once the orthotist selects the motion controls to be incorporated into
an orthosis, appropriate orthotic components are selected. Four
categories of components are interface components, articulating
components, structural components, and cosmetic components (ISO
13404:2005). 4

• Interface components: Interface components are defined by

ISO as those components that are in direct contact with the
 orthosis user, are responsible for transmitting the forces
required for function, and help hold the orthosis in place on
the body. Examples include shells, pads, straps and, when
used with an orthosis that encompass the feet, shoes.
• Articulating components: Articulating components are defined
by ISO as components used to allow or control the motion of
anatomical joints. Articulating components are further defined
by the joint that they are intended to control, the permissible
motion of the joint in the final orthosis, the form of
articulation (i.e., either by motion between parts, as in a hinge,
or deformation of a part of the joint). These components
control the axis of rotation (i.e., monocentric or polycentric)
and the type of motion control, which is described in Table
18.2.
• Structural components: As defined by ISO, structural
components are those that connect the interface and
articulating components, acting to maintain the alignment of
the orthosis (e.g., metal uprights and plastic shells).
• Cosmetic components: Cosmetic components are the means of
providing shape, color, and texture to orthoses. Examples may
include fillers, covers, sleeves, and patterns or pictures
embedded into plastic shells.

When selecting orthotic components, the orthotist considers the

client’s height, weight, and activity level to ensure that the
components are robust enough to function optimally and be durable
without being excessively heavy or bulky. Articulating components
are available in a variety of configurations and can influence joint
motion in many ways. The simplest configuration is a single-axis joint
that features a locking mechanism to create a hold in a specific plane.
Orthoses may also feature relatively dynamic joints designed to
impose an external torque across a joint. For example, a client who
presents with a knee flexion contracture of 20 degrees may benefit
from low-load, long-duration stretching if the interdisciplinary team
feels that they have the potential to improve muscle length and range
of motion. The orthotist may fit a device that uses a spring-loaded
articulation to apply an external extension torque at the knee, with the
ultimate goal of increasing knee range of motion over time. This
dynamic joint enables clients to continue to gain the benefits of
stretching, while being able to remove the orthosis for skin hygiene
and comfort in contrast to serial casts that must remain in place 24
hours per day.
Regardless of joint design, alignment of anatomical and mechanical
joint axes is important. If the axes do not coincide, undesirable forces
(both shear and compressive) and moments (i.e., torques) are
generated as joints move through their range. 8 Appropriate
alignment of joint axes has consequences not only for the soft tissue at
the interface, but also the integrity of the joint. However, there are
occasions for which joints are intentionally misaligned to create a
desired outcome. For example, a posterior offset knee joint used in a
KAFO places the mechanical knee axis posterior to the client’s
anatomical knee axis in the sagittal plane but parallel in all other
planes. The objective of this alignment is to position the client’s
weight line anterior to the mechanical joint, thus creating an external
extension moment (or torque) across the knee during stance phase.
This facilitates knee stability without having to lock the mechanical
knee joint entirely.

Materials Science
Once the orthotist chooses the specific components to be included in
the orthosis, selection of the appropriate materials to create the
structural components of the device occurs. Orthotists fabricate the
vast majority of orthoses from thermoplastics, thermosets,
metals/alloys, and foam interface materials. Within the realm of LE
orthotics, metal or alloy systems were prominent until the 1970s when
high-temperature thermoplastic materials and vacuum-forming
techniques were introduced into clinical practice. Although metal
orthoses are still used (often by long-time users), thermoplastic
systems have become the standard so long as there are no
contraindications to their use, such as an allergy to the thermoplastic,
heat sensitivity from total contact, or uncontrolled fluctuating edema.
High-temperature thermoplastics are typically used in the
fabrication of LE orthoses, because they have greater strength and
fatigue resistance when compared with the low-temperature
thermoplastic materials typically used in the fabrication of upper
extremity orthoses. High-temperature thermoplastic materials become
malleable at temperatures above 80°C (180°F) and must therefore be
shaped over a heat-resistant model of the client’s limb. Thermoplastic
materials are relatively inexpensive and available in a wide variety of
strengths and thicknesses. They are popular because they can be
heated multiple times and remolded, allowing for alterations to the
contours of an orthosis to accommodate any changes in limb shape
and volume. The most common high-temperature thermoplastic
materials used in LE orthoses are polypropylene, copolymer, and
polyethylene. Polypropylene is a strong but notch-sensitive plastic
that is typically used where rigidity is required, especially in clients
who have higher weight or activity levels. Copolymer is also a
relatively strong thermoplastic material but typically lacks the rigidity
of polypropylene of the same thickness, often being used in instances
where some flexibility is desired. Polyethylene is a flexible plastic that
is well suited to applications where weight is not necessarily borne
through the material. Polypropylene and copolymer offer adequate
tensile and bending strength for LE applications in pediatric and adult
clients so long as the resultant orthosis is fabricated with appropriate
thickness.
Thermoset materials used in LE orthoses generally consist of fiber-
reinforced, laminated resins with layers of natural or synthetic fibers.
Thermosets are composed of three principal materials: resin, matrix,
and promoter. The resin is in a liquid form until it is combined with a
promoter. The promoter converts the liquid into a solid material.
While in its liquid state, the resin is poured over the matrix and is
allowed to set or cure until the material hardens. To manufacture a
laminated orthosis, the orthotist relies on a positive model of the
client’s limb due to the exothermic reaction that occurs during curing.
The material properties of the finished orthosis are more reliant on the
type and orientation of the matrix materials than the chosen resin or
hardener, which serves to bind the layers of matrix together. Common
resins used in orthotic practice include polyester, acrylic, and epoxy,
whereas common matrices include nylon, carbon, and glass fiber.
Adding fibers and orienting them in an optimal manner increases the
maximum strength and stiffness of the thermoset. Thermosets have
the potential to provide relatively lightweight and stronger orthoses in
contrast to thermoplastics but are potentially more costly. Once cured,
thermosets cannot be reheated or reformed, although they can be
sanded and trimmed; therefore they are best used with clients who are
stable with regard to fluid volume.
Where durability is critical, orthoses can be fabricated primarily
from metal and alloys. Metals and alloys are also used in
thermoplastic or thermoset orthoses as many orthotic joints, rivets,
screws, and chafes are manufactured from alloys. The most common
metals/alloys used in the manufacture of LE orthoses are aluminum,
stainless steel, and titanium. All of these materials can be treated and
manufactured to create different properties. Aluminum and stainless
steel are used more commonly in clinical practice as they are easier to
work with from a fabrication standpoint and less expensive than
titanium alloy.
Interface materials are the final consideration in the manufacture of
orthoses. Orthotists use a wide array of natural and synthetic
materials to create an interface between the client and the orthosis.
The simplest interface is the application of a sock; a cotton or wool
sock allows the skin to breathe while wicking sweat and oils from the
LE. Interface components may also be lined with materials designed
to increase wearing comfort. Nylon, Neoprene, and thermoplastic
foams can be attached to the inner surface of the interface component
during the manufacturing process or as needed at follow-up
assessments. For example, clients with peripheral neuropathy are at
high risk of ulceration on the plantar surface of their feet. The orthotist
may elect to line the plantar interface component of an orthosis with a
foam such as Plastazote, which is similar in durometer to soft tissue.
With pressure, this material yields over areas of bony prominence and
helps redistribute pressure over the plantar surface of the foot.

Gait Biomechanics

Observational gait analysis

As already mentioned, prescription criteria for LE orthoses are based
on a thorough assessment of the client, including evaluation of gait
where appropriate. Ideally, observational gait analysis (OGA) is
performed with the client wearing minimal and/or snug-fitting
clothing. This allows the observer to relate the function of the lower
limbs to the stability of the upper torso. Walking is observed with the
client barefoot and then while wearing any existing orthoses or
ambulation aids. Observation of gait is facilitated by use of video
recordings that can be replayed and/or played in slow motion.

Normal gait
Normal gait is characterized by smooth, rhythmic patterns of motion
that require relatively little effort. Normal gait is often described in
terms of a gait cycle, which is defined as initial contact of one foot to
the next initial contact of the same foot (Fig. 18.3). The gait cycle is
partitioned into stance and swing phases, with stance phase including
periods of double- and single-limb support. Stance phase is further
divided into more specific functional subphases: loading response,
midstance, terminal stance, and preswing; whereas swing phase can
be divided into initial swing, midswing, and terminal swing. 38 Gard
and Fatone 12 described the following important functions associated
with normal walking: gait initiation and termination, balance and
upright posture, stability of the stance leg, execution of the stepping
motion, forward progression, shock absorption, and energy
conservation. These functions are further detailed later.
 FIG. 18.3 The normal gait cycle consists of swing and stance phases
with periods of double- and single-limb support. Swing and stance
phases are further subdivided into seven functional subphases.

Two-thirds of the body mass is carried above the hips when

standing. Being top-heavy in this way challenges stability with active
intervention required to maintain balance of the head, arms, and
trunk over the legs and pelvis. Abdominal and pelvic muscular effort
is reduced by holding the trunk vertical and positioned over the legs.
During standing, static balance is achieved by positioning the body’s
center of gravity (weight line) within the base of support created by
the perimeter of the feet. If the center of gravity moves outside the
base of support, the person falls over. However, during walking the
center of gravity does not need to be positioned directly over the base
of support. The person walking maintains a dynamic equilibrium in
which the motion of the body mass plays a role in maintaining an
upright posture and balanced state. The dynamics associated with
forward momentum of an able-bodied person enable body
configurations to be assumed during gait for which static balance
would not be possible.
Walking requires that a person successfully accelerate the body
forward from a standing position and stop walking while maintaining
an upright, balanced state. 12 In able-bodied people, steady-state
walking speed is achieved within two to three steps. During standing
and walking, the stance leg must have the ability to support the
weight of the body, especially during single support, when the body
progresses forward over the supporting leg while the contralateral leg
is swinging forward. This requires a combination of adequate
muscular strength and appropriate leg positioning. During walking
the body appears to increase stability of the lower limb joints through
careful control of the ground reaction force (GRF) vector, reducing
joint moments (i.e., torques) and muscle forces. The GRF is the
reaction to the force exerted by the body on the ground.
Weight transfer onto the leading leg during gait is rapid and fairly
abrupt. Weight transfer creates the challenge of accepting fast-moving
body weight in a manner that both absorbs the shock of floor contact
and creates a stable limb over which the body can advance. 38 Normal
ambulation is characterized by knee flexion during loading response,
which serves to provide shock absorption by decreasing leg stiffness.
13
Normal walking requires the ability to advance the leg from behind
to in front of the body so as to execute the stepping motion in a
smooth, efficient manner that does not disrupt forward progression.
To accomplish this objective the leg must be sufficiently shortened so
that it does not contact the ground during swing, and it must then be
rapidly lengthened as it moves in front of the body in preparation for
initial contact and stance phase.
Able-bodied walking is characterized by symmetry with the stance
and swing phases of one leg nearly equal in duration to those of the
other, providing an even, rhythmic pattern. Stance phase duration
during freely selected able-bodied gait is approximately 62% of the
gait cycle, with swing phase constituting approximately 38% and
double-support phases lasting approximately 12%. Phase durations
are modified with faster or slower walking speeds. 31 The stepping
rate (i.e., cadence) is influenced significantly by the swing leg: walking
speed is difficult to change without the ability to control swing phase
duration.
Able-bodied adults generally adopt a freely selected walking speed
of approximately 1.3 to 1.4 m/s and are able to comfortably walk
across a range of speeds from approximately 0.8 to 1.8 m/s. 24 Walking
speed is determined by both step length and step rate. As the limb
prepares for initial contact, the swing leg hip is flexed and the knee
extended so as to move the foot to a position in front of the body,
allowing for an adequate step length. Inability to flex the hip or extend
the knee sufficiently results in short step lengths and slows forward
progression. Faster walking speeds tend to be accompanied by greater
pelvic rotation, 35 which serves to further increase step length. Rate of
stepping relies on the ability to transfer body weight to the leading leg
and swing the trailing leg forward without hindering forward
progression.
Knee flexion is the primary mechanism by which the leg is
effectively shortened for swing phase ground clearance of the foot.
Knee flexion during swing phase converts the leg into a double (i.e.,
compound) pendulum, enabling the leg to swing forward with less
effort and energy. Effort required to rotate the leg is reduced by knee
flexion as it brings the foot and shank masses closer to the hip joint’s
axis of rotation. This also enables the leg to swing forward in shorter
time than if the leg were fully extended. 23
Able-bodied people use mechanisms to conserve mechanical energy
and preserve forward momentum of the body, enabling forward
progression with only relatively small additions of metabolic energy
from step to step. Perry and Burnfield 38 suggested that three rocker
mechanisms (heel, ankle, and forefoot) serve to facilitate forward
progression, whereas Gard and Childress 11 proposed that these three
rocker mechanisms can be integrated during walking to create a
single, smooth “roll-over shape.” Regardless of how it is defined, an
altered foot rocker mechanism disrupts forward momentum of the
body and decreases walking speed. 9
During double support, body weight is rapidly transferred to the
leading leg so that the trailing leg can be lifted and advanced in front
of the body. Weight transfer must occur quickly and efficiently so that
the knee of the trailing leg can begin flexing in preparation for swing
phase and the leg can begin accelerating forward. Knee flexion and
ankle plantar flexion in the trailing leg during double-support phase
serve to lengthen the leg. This allows the trailing leg to maintain
contact with the ground and provide stability while facilitating
transfer of load to the leading leg. Serving as a mobile link between
the two legs, the pelvis facilitates smooth transmission of body weight
from one leg to the other and provides shock absorption. 10 Rapid
flexion of the hip in late stance accelerates the leg forward, and further
knee flexion occurs passively. Inhibition of knee flexion at the end of
stance phase or delay in knee flexion initiation reduces acceleration of
the trailing leg, prolonging double-support phase and slowing
forward progression of the body.
Cushioning of impact forces generated during normal walking are
achieved through the physical properties of biological tissues,
footwear, and walking surfaces 20 and through actions of the lower
limb and pelvis, such as stance phase knee flexion and coronal plane
pelvic motion (i.e., pelvic obliquity). 10,13,38,43 The motions that occur
during loading response provide shock absorption. At initial contact,
ankle plantar flexion and knee flexion serve to lessen the impact of
floor contact. 32,37,41 Increasing knee flexion in early stance decreases
the stiffness of the leg and diminishes transmission of mechanical
shock to the head. 15,20,27
Able-bodied walking is characterized by remarkable efficiency,
which seems to be accomplished by two primary means: managing
the GRFs in such a manner that the internal muscle moments (i.e.,
torques) about joints are reduced and by conserving mechanical
energy associated with moving the segment masses of the body. Able-
bodied people are able to capitalize on these energy-conserving
mechanisms, reducing the amount of metabolic energy that must be
added from step to step. Recordings of muscle activity during walking
show that for much of stance phase muscles are largely silent,
indicating that little effort is required to maintain stability and
advance the body forward. 38 Muscles appear to be used primarily to
accelerate and decelerate the head, arms, trunk, and lower limb
segments, with significant reliance on momentum of the body masses
that enable muscles to be turned off in midstance and midswing.
Perry and Burnfield 38 suggested that sufficient gait velocity is
required to preserve the advantages of momentum and reduce
demand on muscles.
Pathological gait
A pathological gait pattern often develops secondary to
neuromuscular deficits, joint instabilities, pain, disease processes,
congenital impairments, and many other conditions. Excessive or
insufficient joint motion can lead to exaggerated, inhibited, or
compensatory movements of the body throughout the gait cycle. 38 As
a result, the normal walking speed of the individual is often
diminished. Clinical training in OGA ensures the identification of all
pathological gait deviations in need of LE orthotic intervention. Gait
deviations are considered as either primary and directly caused by the
pathology, or secondary compensatory maneuvers. When a primary
deviation is identified, the observer looks for secondary gait
deviations. Where a secondary gait deviation is observed, the observer
looks elsewhere for the primary problem. It is important to realize that
correction of the primary deviation will resolve the secondary
deviation, but not vice versa. Deviations can occur in combination
with each other (e.g., stiff knee gait coupled with hip hiking), and the
magnitude of deviations in any individual subject may vary with
severity of the pathology. Commonly observed primary gait
deviations include footdrop, tone-induced equinovarus, knee
hyperextension, knee instability, genu varum, genu valgum, and stiff
knee gait. Commonly observed secondary or compensatory gait
deviations include increased step width, vaulting, steppage gait,
circumduction, hip hiking, and lateral, anterior, and posterior trunk
lean. These gait deviations are described in more detail in the
following sections.

Primary deviations
Primary gait deviations may be due to the impairment or may also be
caused by orthotic interventions acting appropriately or
inappropriately (e.g., due to worn-out orthotic components).
Examples of primary gait deviations include footdrop (insufficient
dorsiflexion during swing as a result of dorsiflexor muscle weakness)
and tone-induced equinovarus (excessive plantar flexion during
swing as a result of calf muscle spasticity or hypertonicity). A worn
out plantar flexion stop or dorsiflexion assist spring on an AFO can
also create problems with the ankle alignment needed for swing phase
ground clearance of the limb. When dorsiflexion of the ankle is
compromised in any of these ways, not only will the toes drag on the
ground during swing phase, but initial contact with the ground
during loading response will occur with the toes or forefoot rather
than the heel. In response to these problems, clients will, if possible,
adopt secondary gait deviations that provide ground clearance of the
plantar flexed foot during swing phase, such as exaggerated hip and
knee flexion (i.e., steppage gait) or hip circumduction. However,
without the assistance of a LE orthosis, it is very difficult to
compensate for the inappropriate initial contact. Disruption of the heel
rocker in this manner compromises forward progression and slows
walking. 34

Secondary deviations
Secondary (compensatory) gait deviations are a functional response to
an impairment or orthotic intervention that disrupts the ability to
walk. However, although secondary deviations facilitate walking,
they can often be in and of themselves inefficient and energy
expensive. Examples of common secondary gait deviations include
vaulting, circumduction, and hip hiking. Each of these deviations
compensate for a limb that is functionally too long during swing
phase or cannot be shortened at the appropriate time (e.g., where knee
motion is reduced due to a locked KO or hypertonicity/spasticity of
the knee extensors; where there is a limb length discrepancy; where
the dorsiflexor muscles are weak and the toe drags during swing).
Vaulting involves exaggerated plantar flexion of the contralateral
(uninvolved) ankle during midstance. By rising up on the stance limb,
extra ground clearance is created for the swing limb in which hip and
knee flexion or ankle dorsiflexion are compromised. When
circumducting, the impaired limb follows a laterally curved path
during swing rather than swinging straight forward; less knee flexion
is therefore needed for the foot to clear the ground during swing. Hip
hiking involves elevation of the pelvis (and consequently the hip) on
the impaired side in the coronal plane during swing. Hip hiking raises
the leg more than it otherwise would be raised. Although these
deviations help ensure that the swing limb clears the ground during
swing phase, they require larger displacement of segment masses,
which increases muscular effort and energy expenditure and
diminishes conservation of mechanical energies.
These energetic issues are even worse when trunk deviations (such
as lateral, anterior, or posterior trunk lean) are used to compensate for
lower limb impairments, such as weak hip abductors, weak knee
flexors, and weak hip extensors, respectively. Weakness of these
muscles compromises stance phase stability at the respective joint.
Shifting the trunk center of mass during stance on the
impaired/weakened limb reduces the moments (or torques) that the
weakened muscles must counteract to maintain upright stability.
Moving the trunk laterally over the stance limb reduces the internal
hip abductor moment needed from the muscle to maintain a level
pelvis during single-limb stance. Similarly, moving the trunk
anteriorly over the stance limb increases the external knee extensor
moment acting to stabilize the knee during single-limb stance.
Some pathological motions are more difficult to compensate for in a
functional manner. Knee hyperextension is such a condition (Fig.
18.4). This occurs as the knee moves in a backward direction during
midstance (i.e., opposite to the direction of walking), often secondary
to weakness of the quadriceps and/or calf muscle groups. Without
hyperextension the person experiences uncontrolled knee flexion and
collapse. Unfortunately, ongoing knee hyperextension results in
increasing knee deformity and pain and disrupting the efficiency of
gait because the LE is forced backward as the body mass is attempting
to move forward over the stance limb.
Foot Orthoses
General Description
The most common LE orthoses are foot orthoses (FOs), not only
because they form the basis of many of the more proximal LE
orthoses, but also because they are prescribed for an extremely broad
range of pathologies from mild to severe. FOs are those devices that
encompass all or part of the foot but terminate distal to the ankle joint.
4 A variety of FO designs are shown in Fig. 18.5. They may extend the

length of the foot or terminate at the toe sulcus or proximal to the

metatarsal heads. FOs benefit the foot primarily in stance and are held
in position against the foot by shoes. 30 FOs may be used to treat foot
instability or deformity caused by muscle weakness and/or imbalance,
structural malalignment, and loss of structural integrity due to
ligamentous laxity or rupture. FOs may also address more proximal
disorders because the foot is the base of support for the entire body
during standing and walking. Alignment of the foot can affect plantar
pressure distribution, center of pressure progression, and moments
occurring at proximal joints by altering the orientation of the GRF
vector with respect to joint axes.
Shoes are an integral part of LE orthosis function because they form
the base upon which almost all LE orthoses must work. Footwear
must be spacious enough to accommodate the orthosis (e.g., they may
be a half-size larger or have removable inserts). To appropriately
support the orthosis, it is helpful for the shoe to be of stable
construction, including a heel counter and a nonskid sole. For
dysvascular feet at high risk of pressure ulcers, shoes should be made
of soft materials, constructed without seams and provide extra depth
to ensure the toe box does not place pressure on the dorsum of the
foot. Velcro closures with longer openings can facilitate donning.
 FIG. 18.4 Knee hyperextension (genu recurvatum) is a progressive
stance phase deformity. The knee moves posteriorly upon weight
bearing, serving to disrupt forward momentum and functionally
shortening the limb during loading response.

Most FOs are biplanar by design, addressing joint deviations and

providing support in the sagittal (e.g., midfoot depression) and
coronal planes (e.g., hindfoot varus or valgus). More involved FO
designs, such as the University of California Biomechanics Laboratory
(UCBL), offer triplanar support with added control for transverse
plane deviations (e.g., forefoot abduction or adduction).
Michael 29 identified three broad categories of FOs: accommodative
or soft FOs, intermediate or semirigid FOs, and corrective or rigid FOs
(see Fig. 18.5). Soft FOs are made from soft or flexible materials, such
as closed and open cell foams. Soft FOs accommodate and protect
rigidly deformed or dysvascular feet. These orthoses attempt to
increase the weight-bearing surface area, redistribute the plantar
pressures, and decrease the forces applied to the tissues at risk for
ulceration and breakdown. Semirigid FOs are made by layering
different density foam materials. The composition of the layers
dictates the degree of support and biomechanical control. Semirigid
FOs include many prefabricated, commercially available FOs.
Accommodative and semirigid devices are fabricated by molding
foam directly to the plantar surface of the foot or by using crush boxes
(blocks of foam whereby an impression of the foot is made by
crushing the foam beneath the foot and subsequently filling the
indentation with plaster to create a positive model of the foot used to
vacuum-form the FO). Rigid FOs correct flexible deformities,
especially those that include hind-foot varus or valgus. The orthosis
must be rigid to contour to the calcaneus (heel) and provide control of
hind-foot alignment and motion, especially during weight-bearing
activities. Rigid orthoses are generally made from high-temperature
thermoplastic materials and require a heat-resistant positive model of
the foot.

Clinical Considerations for the Occupational

Therapist
When wearing FOs it is recommended that OTs educate clients with
insensate feet about visual skin inspection. Education is important to
ensure skin integrity and prevent skin breakdown. Handheld skin
inspection mirrors are indicated for clients with reduced LE range of
motion to ensure comprehensive inspection of the plantar surface of
the foot. Checking the skin’s color and temperature is essential for
clients with major vascular issues and neuropathy. The OT plays an
important role in educating the client in regular skin inspection and
implications to overall health. Communicating any concerns to the
interdisciplinary team is helpful to developing a long-term care plan
and to voice concerns to family members or caretakers.
FIG. 18.5 Common foot orthosis (FO) designs. A, Accommodative or
soft FO. B, Intermediate or semirigid FO. C, Corrective or rigid triplanar
FO.
Courtesy University of California Biomechanics Laboratory.
Ankle-Foot Orthoses
General Description
AFOs are devices that encompass the ankle and the whole or part of
the foot (Fig. 18.6). 4 AFOs primarily provide ankle motion control in
the presence of various foot and ankle pathologies. AFOs may also
provide some control of subtalar motion. Some AFOs and SMOs have
trimlines that terminate immediately proximal to the ankle. The more
common AFO design includes a proximal trimline that terminates 20
mm distal to the neck of fibula. The trimline provides the longest
possible lever arm for ankle motion control, particularly with
spasticity of the calf muscle. Depending on the lever arm, an AFO not
only controls the ankle directly but also influences the knee (and
perhaps the hip) indirectly by altering the moments acting about it. 4
AFOs are usually prescribed for clients who have muscle weakness
controlling ankle-foot position, who have muscle hypertonicity or
spasticity, or who have conditions resulting in pain or instability due
to a loss of integrity of the structures of the lower leg, ankle, and foot.
AFOs may be made of metal, plastic, or a hybrid of metal and
plastic. In most AFO designs, an anterior opening allows for donning
and doffing. The anterior closure (calf strap) secures the orthosis to
the limb. The closure mechanism varies depending on the manual
dexterity of the client. Most AFO designs incorporate a foot plate to
control the foot and ankle, an articulated or nonarticulated ankle
(depending on the desired motion control), and a calf section to
provide mechanical leverage for ankle and knee control. Metal AFO
designs are attached externally to a shoe or incorporated into a foot
plate that fits within the shoe. Thermoplastic material and thermoset
AFO designs use a molded foot plate to improve midtarsal and
subtalar joint control. This AFO improves aesthetics and allows
different shoes to be worn. A common heel height when changing
shoes is needed to maintain the desired ankle-foot and tibia-to-vertical
alignment. In a thermoplastic AFO the degree of ankle motion control
is determined by material selection, trimline placement around the
ankle, conformity, and articulation configuration. The function
imparted by an AFO relies largely on the degree of resistance
provided to rotation about the ankle. 42 One function common to
many AFOs is the support of the foot at an appropriate angle for
clearance of the ground during swing. Clearance is usually
accomplished by limiting plantar flexion range.
AFOs are either articulated or nonarticulated. Nonarticulated AFOs
are used to rigidly encase the ankle joint (usually leaving only an
anterior opening for donning and doffing), limiting ankle motion in
the coronal and sagittal planes. Nonarticulated AFOs are used when
the ankle requires complete immobilization to reduce pain and/or
ensure stability. However, a posterior leaf spring AFO is an example
of a nonarticulated AFO that permits dorsiflexion motion but
provides resistance to plantar flexion. By virtue of its trimlines around
the ankle joint, the posterior leaf spring orthosis is more flexible in one
direction than the other, permitting dorsiflexion through bending of
the plastic. Articulated AFOs allow ankle motion in the desired plane
and direction by incorporating orthotic ankle joints and motion
control devices (mechanical stops). Orthotic ankle joint components
are configured to provide motion within a specific range, limit motion
in a particular direction (e.g., a plantar flexion stop), and/or assist
motion in a particular direction (e.g., dorsiflexion assist joints) (see
Table 18.2).
An AFO is designated as a floor-reaction AFO if it is designed
specifically to act indirectly at the knee. Manipulating ankle-foot
alignment alters moments at the knee. Any AFO that affects ankle-foot
alignment has an indirect effect at the more proximal joints. Creating
an external knee extension moment during stance provides knee
stability when it is absent or compromised. This moment is achieved
with or without articulation at the ankle joint. An external knee
extension moment is created during the stance phase by either a rigid
AFO set in slight plantar flexion or an articulated AFO with a
dorsiflexion stop.
Clinical Considerations for the Occupational
Therapist
Similar issues apply for AFOs as for FOs with people who have
insensate feet. The need for education regarding visual skin inspection
exists. AFOs may be needed when the client is in a critical recovery or
rehabilitation period, as in the case of cerebrovascular accident (CVA).
OTs assist in making this process acceptable to the client by educating
them on what to expect from the AFO. Educating clients on how the
orthosis works, what muscles it may be assisting, and why it has to be
constructed, is vital to acceptance of the orthosis, orthotic use, and
recovery. Certain AFO design options positively or negatively
influence occupational performance tasks. For example, a rigid ankle
design provides appropriate biomechanical alignment and joint
correction. The rigid design completely restricts ankle range of
motion. The ankle movement restriction results in difficulty with
activities, such as operating an automobile gas pedal, kneeling,
bending at the waist, using stairs, or rising from a chair. Helping
clients learn adaptive techniques to perform such activities while
wearing the orthosis is important.
 FIG. 18.6 Various ankle-foot orthosis (AFO) designs. A,
Supramalleolar orthosis (SMO). B, Articulated AFO with posterior
plantar flexion stop and full-length foot plate. C, Posterior leaf spring
AFO. D, Double-upright design with medial T-strap and dorsiflexion-
assist ankle joints. E, Solid ankle AFO with instep strap.
Knee Orthoses
General Description
KOs are generally prefabricated or custom fit to encompass the knee,
and they act in the coronal and sagittal planes (Fig. 18.7). As classified
by the American Academy of Orthopaedic Surgeons (AAOS), the KO
function falls into three categories: prophylactic, rehabilitative, and
functional. 46 Prophylactic KOs prevent or reduce the severity of
injury for otherwise healthy able-bodied persons involved in high-
impact or contact sports. In these circumstances, KOs act
kinesthetically to remind the wearer of a recent injury. Rehabilitative
KOs are prescribed after a surgical procedure to limit knee range of
motion while soft-tissue structures (e.g., reconstructed ligaments)
heal. Functional KOs provide ongoing mechanical stability to the
chronically unstable or reconstructed knee joint or alter knee moments
and unload knee joint compartments affected by osteoarthritis.
Fit, joint alignment, and suspension are critical factors in the
effectiveness of KOs. Given the cylindrical shape of the limb,
mitigating distal migration of the orthosis can be challenging. If the
orthosis is not maintained in proper position, joint alignment is
sacrificed. Often a discrepancy is created between the anatomical and
mechanical joint axes. Single-axis and polycentric joint designs refer to
the pivoting motion of mechanical knee joints. A single-axis joint
functions as a single hinged action. Polycentric joints produce a
shifting axis to mimic the functional motion of the anatomical knee.
Size, weight, function, and durability are important factors in
selection. Specially designed straps, supracondylar pads, or inner
sleeves prevent distal slipping of the orthosis during ADLs. The client
must properly don and do periodic checks of the alignment of the
orthosis throughout the day.
 FIG. 18.7 Various knee orthosis (KO) designs. A, Soft Neoprene knee
sleeve. B, Postoperative KO controls flexion and extension range of
motion with adjustable joints. C, Prophylactic KO with lateral joint. D,
Rehabilitative design to control knee hyperextension. E, Custom KO to
stabilize injured knee.

Clinical Considerations for the Occupational

Therapist
People receiving functional KOs to prevent further osteoarthritic knee
deformity may also experience upper extremity degenerative changes
that limit hand function. Although most KO designs use Velcro
closure systems, deciding between medial and lateral placement of
closures is critical to enhancing available functional dexterity.
Closures that include a wider chafe opening allow the client with
impaired hand function to feed Velcro straps through the opening
with less difficulty.
Wherever possible, KOs are generally designed to provide total
contact and are worn directly against the skin. Donning/doffing
procedures are reviewed with the client to ensure that an effective
dressing routine is established. For older adult clients the sequencing
of how to cinch straps is important to prevent migration of the
orthosis and skin breakdown.
Knee-Ankle-Foot Orthoses
General Description
KAFOs encompass the knee, ankle, and whole or part of the foot. 4
KAFOs include an AFO component and therefore incorporate some of
the same concepts described previously. Compared to AFOs, KAFOs
extend proximally, bridging the knee and containing the thigh tissues.
KAFOs allow for coronal and sagittal plane control of the knee.
Transverse plane control is determined distally by the AFO foot plate
design. Skeletal knee alignment is achieved by applying corrective
forces through the soft-tissue structures of the thigh. Therefore a well-
molded and fitted thigh shell is an important component of the
orthotic design. Excessive gapping reduces the mechanical effect of
the design and reduces potential stability and function. Most KAFOs
are custom made from measurements or casts and are fabricated from
metal and leather, thermoplastic, laminates, or combinations of these
materials. Material selection is generally based on height, weight,
activity level, and functional requirements (Fig. 18.8).
The most proximal component of the KAFO is the thigh section.
Posterior shells with anterior straps, anterior shells with posterior
straps, and full circumferential shells are common thigh designs.
Thigh shells are fabricated of rigid or flexible material. The thigh shell
may be designed to “unweight” or “unload” the lower limb by
providing a shelf for the ischium to sit on in combination with soft-
tissue containment of the thigh tissues (see Fig. 18.8B). The principal
impairments addressed by KAFOs are weakness of the muscles
controlling the knee (and perhaps the hip and ankle), upper motor
neuron lesions resulting in LE hypertonicity (spasticity), or loss of
structural integrity of the hip or knee. KAFOs improve stability and
functional mobility for clients with significant genu valgum, genu
varum, genu recurvatum, or knee flexion instability. 7
Similar to KOs, orthotic knee joints may be single axis or
polycentric. There are four basic knee control options available in
KAFOs (Fig. 18.9):

1. Free motion joints

2. Posterior offset joints (see Fig. 18.9A)
3. Joints with a manual lock (see Fig. 18.9B–D)
4. Stance control joints

Free motion joints provide support in the coronal plane while

allowing sagittal plane motion. A mechanical block limits movement
of the knee into an abnormal extension range. A locked knee KAFO
provides support in the sagittal and coronal planes. The lock may be
manually disengaged for sitting. Common locking mechanisms
include the drop lock and bail or lever lock designs. 5 Drop locks are
designed to fall into place over the mechanical hinge when the client
stands. These locks must be manually lifted before engaging in any
activity that requires knee flexion (e.g., sitting). Bail or lever locks are
designed to snap into place, locking the knee once it is extended. The
joints must be unlocked before sitting and can sometimes be
disengaged by bumping the posterior lever mechanism on the seat of
a chair. Although a locked KAFO is able to reliably provide stability in
stance, it does not allow for flexion of the knee in swing, resulting in a
functionally longer limb. The longer limb leads to secondary gait
maneuvers, such as vaulting, hip hiking, and circumduction, to ensure
clearance of the ground by the foot during swing phase. 21,47 Walking
with a locked knee results in a slower, more asymmetrical gait and
increases the energy expenditure of walking. 16,18,25,39,44
 FIG. 18.8 Various knee-ankle-foot orthosis (KAFO) designs. A,
Thermoplastic KAFO with molded foot plate, articulated ankle, long
anterior tibial shell, drop locks, and circumferential thigh shell. B,
Thermoplastic KAFO with molded foot plate, solid ankle, drop locks,
and quadrilateral thigh shell for weight support. C, Double-upright
KAFO attached to shoe with articulated ankle, posterior calf band, bail
lock knee, and two posterior thigh bands.

Posterior offset knee joints allow swing phase knee flexion and rely
on geometric alignment to ensure stability of the knee in stance. The
posterior offset knee joint assumes that in a normally aligned knee the
vertical GRF vector is oriented through the knee joint during limb
loading. The alignment ensures stability with little muscular effort. By
positioning the mechanical knee joint axis posterior to the anatomical
knee joint axis in the sagittal plane, the vertical GRF vector is
positioned anterior to the mechanical joint during the first part of
stance. This alignment creates an external extensor moment (torque)
and ensures that the mechanical joint is stable during weight bearing.
Consequently, stability of the anatomical knee joint is ensured.
However, stability provided in this manner can be unreliable,
especially over uneven terrain and slopes. Posterior offset knee joints
should be used only when the client has:

• Adequate muscular control around the hip

• Proprioception at the knee
• Good balance

Such criteria ensure stumble recovery if geometric stability of the

knee cannot be achieved.
Stance control knee joints employ various mechanisms to lock the
knee in stance and automatically unlock in swing. Stance control knee
joints include cable control, a position-dependent pendulum, and
microprocessors. 7 Depending on the mechanism, these joints are used
with KOs and KAFOs. Stance control joints allow for a more normal
gait pattern because the knee is not required to be locked during
stance and swing to prevent stance phase knee flexion. Some of these
joints offer a triphasic mode of operation: automatic lock/unlock,
always unlocked, and always locked. Different modes are selected for
different activities (e.g., the automatic mode for walking, unlock for
sitting, and lock for standing or added security when walking over
uneven terrain). The ideal candidate for stance control knee joints
presents with isolated unilateral quadriceps weakness, a relatively
sound contralateral side, minimal contractures, minimal spasticity,
and reasonable hip musculature. 36
Genu recurvatum is a common condition for KAFO application.
Specifically, knee joint laxity allows the anatomical knee center to
move posteriorly during weight bearing. Genu recurvatum is usually
an acquired deformity that develops secondary to weakness of the
quadriceps or posterior calf muscles. The client compensates by
maintaining the knee posteriorly and shifting the body weight
anteriorly through hip flexion and anterior trunk lean. The
compensations effectively place the body weight in front of the knee
joint to prevent collapse and falling. Genu recurvatum may also
develop secondary to a plantar flexion contracture at the ankle pulling
the tibia backward, forcing the knee posteriorly during loading
response and disrupting forward progression during stance. Load-
bearing stresses cause permanent damage to the posterior capsule and
soft-tissue structures. Such deformity continues to progress over time.
The potential for the development of a severe deformity with
permanent damage to the knee necessitates prompt attention.
The objective of a KAFO varies for clients with genu recurvatum
(see Fig. 18.4). In some orthotic designs, complete sagittal plane
correction is the goal as long as there is a mechanical means of
providing stance stability to prevent collapse into knee flexion when
weakness is noted. For other clients, partial correction reduces the
deforming forces to the knee and limits progression of the deformity.

Clinical Considerations for the Occupational

Therapist
Using a KAFO that locks the knee in extension is a significant issue
with regard to occupational performance. Unfortunately, locking of
the knee during walking was once unavoidable for clients who
required knee stability and were at risk of falling because of
quadriceps weakness. To some extent, locked knees are ameliorated
with the availability of stance control orthotic knee joints. However,
some clients still use locked knee KAFOs. Then the OT considers the
manual dexterity required to engage and disengage the locking
mechanism safely. Additionally, a locking knee interferes with
activities, such as rising from a chair, toileting, getting in and out of a
car or confined space, and so on. Helping clients learn adaptive
techniques for how to perform these activities with an immobile knee
plays a major role in the successful occupational performance while
wearing the KAFO. KAFOs in general have a number of straps and
can be awkward to don and doff. This likewise will deserve the
attention of an OT.

FIG. 18.9 Various knee joint locking mechanisms. A, Free posterior

offset. B, Posterior offset with drop locks. C, Bail lock. D, Trigger lock.
HIP Orthoses
General Description
Hip orthoses (HOs) are devices that encompass either unilaterally or
bilaterally the hip(s), consisting of a pelvic section, mechanical hip
joint(s), and thigh cuff(s). Occasionally a shoulder strap is used to
assist with suspension of the orthosis. HOs are primarily prescribed
for problems associated with the femoral head or acetabulum where
there is a need to control range of motion, alignment, and dislocation.
However, the hip is a universal ball-and-socket joint with motion in
all three planes. Although many orthoses control abduction/adduction
and flexion/extension reasonably well, controlling internal/external
rotation is difficult.
HOs are used to treat congenital, dysplastic, traumatic, or
degenerative hip conditions (Fig. 18.10A–C) or after postoperative hip
procedures (see Fig. 18.10D). 14 Pediatric and adult populations
require different orthotic approaches. Pediatric HOs for congenital hip
disorders are typically designed to maintain good joint alignment
during bone growth. Dysplastic joints present with varying degrees of
severity. In the beginning of the disease process, occlusion of blood
supply to the head of the femur promotes necrosis. Although
revascularization eventually occurs, the bony contouring of the
femoral head does not develop normally. Continued weight-bearing
stresses increase deformation of the hip joint and can result in
permanent disability. Maintaining maximum joint congruency and
controlling forces through the hip joints using a variety of HO designs
(see Fig. 18.10) promotes normal development of the head of femur
and acetabulum. As with most HOs, this type of orthotic treatment is
temporary.
HOs for adults usually address the effects of joint deterioration.
Clients with degenerative conditions are usually placed in HOs that
limit range of motion to support and control compromised muscles,
prevent dislocation following primary or revision surgery, and
decrease pain. In adults who have had a hip replacement surgery, the
HO is designed to provide different alignment options as the client
progresses through the rehabilitation process. Usually the hip joint is
aligned to maintain 10 to 20 degrees of abduction and allows 0 to 70
degrees of flexion when there is risk of posterior dislocation following
surgery. 22 When there is risk of anterior dislocation postoperatively,
hip motion is blocked at 40 degrees extension and 70 degrees flexion.
Flexion and extension ranges are limited to prevent dislocation while
allowing the client sufficient motion to sit and walk. Internal and
external rotation control is limited to some degree by “grasping” the
soft tissue of the thigh. Proper fitting, adjustment, and donning of the
orthosis are critical to maximizing function and benefit.
Postoperatively the HO is usually worn at all times for 3 to 6 months
to allow the soft tissue to heal and to serve as a kinesthetic reminder
to maintain proper positioning during ADLs. Although recurrent hip
dislocation after surgical repair is rare, occasionally ongoing external
support may be required for complicated procedures, revisions, or
poor surgical outcomes.
Children with spasticity of the hip muscles may develop hip
instability and pain, requiring surgical release of the hip adductors,
flexors, and internal rotators or more complicated bony osteotomies of
the pelvis or femur. HOs used postoperatively in these cases ensure
that the hips are maintained in an appropriate position for healing
while still allowing some small amount of motion to facilitate
function. Additionally, HOs are usually equipped with two sets of
liners that can be washed daily to eliminate odor and improve
hygiene. When the HO is no longer used 24 hours a day to protect the
surgical correction, it transitions to a functional orthosis during the
day or a positioning orthosis at night.
 FIG. 18.10 Various hip orthosis (HO) designs. A, Pavlik harness used
to manage congenital dysplasia of the hip. B, Ilfeld orthosis used to
manage congenital dysplasia of the hip. C, Bilateral hip abduction
orthoses with pelvic band. D, Postoperative hip abduction orthosis.

Clinical Considerations for the Occupational

Therapist
After total hip surgery and while wearing an HO, both adult and
pediatric clients require training in self-care activities, such as
dressing, bathing, toileting, and hygiene. An OT is essential in
assisting a client to maintain hip precautions while donning the
orthosis. An OT educates the client in the use of adaptive equipment
(e.g., a reacher, sock aid, long-handled bath sponge, long-handled
shoe horn, and raised toilet seat) and may reduce excessive hip
motion during hygiene and self-care.
HIP-Knee-Ankle-Foot Orthoses
General Considerations
Hip-knee-ankle-foot orthoses (HKAFOs) encompass all three major
lower limb joints and build upon the basic concepts already outlined
for KAFOs. HKAFOs provide varying levels of mechanical control
(Fig. 18.11). Most simply, a unilateral KAFO is attached to a pelvic
band with a single-axis joint to control rotational alignment of the
limb during swing (see Fig. 18.11B). This alignment allows proper
positioning of the limb for stance. Bilateral mechanical hip joints and a
pelvic/trunk section are used to provide additional control and
stability for paraplegic standing and ambulation. HKAFOs may be
used for neurological conditions resulting in severe muscle weakness
(see Fig. 18.11A and C). The hip or pelvic section consists of a narrow
band, or it may completely enclose the pelvis and trunk with a spinal
orthosis attached to the LE orthoses. The amount of bracing of the
trunk segment depends on the functional abilities, control, and upper
body strength of the client. Hip and knee joints may be locked in
extension during standing and walking, and the knees usually are
locked.
Standing frames, such as the parapodium and swivel walker, 40 are
bilateral HKAFOs mounted to a base plate. These devices are
designed to provide support for hands-free standing or limited
mobility by swiveling, wherein shifting weight laterally by rocking or
rotating the trunk unweights one limb and causes the orthosis to
swivel forward on the weight-bearing side. Swivel walkers are used
effectively only on smooth, flat surfaces and provide extremely slow
ambulation. Children are prescribed standing frames because
standing is believed to provide a stimulus for normal development of
bones and bowel and bladder function. In adults, standing is believed
to reduce osteoporosis and improve peripheral circulation.
Ambulation with bilateral HKAFOs requires a “swing-through”
gait pattern assisted by a walker or crutches. The HKAFO is used to
lift the whole body from the ground and swing it forward. Variations
in this pattern of ambulation are known as “swing-to” and “drag-to”
gait. HKAFOs are used for daily activities and therapeutic
intervention programs. High energy costs of these type of gaits may
prohibit use of this orthosis for all ADLs, and wheelchair mobility
may be a better option for some clients. 7,45
 FIG. 18.11 Various hip-knee-ankle-foot orthosis (HKAFO) designs. A,
Bilateral thermoplastic HKAFOs. B, Unilateral double-upright HKAFO.
C, Bilateral double-upright HKAFOs. D, Reciprocating gait orthosis
(RGO).

More complex HKAFO designs facilitate a reciprocal gait pattern so

that extension of one limb promotes flexion of the contralateral limb
and vice versa (see Fig. 18.11D). These reciprocating gait orthoses
(RGOs) employ a linkage between the hip joints either by interlinked
cables or a posterior, pivoting metal bar. RGOs are used in pediatric
and adult populations, primarily for clients with flail bilateral lower
limb involvement. Good upper extremity strength and adequate trunk
control are prerequisites for RGOs because the main propulsive forces
for this form of ambulation come from the arms via crutches or similar
assistive devices. Reciprocal gait is more cosmetic and stable than
swing-through gait. However, a greater level of training is required to
ensure effective ambulation, and the complexity of orthotic design
increases the need for maintenance. Although RGOs are used
effectively by children with growth and body mass increases, it
becomes more energy efficient to use a wheelchair than to ambulate
with an RGO. Hence the use of RGOs is lower among adults. 7
HKAFOs are commonly prescribed for clients with spina bifida or
spinal cord injury or for any client presenting with a flail lower limb
and limited hip control. Individual height, weight, strength,
endurance, motivation, physical assistance requirements, donning
abilities, and psychosocial situations are evaluated with regard to the
potential success of the orthotic program. Upright weight bearing is
believed to improve cardiopulmonary function, bowel and bladder
function, circulation, and bone density. 19,28,33 Children benefit from
the social interaction with their peers and can alternate with
wheelchair mobility as needed. Almost all adult clients with traumatic
spinal cord injury retain the desire to walk as a primary goal
throughout their rehabilitation program.

Clinical Considerations for the Occupational

Therapist
HKAFO systems require much higher levels of energy expenditure,
upper extremity strength, and endurance than many clients are able to
maintain on a regular basis. Although it may be apparent to members
of the interdisciplinary rehabilitation team that the client achieves
higher levels of functional independence when using a wheelchair for
mobility, the client may prefer to focus on ambulation as a primary
goal. Adding a pelvic component, hip joint, knee joint, or ankle
control to an orthosis increases the difficulty of dressing and
undressing. Difficulty with dressing tasks is magnified when the
client is at work or school, and it will require loose-fitting clothing and
adaptive strategies for donning and doffing clothing. In addition, the
OT provides consultation for proper seating for toileting, desk work,
and transportation.
Summary
An interdisciplinary approach is important for all aspects of
rehabilitation care, including LE orthotic management. The OT should
confer with the CO in the development of the LE orthotic prescription
to ensure that the orthosis addresses the client’s occupational goals.
Such goals include but are not limited to the ability to don/doff the
orthosis successfully and integrate the LE orthosis into ADLs. LE
orthoses address a large number of issues from pain management to
mobility. Regardless of the goals it is important that the health care
team have a working knowledge of the biomechanical principles
necessary to achieve the intervention goals. LE orthotic management
is unique when compared with the upper extremity in that it often
requires more robust designs and materials due to the magnitude of
the forces associated with weight-bearing activity and ambulation.
Sound understanding of normal gait is important when assessing a
client with mobility deficiencies. Knowing whether a gait deviation is
primary or secondary (compensatory) is important to determine the
ultimate design of the orthotic intervention. Once the specific
biomechanical deficiencies are identified, the practitioner has a wide
variety of orthotic designs available to address the client’s specific
needs from relatively simple FOs to the reciprocating gait orthosis,
which spans all major joints associated with LE function.

Review Questions
1. What health care professional provides custom orthotic
services to persons with LE impairments?
2. What are four clinical objectives of a LE orthosis?
3. What are the major joints that contribute to lower limb
function?
4 What are the three key biomechanical principles of LE
orthotic management?
5. What are the basic differences between low-temperature
and high-temperature thermoplastic materials?
6. What are the seven subphases of gait?
7. What is the main distinction between a primary and
secondary gait deviation?
8. What is the role of the OT in the development of the
orthotic intervention program?
9. What skin inspection techniques are taught to the person
with insensate feet?
10. What are two control options for the ankle joint of an
articulated AFO?
11. What are two design parameters that can be integrated
into a KO to prevent migration and to ensure proper
alignment of the anatomical and mechanical joint axes?
12. What are the four main types of knee joints used in
KAFOs?
13. What type of training would a person wearing a
postoperative HO require?
14. What clinical presentation would most benefit from a
RGO?
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47. Zissimopoulos A, Fatone S, Gard S.A. Biomechanical
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Appendix 18.1 Case Studies
Case Study 18.1 a

Read the following scenario, and answer the questions based on information
in this chapter.
A 67-year-old man sustained an acute cerebrovascular accident
(CVA) to the right hemisphere of his brain and now presents with left-
sided hemiparesis. The client complains of difficulty ambulating,
standing for long periods of time, and performing his activities of
daily living (ADLs). During ambulation the client’s left lower
extremity (LE) presents with paralytic equinus during swing phase,
lateral forefoot initial contact, and asymmetrical step lengths.

1. What are some of the potential roles an occupational therapist

(OT) may play in the intervention of this client?
2. What intervention goals can be addressed for this client using a
LE orthosis?
3. What biomechanical principles might be implemented in the
design of this client’s LE orthosis?
4. What type of LE orthosis might this client benefit from?

Case Study 18.2 a

A 62-year-old male client has a diagnosis of type 2 diabetes mellitus
and associated peripheral neuropathy. The client complains of
callousing on the plantar aspect of metatarsophalangeal (MTP) joints
and tightness wearing the Oxford style shoes he typically wears. On
clinical examination the client presents with clawed toes, atrophy of
the intrinsic muscles of the foot, and depressed medial longitudinal
arches during weight bearing. Results from a monofilament
assessment of the plantar aspect of the foot confirmed peripheral
neuropathy. LE strength and active range of motion are within normal
limits at all major joints. The client receives bilateral, custom-
fabricated, full-length accommodative foot orthoses (FOs)
manufactured from multidurometer foams and extra-depth footwear
to accommodate the claw toe deformity. The multidurometer foam
construction allows for distribution of forces throughout the plantar
aspect of the foot, which reduces peak plantar pressures and
minimizes the risk of plantar ulceration. The extra-depth footwear
allows for needed adjustments of volumetric changes of the foot and
accommodates the thickness of multidurometer FOs.

1. How might neuropathy negatively impact this client?

2. What benefits do extra-depth footwear have?
3. Why was the client provided accommodative instead of
corrective foot orthoses?

Case Study 18.3 a

A 62-year-old male client is 2 weeks post right total knee arthroplasty.
During the surgery he sustained an iatrogenic peroneal nerve lesion at
the level of the fibular head. He complains of difficulty walking and is
dragging his toe. The client is otherwise healthy and has no edema.
On clinical examination the client presents within functional limits for
bilateral passive range of motion at the midfoot, ankle, subtalar, hip,
and knee joints. A manual muscle test reveals he has 0/5 dorsiflexion
and eversion. He has sensory loss over the dorsal aspect of the foot
and lateral compartment of the leg. While ambulating the client
exhibits secondary compensations with hip hiking during the swing
phase on the affected limb and initial contact with the lateral forefoot.
The client receives a custom thermoplastic ankle-foot orthosis (AFO)
with a flexible ankle trimline fabricated from 5⁄32-inch (4 mm)
copolymer (similar to Fig. 18.5C). Resistance to plantar flexion from
the AFO coupled with the full-length foot plate provides the client
with improved swing phase clearance. The foot plate eliminates the
need for compensatory hip hiking and encourages a normal heel
strike at initial contact. A flexible ankle trimline allows the tibia to
progress forward during stance, and the thermoplastic design allows
for a lightweight orthosis that can be readily changed from shoe to
shoe with equal heel heights.

1. Why does the client present with both dorsiflexion and

eversion weakness?
2. How would the client’s gait be affected if he were provided a
solid ankle AFO instead of the orthosis described above?

Case Study 18.4 a

A 54-year-old female client has right lateral compartment
osteoarthritis with associated genu valgum. The client complains of
knee pain during weight-bearing activity that increases
proportionately with activity level. Clinical evaluation reveals
bilateral genu valgum and palpable swelling over the lateral joint line
of the right knee. The client receives a functional knee orthosis (KO) to
unload the lateral joint compartment of the right knee. The KO’s
three-point force system (acting through straps in the coronal plane)
applies medially directed forces at the proximal and distal aspects.
The KO’s laterally directed force at the medial femoral condyle results
in unloading of the lateral compartment of the knee joint. Polycentric
knee joints are used to match the natural movements of the knee.
Composite construction of the articulating and structural components
ensures that the orthosis is structurally sound yet lightweight.

1. Why are polycentric articulations most appropriate when

providing a knee orthosis?
2. What is the primary biomechanical objective for the provided
orthosis?

Case Study 18.5 a

A 47-year-old client has paralytic postpolio syndrome. The client
complains of severe left knee pain while walking. The client was
diagnosed with acute polio at 3 years of age and has noted increased
symptoms of weakness with age. Clinical examination reveals that the
client has a 15-degree plantar flexion contracture and 30 degrees of
knee hyperextension during loading response. There is laxity of the
right knee in the sagittal plane and palpable swelling throughout the
popliteal fossa. Sensation, vascular function, and proprioception are
within normal limits. With ambulation the client exhibits secondary
hip hiking during swing, initial contact with the forefoot, and severe
hyperextension during stance. The client receives a thermoplastic
knee-ankle-foot orthosis (KAFO) with posterior offset knee joints,
solid ankle, and metatarsal-length foot plate. The thermoplastic KAFO
design accommodates the client’s plantar flexion and knee
hyperextension. The design allows the weight line to pass anterior to
the anatomical knee and posterior offset knee joints. The posterior
offset knee joints create a knee extension moment at both joints
throughout stance phase. The KAFO serves to limit additional knee
hyperextension and increases stability. The three-quarter–length foot
plate facilitates heel off in preswing, allowing the transition to swing
phase.

1. How is the sensation and proprioception affected in a client

with paralytic postpolio syndrome?
2. How would your recommendation change if the client
presented with a 10-degree knee flexion contracture instead of
knee hyperextension?

Case Study 18.6 a

A 62-year-old client is seen in the postanesthesia recovery unit after a
total hip arthroplasty revision. The client has a history of hip joint
subluxation. The physician would like the hip to be maintained in a
flexed and abducted position. The client has normal anatomy and a
thin dressing placed at the incision anterior to the greater trochanter.
The client receives a prefabricated hip orthosis (HO) with an
adjustable range-of-motion joint. This articulation enables the orthotist
to set the hip joint to a fixed abduction angle while allowing some
flexion for ADLs. The orthotic alignment is intended to encourage
proper healing of the soft tissues surrounding the hip prosthesis.
Although the HO provides mechanical control of the hip joint, it is
imperative that the OT reinforce hip joint precautions and facilitate
the integration of the orthosis into ADLs.

1. Why would the physician request a flexed and abducted

alignment?
2. What activities might the patient have difficulty achieving
given the motion limitations the hip abduction orthosis is set
to?

Case Study 18.7 a

A 6-year-old child diagnosed with a low thoracic myelomeningocele
lesion presents with absent sensation and motor function of bilateral
LEs. The intervention goal is an orthosis that facilitates static standing
and the ability to ambulate in as normal a manner as possible. The
child has access to both pediatric physical therapists and OTs at
school and has excellent upper limb strength and dexterity. The child
is provided a custom reciprocating gait orthosis (RGO) because it
facilitates static standing and step-over-step ambulation. To take
advantage of this orthosis, it is imperative that the child have access to
therapists to develop the skills needed to successfully integrate the
orthosis into ADLs and have the requisite training to use crutches or
other assistive devices necessary to successfully ambulate with the
orthosis.

1. Why couldn’t this client be provided ankle-foot orthoses

instead of the relatively cumbersome RGO?
2. What advantage does the RGO have over a hip-knee-ankle-foot
orthosis (HKAFO) with locked hips and knees and fixed
ankles?
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
19
Casting
Audrey Yasukawa

CHAPTER OBJECTIVES
1. Identify the types of upper extremity casts and the criteria for use.
2. Describe casting interventions for common upper extremity
range-of-motion limitations and alignment issues that affect
function.
3. Describe the rationale for upper extremity casting.
4. Describe therapeutic methods to use in conjunction with and after
implementation of a casting program.
5. List three criteria for a successful upper extremity casting
program.

KEY TERMS
antagonist
contracture
myostatic
submaximal range

Troy is a 16-year-old varsity football player who sustained a Bennett

fracture (an intra-articular fracture-dislocation of the thumb metacarpal
at the carpometacarpal joint). Troy sustained the fracture during a
football game, and he received a Neoprene thumb spica sleeve for
stabilization for the remainder of the game. Once confirmed by
computed tomography (CT) scan, Troy’s fracture was reduced in a long
thumb spica cast that extended beyond his wrist but allowed motion at
the metacarpophalangeal (MCP) joints of the fingers. Troy was
concerned about the limitations of motion and asked the physician if he
could get a “game day” cast that allowed more motion. The physician
referred him to occupational therapy.

Julie is a 5-year-old who experienced brachial plexus palsy at birth.

Subsequently, she presents with an elbow flexion contracture associated
with the palsy. Her elbow is contracted more than 30 degrees in a flexed
position. The occupational therapist now seeing Julie is considering a
serial casting intervention to increase Julie’s elbow extension, which will
benefit her performance in tasks such as putting on shirts and coats.
Diagnostic Indications for Casting
Casting intervention may be considered for a variety of conditions
(Box 19.1), including orthopedic and neurological conditions.

Orthopedic Conditions
As exemplified by the story of Troy, a fracture is an orthopedic
condition requiring immobilization, which is often accomplished with
casting. The traditional intervention for an upper extremity fracture is
to apply an elbow cast, long arm cast, wrist cast, or hand cast. The
physician and cast technician generally apply the cast to stabilize the
fracture site. The physician continues to reevaluate the bone healing
and assess the injury site and stability of the area during healing.
Depending on the injury, the cast may be left in place from 3 to 8
weeks. 7
Burns are another diagnostic group that may benefit from casting.
With burns, contractures result from the damage to the soft tissue and
muscles and scar formation. 3,11,47

Neurological and Neuromuscular Conditions

Casting can also be appropriate for neurological conditions such as
the case with Julie. Such clients clinically present with abnormal tone,
muscle imbalance, and muscle weakness that may limit passive and
active range of motion (ROM) of the upper extremity. Therefore
casting is used as an adjunct to therapy for an individual with motor
disorders, in which contracture or spasticity are often present. 46
Clients with abnormal tone often have stiffness, muscle imbalances,
spasticity, or abnormal response to stretch. Muscles, soft tissue, or
joints that remain in a shortened position for extended periods of time
often present with decreased extensibility. 19,41,54 Once a contracture
occurs, slow gradual stretch of the connective tissue and muscles can
gradually improve ROM. 20,32,33,44 Common neurological diagnoses
that may require casting intervention include spinal cord injury,
traumatic brain injury, stroke, and cerebral palsy. 5,15,18,29,39,49

BOX 19.1 Casting Indications and

Contraindications

AROM, Active range of motion; CIMT, constraint-induced movement

therapy; CP, cerebral palsy; PROM, passive range of motion.

Brachial plexus birth palsy refers to the paralysis of the upper

extremity due to a traction or compression injury sustained to the
brachial plexus during birth. In children with brachial plexus injury,
muscle imbalance, weakness in the antagonist muscle group, and
habitual compensatory movement patterns often lead to the
development of contractures, which may require casting. 12,21
Traditional intervention techniques to address contractures include
passive stretching to restore the normal ROM when the range is
limited by muscle tightness and loss of soft tissue elasticity. However,
muscle/soft tissue tightness is likely to recur with the client who is
dependent on a caregiver for movement. For example, casting may be
used to improve ROM for care and hygiene and to prevent skin
breakdown in a tightly fisted hand or flexed elbow. Increasing joint
ROM may be accomplished by providing the client with an orthosis.
An increase in range may be difficult to maintain unless the extremity
can be positioned using an orthotic device. 35,56–58
 Thus primary indications for casting are soft tissue contracture and
increased spasticity that limits function. Further considerations for
casting are decreased active and passive ROM, inability to tolerate an
orthosis, and poor biomechanical alignment of the arm/hand
inhibiting active movement. Casts can be used to improve motor
training to stabilize a joint, (e.g., wrist stabilization to allow the client
to learn finger extension). Further assessment helps determine if
casting is an appropriate option.
Although casting is often provided for orthopedic and
neurological/neuromuscular conditions, this chapter focuses on
casting for clients with neurological and neuromuscular conditions.
However, some of the discussed concepts can be applied with either
type of condition.
Contraindications to Casting
Casting is not always appropriate for all clients (see Box 19.1). In cases
of severe skin redness, open wounds, shoulder subluxation, edema,
heterotopic ossification, or rigidity, the application of a cast may be
contraindicated. Other contraindications to casting include clients
with severe rigidity, athetosis, fluctuating tone, unstable medical
conditions, or long-standing contractures. For example, a teenager
with cerebral palsy who has a long-standing contracture of the elbow
may not benefit from a casting program if the goal is to gain full ROM.
Increased activity with the arm postured in pronation and elbow
flexion over long periods of time might cause posterior dislocation of
the radial head. 43 This dislocation impairs achievement of elbow
extension actively and passively.
For a developing child with cerebral palsy, as the bones grow, the
muscles may maintain a shortened position. The bony modeling of the
radius and ulna with a forearm in constant forearm pronation and
elbow flexion suggests that bony deformities may result from the lack
of full rotation into supination. 10 In a developing child presenting
with movement restriction due to the long-standing contracture into
elbow flexion and forearm pronation, torsion of the bone may occur.
In this case a consultation with an orthopedic specialist is helpful
before the casting procedure.
Evidence for Casting
Cast provision to address contractures and motor disorders associated
with muscle imbalance and spasticity is well established in
rehabilitation practice. Therapists have identified those patients who
are most likely to benefit from cast intervention. 20,21,32,44,46 A lack of
evidence to support the use of upper extremity casting with stroke
exists. 14,40,48 Upper extremity casting is more successful for clients
with traumatic brain injuries or cerebral palsy. 5,20,44,45 Regardless, the
use of casting and the outcome for each individual varies due to the
severity, tone, and functional status.
The influence of upper extremity casting continues to be
speculative, with a low level of evidence to assist with the clinical
decision making for developing protocols (Table 19.1). Randomized
controlled trials are scarce, with little consistency in outcome measure,
except for the measure of ROM. 27,28,38,50 The evidence base for lower
extremity casts exists; however, it is limited. 4 It is difficult to conduct
a randomized controlled group of human subjects with adequate
sample size to detect the treatment effects for upper and lower
extremity casting. Many subjects in rehabilitation settings receive
medical and pharmaceutical treatment. Most studies are of single case
reports, which describe the use of casting, case series, or chart review.
Therefore therapists must rely on their clinical judgment to determine
if casting is an appropriate intervention. Despite the inherent
limitations associated with single case reports or case series, they do
provide some guidance for treatment interventions. Moreover, they
are an impetus for future research.

TABLE 19.1

Evidence-Based Practice for Casting

AROM, Active range of motion; BI, brain injury; BUE, bilateral upper extremities; CIMT,
constraint-induced movement therapy; CINAHL, Cumulative Index to Nursing and Allied
Health Literature; CNS, central nervous system; CP, cerebral palsy; CVA, cerebrovascular
accident; NDT, neurodevelopmental therapy; OT, occupational therapy; PROM, passive range
of motion; RCT, randomized controlled trial; ROM; range of motion; UE, upper extremity.
Contributed by Andrea Coppola.

FIG. 19.1 This is an example of documenting range-of-motion (ROM)

status during serial casting process.
Photo courtesy Serghiou, M., Cowan, A., & Whitehead, C. [2009].
Rehabilitation after a burn injury. Clinics in Plastic Surgery, 36[4], 675–
686.

Casting Options
Three general casting options are available: serial casts, inhibitory
casts, and drop-out casts. 15 A serial cast is applied and removed
progressively as ROM increases (Fig. 19.1). Cast changes of 1 to 4 days
are common. 15 Often with increased muscle tone, casting is most
effective 2 to 3 weeks post botulinum toxins. 15
An inhibitory cast places a joint in a position that reduces spasticity
in a reflex-inhibiting position (Fig. 19.2). The reflex-inhibiting postures
for the upper extremity include shoulder abduction, elbow extension,
forearm supination, wrist extension, and finger and thumb extension
and abduction. 15
Drop-out casts for a spastic joint allow movement in a desired
position while concurrently preventing the joint from returning to a
contracted position (Fig. 19.3). 15 For example, an elbow with a flexion
hypertonicity may be casted with the posterior portion of the upper
cast cut away to allow the person to extend the elbow, while
preventing the elbow from moving to a flexed position. 15
Upper Extremity Assessment for
Casting
Selection of a casting program requires a comprehensive analysis of
the involved upper extremity, including a baseline assessment before
casting. Ongoing assessments are essential to determining the
effectiveness of the casting program. Assessment is conducted
between consecutive cast application(s) and upon completion of the
casting program. Assessment tools used for the casting program must
be objective and reliable, and have valid outcome measures to
determine the efficacy of the casting intervention. The following
discussion includes considerations for assessment of neurological
conditions for possible casting. Although casting for an orthopedic
issue may require some of the same assessments, not all the following
apply. For example, casting a fracture has no relationship to
assessment of spasticity.
FIG. 19.2 Inhibitory cast—forearm supination cast.
 FIG. 19.3 Drop-out cast.

Range of Motion
ROM assessment is an essential component throughout the casting
program, before and after casting, as well as between each cast
application in the series. Goniometric assessment improves reliability
of measurements when taken by the same examiner. 52 The therapist
measures the specific joint being casted, and the joints proximal and
distal. ROM improvements may be noted in the casted joint, but they
may also occur in other joints. Both active and passive ROM are
measured.

Manual Muscle Test

Motor function assessment of the involved arm or hand is important,
especially in evaluating a short, tight muscle or weakness in an
overlengthened muscle. It is important to examine the specific muscle
or muscle group as compensatory movement patterns can
compromise the function of the muscle. The therapist may need to use
clinical observation of active muscle control if it is difficult to isolate
specific muscles and assess selective motor control (e.g., ability to
isolate wrist extension). Test the performance and strength of the
muscle according to the guidelines of manual muscle testing. 26

Grip Strength
To take the measurements of grip strength, the therapist uses a
dynamometer for adult clients or a rubber bulb dynamometer for
children. A change in wrist ROM into extension and the forearm into
supination may assist with increased strength and dexterity. 13 To
maintain consistency in measurements, document the position of
forearm and wrist and any support given.

Modified Ashworth Scale

The Modified Ashworth Scale (MAS) is a numerical scale that grades
the resistance felt by the therapist during a quick-stretch maneuver
opposite to the pull of the muscle group being tested. The MAS
measures the level of resistance to passive movement but does not
evaluate the velocity of passive joint movement. The MAS is effective
in clinical practice because of its ease of use, but it shows only
moderate to good intrarater reliability and poor to moderate interrater
reliability. 6,17,31 However, if it is consistently used by the same
evaluator, the MAS assists with assessment of tone in the upper
extremity and the joint to be casted. Table 19.2 describes scale of
resistance to passive movement of the MAS.
Severity of hypertonicity (spasticity and muscle stiffness) is
characterized as mild, moderate, or severe. The therapist documents
the availability of active movement and the presence of soft tissue
contracture. A client with mild hypertonicity may display a stretch
reflex only at the end range of movement, or no hypertonicity at rest.
A client with moderate hypertonicity may display a stretch reflex at
midrange, and a client with severe hypertonicity may display a stretch
reflex at the beginning of range. 51

Sensibility
The identification of sensory deficits is an important consideration
when establishing functional goals and predicting success of a casting
program. Evaluation of sensory function requires the client to interact
with the examiner to answer questions. If the client is unable to
respond, the examiner uses clinical observation to note sensory
neglect of the arm or hand during functional tasks. There are many
possible ways of testing hand sensation, as described in previous
chapters. These include touch, pain, two-point discrimination,
stereognosis, and position sense. Sensory impairment may be an
important factor that limits functional outcome. Evaluation of
deficient sensation of the hand or arm may have implications for
training in activities of daily living and use of appliances in aspects of
the client’s management after the casting program. 9,36,58

TABLE 19.2

Modified Ashworth Scale

0 = No increase in muscle tone

1 = Slightly increased muscle tone, manifested by a catch and release or minimal resistance
at end ROM
1+ = Slightly increased muscle tone, manifested by a catch and release or minimal
resistance through remainder (less than half) of the ROM
2 = More marked increase in muscle tone through most of range, but affected parts are
easily moved
3 = Considerable increase in muscle tone; passive movement difficult
4 = Affected part(s) rigid in flexion or extension

ROM; Range of motion.

Skin Condition
The condition of the skin is important to consider before casting.
Assessment of circulation and temperature of the hand to be casted is
compared with the other hand. At times there may be a temperature
difference in the more involved upper extremity when comparing it
with the less involved arm. This temperature difference should be
noted before placing the cast. After cast application the therapist
always rechecks the extremity temperature, the pulse at the wrist (as
able), fingers and thumb tips for blanching, and any tendency for
edema.

Postural Control
Children and adults with neuromotor impairments may have poor
postural control and demonstrate instability or insecurity when sitting
or standing up against gravity. Casting may assist with reduction in
spasticity, but as the client becomes upright in standing, it may also
place more demands and stress on the arm. The therapist evaluates
and documents the posture of the client’s arm during ambulation,
going up and down stairs, and when performing functional tasks. The
client who has difficulty weight shifting onto the more involved
leg/foot may demonstrate posturing of the arm due to a poor base of
support. The client may use the arm for postural control when
upright, limiting freedom of control during challenging motor tasks.
An example of this is decreased reciprocal arm swing during
ambulation. The therapist assesses postural alignment and the
position of the arm at rest, in standing, and during movement.

Functional Use
Functional assessment is important and needs to include active
placing and holding of the arm and active flexion and extension of the
elbow during functional tasks. Functional assessment considers the
ability to rotate the forearm to orient the hand for grasp and release of
objects to use for activities of daily living.

TABLE 19.3
Functional Classification System
Class Description Activity Level
0 Does not use Does not use

1 Poor active assist Uses as stabilizing weight only

2 Fair passive assist Can hold onto object placed in hand

3 Good passive assist Can hold onto object and stabilize it for use by other hand

4 Poor active assist Can actively grasp object and hold it weakly

5 Fair active assist Can actively grasp object and stabilize it well

6 Good active assist Can actively grasp object and then manipulate it against other hand

7 Spontaneous use, Can perform bimanual activities easily and occasionally uses the
partial hand spontaneously
8 Spontaneous use, Uses hand completely independently without reference to the other
complete hand

Data from House, J. H., Gwathmey, F. W., & Fidler, M. O. (1981). A

dynamic approach to the thumb-in-palm deformity in cerebral palsy.
Journal of Bone and Joint Surgery, American Volume, 63, 216–225.

House et al. 23 devised a nine-level functional classification system

(House Classification [HC]) to describe the characteristics of hand
function in children with cerebral palsy (Table 19.3). The scale was
further modified. The Modified House Classification (MHC) can be
used objectively in children with unilateral cerebral palsy and may be
useful in measuring the functional capability of the affected hand. 16 A
standard group of tasks that require a variety of upper extremity
motions can be used, as well as tasks devised for a particular client.
Assessment Between Casts
During application of a series of casts, ROM of the joint casted,
spasticity, and active motor control are reassessed before each new
cast is fabricated. The skin is checked to ensure there are no reddened
or open areas resulting from the cast. If there is skin breakdown, the
cast program may need to be placed on hold until the skin area heals.
If edema and swelling are noted, a delay in the application of another
cast is likely. This may require discussion with the physician before
placing another cast.
Client Participation And Other Client
Factors
After the assessment has determined the need for a cast, the ability of
the client to participate in treatment is a key factor in a successful
casting program. As the tight muscle/soft tissue is lengthened, the
opposing and overstretched weak muscle requires a strengthening
program. Ultimately, the weak antagonist, the muscle that opposes
the action of the tight muscle, can be activated and strengthened. 29,55
Improved muscle balance around the joint may result, decreasing the
potential for recurrence of the myostatic contracture. Strengthening
the muscle opposing a contracted muscle is an intervention approach
that should be incorporated into the client’s activities of daily living.
The long-term effectiveness of maintaining a good outcome is
dependent on the practice of the functional activities that are to be
performed when the casting program is completed.
Clients with significant spasticity or stiffness may require oral
medication such as baclofen to help relax the muscles to improve the
ease of cast application. Botulinum toxin type A (BtA) injection is used
to inhibit the release of acetylcholine, functionally denervating or
decreasing neural input to the tight muscle. Return of the neural input
occurs with regeneration and collateral sprouting of the nerve
endings. The chemodenervation effect generally lasts for 3 to 5
months, depending on the size and function of the muscle injected.
Changes in muscle tone, ROM, and functional activities have been
reported. 14,22,34,42 BtA weakens the injected muscle, but it will not
increase the muscle length. Casting is frequently used in conjunction
with BtA management to elongate the injected muscle. BtA in
conjunction with an occupational therapy program, including casting,
has improved outcomes compared with BtA only. 14,24,34,40,53
Types of Casts, Rationale for Use,
Instruction for Application
After the initial assessment the therapist selects the type of cast that is
deemed most effective to improve ROM and optimize function. The
therapist uses clinical judgment and problem-solving skills to decide
which cast is the most appropriate and determines the appropriate
follow-up treatment during and after the casting program.
During casting, joints are positioned statically in submaximal range
to avoid elicitation of the stretch reflex and to prevent microtearing
and overstretch of the soft tissue, nerves, and blood vessels.
Submaximal range is defined as 5 to 10 degrees less than the range
available with maximal stretch. When casted at maximal stretch, there
is a chance that the muscle will rebound when the cast is removed.
Microtearing of the overstretched muscle may occur and cause pain,
muscle spasm, or loss of ROM. The goal of gentle serial casting at
submaximal range is to provide a low-load, prolonged stretch. An
increase of at least 5 degrees in passive ROM is expected when the
cast is removed. The casting program is discontinued when ROM has
not increased or there is no improvement in volitional movement. If
changes in spontaneous movement or ROM are noted later, the
casting program may be reestablished.
Inhibitory casts are those used to reduce the effects of abnormal
muscle tone. Casting one portion of the arm may have a relaxing effect
on the other muscles in that extremity. For example, positioning the
thumb into extension with input into the thenar eminence and palmar
arch may relax the tightness in the fingers. Positioning the forearm in
supination with elbow extension may have an inhibitory effect on the
spasticity or stiffness in the elbow, wrist, or hand.
The tight muscle is maintained in a gradually lengthened range,
while the antagonist is in a shortened range, to improve active and
passive ROM.
Cast fabrication and application requires two therapists or the
primary therapist casting and an aide or assistant instructed in the
casting and holding techniques. It is extremely important that the
assisting person who holds the arm and the person applying the cast
work as a team. The holder is responsible for assisting with
maintaining the alignment of the arm or hand during the casting
procedure. The holder of a cast is crucial when applying a cast on a
client who has significant spasticity or muscle weakness to ensure that
the involved arm is in good alignment and position to optimize
achievement of ROM during the casting process.
Protocol
Casts are often applied in series, with each cast being left in place for 3
to 7 days, depending on the severity of tone or stiffness and the type
of cast. 5,20,30,44 For a client with burns the cast may be left on for 2 to 3
days, depending on the skin integrity and precautions. 3,11 When one
cast in the series is removed, the skin is cleansed and checked for
pressure areas. The therapist assesses the ROM and muscle tone, and
then another cast is immediately applied. The casting series is
generally limited to five to seven casts to prevent stiffness and to
incorporate gains made with the casting program into functional
movement.
A bivalve cast or orthosis can be fabricated to maintain the ROM
while other treatment methods are explored. When a cast is intended
to be used as a bivalve splint or orthosis for maintenance, fiberglass
casting materials are often used for durability. A bivalve cast is cut
into two halves, with the edges finished and straps applied to hold
both sections together.
After a cast is applied, the client or caregiver is provided with
information on care of the cast and receives instructions on areas to be
monitored. The client is instructed in warning signs and provided
with written instructions (Table 19.4). For a cast that must be removed
using a cast saw, it is helpful to provide a letter to present to the
emergency department physician describing the purpose of the cast
(Table 19.5).
It is further important to incorporate active movement and exercise
upon removal of the cast to translate the gains from casting into
functional movement.
Casting Materials
Therapists will likely develop preferences for casting materials as they
become more familiar with the various properties. Local hospital and
orthopedic supply vendors often present updates and training about
casting products, such as stockinette, padding, fiberglass, and plaster.
There are many choices of casting products in terms of the texture,
feel, and setting characteristics. For example, a therapist may choose a
type of padding because it is easy to tear, conforms easily, or is more
durable. Plaster materials are available from fast setting to extrafast
setting, with varying smoothness and conformability of the material
(Table 19.6).

TABLE 19.4

Cast Care and Precautions

This cast will be removed on ______________. Please read the following to learn about the
cast and precautions for your cast.
Precautions
If your cast causes any of the following conditions, contact your therapist.

1. Swollen or puffy fingers

2. Differences in temperature or color between the casted and uncasted arm

3. Pain

4. Numbness or tingling

5. Blueness in fingernails

6. Bad odor

Do not get your cast wet since it will become soft and cause skin problems. Cover the
casted arm with a plastic bag when taking a shower or bath. If the cast becomes wet, it
must be removed as soon as possible to prevent skin breakdown.
If the cast is able to be taken off by unraveling, please remove immediately if there is a
problem. If it is too tight, unravel some of the cast and monitor the skin to see if this will
alleviate the problem.
Elevate your casted arm/hand periodically. Do not let it just hang at your side.
Initially check the cast every hour to monitor skin.
 ____________________________________________________
Therapist Telephone

TABLE 19.5

Sample Letter to Emergency Department Physician Describing Purpose of the

Cast

Name:
DOB:
Type of cast:
Date:
Emergency Department Letter
To whom it may concern:
I have applied plaster/fiberglass cast(s) to the ____________ of ______________________,
who is an outpatient at ______________ Hospital. The cast has been applied to gain range
of motion and improve strength. There is NO fracture or joint instability to be concerned
about if the cast is removed. The patient has been instructed to go to the nearest emergency
department if problems arise when we are not available.
Please remove the cast(s) if there is any question of compromised circulation or if the
patient is complaining of significant pain. There is a minimum of three (3) layers of cotton
padding under the shell of the cast.
If there are problems with the cast, please call me at __________________.
Thank you for your assistance.
______________________________________________________________________________

TABLE 19.6

Casting Materials
 When unrolling the padding, place the roll facing up and unwrap
gently, without pulling the material, as this may cause increased
tightness and circumferential restriction. During application of the
plaster or semirigid soft cast, hold the material at the end of the roll
and dip into warm water. Gently squeeze the roll to get rid of excess
water, and begin application on the arm. The plaster or the semirigid
cast material sets quickly, so plan and practice the technique and
position needed for the holder before application. Unroll the material
similar to the padding method.

TABLE 19.7

Rigid Circular Elbow Cast Using Plaster or Semirigid Materials

Rigid Circular Elbow Cast
Rationale for Use
A loss of elbow extension with contracture results in serious
impairment in performance of activities of daily living. A series of
rigid circular elbow casts is applied to gradually increase elbow ROM.
The elbow cast is effective for improving elbow extension in clients
with central nervous system (CNS) dysfunction, muscle imbalance
from peripheral nerve injury, or myostatic contracture. In clients with
fluctuating tone the elbow cast assists with providing equalized
pressure for gradual improvement in extensibility. If the client
presents with severe rigidity or heterotopic ossification and
immobility is contraindicated, the elbow cast should not be used.
When casting the elbow of clients with severe to moderate
spasticity, it is important to apply equalized pressure throughout the
humerus and forearm to prevent pressure directly on the olecranon. It
is important to wrap around the olecranon in a figure-eight wrap,
rather than a direct pull over the bony prominence. The figure-eight
padding wrap distributes the pressure evenly over the olecranon.
The rigid circular elbow cast is left in place for 5 to 7 days to
provide a slow, gradual stretch. After removal the arm is checked and
cleaned, and ROM is documented. A new cast is applied to continue
increasing ROM into further elbow extension. Materials for elbow
casts are listed in Table 19.7.

Cast Application Instructions (Box 19.2)

Measure stockinette from the acromion to the posterior aspect of the
olecranon to accommodate for the length of the material to the distal
proximal interphalangeal (PIP) joint (Fig. 19.4).

1. For a severe to moderate elbow flexion contracture of 45

degrees or more, cut a slit on the stockinette at the anterior
 elbow crease horizontally from one epicondyle to the other.
Overlap the stockinette. This is to keep the stockinette from
bunching and wrinkling at the antecubital crease.
2. Apply the felt strips to the following: distal to the axilla
circumferentially, over ulnar styloid circumferentially, across
the olecranon vertically along the ulna and up on the humerus,
and horizontally across both epicondyles (Fig. 19.5).
3. Apply padding beginning proximally or distally, and wrap
circumferentially, overlapping each wrap by third. If the
padding is bulking on one side, tear the opposite side to
conform the material smoothly on the arm (Fig. 19.6A–B). The
padding should cover the ulnar styloid distally and extend
fully up onto the axilla.
a. For plaster cast, apply five or six layers of padding
at both distal and proximal ends and four or five
layers covering the midsection of the arm.
b. For semirigid soft cast less padding is required as
the material can be unraveled and peeled off versus
using a cast saw.
4. Apply a figure-eight padding wrap at the olecranon for the
elbow flexed at 45 degrees or more. Padding should crisscross
at the anterior elbow crease and overlap approximately 1 inch
over the olecranon; wrap again to overlap by 1 inch over the
olecranon. There are initially two layers of padding over the
olecranon (Fig. 19.7A–B). Continue to figure-eight again
around the olecranon to provide four layers, and continue
down the arm. If going up the arm again, you can unroll the
padding without doing the figure-eight wrap to complete.
5. Apply plaster cast ½ inch below the top of the padding at the
axilla, down the humerus to ½ inch proximal to the ulnar
styloid. If the plaster bulks or narrows, tuck it where it is
bulking (Fig. 19.8).
 FIG. 19.4 Measure stockinette from the acromion to the
posterior aspect of the olecranon to accommodate for the length
of the material to the distal proximal interphalangeal (PIP) joint.
 FIG. 19.5 Applying felt strips to the stockinette.

6. The holder can assist with pulling the stockinette over the edge
of the plaster cast and secure the stockinette with the plaster
cast material.
7. Rub the plaster cast well into the gauze, and allow it to set.
Flare the proximal and distal edges with a circumferential
motion combined with outward pull of the index finger. Do
not apply counterpressure with thumb. The completed rigid
circular elbow cast is shown in Fig. 19.9.

BOX 19.2 Occupational Therapy Guidelines

Regarding Casting of Upper Extremities

A. OT staff will evaluate for and apply casts

to patients’ UEs on referral from
physician.
B. Types of casts applied include rigid
 circular long arm, elbow, wrist, wrist with
thumb enclosed, or MCP wrist cast.
C. Casts will be applied to improve passive
range of motion for hygiene care/skin
care, to reverse contracture, to manage
abnormal tone in conjunction with
botulinum toxin or oral baclofen, to assist
with strengthening/rebalancing muscles,
or to assist with application of orthoses for
positioning or CIMT.
D. Application of casts is not recommended
in the following:
Bilateral casts to patients with
hypertension
Skin surface that is not intact
Joints with heterotopic ossification
E. Special consideration should be taken
when casting patients with the following:
Heterotopic ossification
Decreased circulation/edema
Decreased sensation
Decreased orientation/alertness
Decreased stability of proximal
joints
F. Qualified OT staff will assume
responsibility for monitoring casts and
 documentation of process results and
complications.

Procedure

1. A. Referrals may be made to OT by any

referring physician who states: “Evaluate
for cast and splints as needed.”
• Referrals may include area to be
casted (elbow, wrist, digits),
extremity to be casted, and type of
cast
• Or a qualified OT may recommend
casting and request orders from the
physician.
2. Qualifications of OT personnel assessing
for and applying cast.
A. OTRs may be qualified to assess
for and apply casts.
B. To be qualified, therapist must
be able to review the following
information to a qualified staff
member:
1. Indication for the
cast to be used
2. Contraindications
 3. Safety
precautions/emergency
removal procedures
4. Casting application
procedure
C. To be qualified, therapist must
demonstrate cast technique for
qualified staff by applying and
removing cast on another staff
member.
D. Cast applications, monitoring,
and removal to be directly
supervised by qualified
therapist until technique skill is
ensured.
E. Before cast application, a
qualified staff member must
okay type of cast for QA
monitor.
F. OT students may be qualified
but MUST continue to be
directly supervised in all aspects
of casting.
3. Application of casts
A. Precast evaluation to include:
1. Goniometric
 evaluation
2. Notations of skin
condition
3. Goniometric
measurement of
point-of-stretch
reflex
4. Goniometric
measurement of
wrist position when
hand is fully flexed
and extended
5. Recording sensory
status over area to
be casted
6. Cognition
7. Spontaneous
functional use
8. Functional arm
placement/hand use
B. Cleanse area to be casted
C. Apply stockinette
D. Apply felt over bony
prominences and distal and
proximal borders if needed
E. Apply material:
1. Plaster—requires
cast saw for
removal, except for
finger cast
2. Fiberglass—requires
cast saw for removal
3. 3M Scotchcast soft
cast—unravels off,
but has fiberglass
4. Delta-Cast soft—
unravels off, made
of polyester
5. Delta-Cast
Conformable—
polyester, FCT. This
material is used for
fabricating a splint.
No padding is
needed; must use
the special Terry-
Net stockinette. The
technique is to
provide rigidity
where the patient
will need it and
flexibility in areas
 not requiring rigid
immobilization. This
requires a cutting
stick to be placed
before application of
the material for safe
removal.
4. Monitoring
A. Document date cast applied and
date to be removed. If applying
the soft cast, instruct caregiver
on the removal process. The
caregiver should remove cast at
home if there are any problems
with child’s ability to tolerate
the cast.
B. After cast application, always
monitor the following:
1. Red areas
2. Pulse at points distal
to cast
3. Temperature
comparison both
UEs
4. Pain
5. Edema
 6. Discoloration of
hand/nail beds
C. Qualified OT will monitor cast
and notify nurse in charge for
inpatients. For outpatients,
discuss precautions and instruct
in removal technique.
Parents/caregivers should
remove the cast if there are any
difficulties at home. If the soft
cast is too tight, let caregiver
know that the cast can be
gradually unwrapped to loosen
the cast without having the cast
totally removed.
D. Use of the cast saw
1. For plaster cast or
fiberglass materials,
the cast saw must be
used for removal.
2. OT staff must
practice removal
from a qualified OT
before using the
saw.
3. Before removing the
cast, explain the use
of cast cutter.
a. The
sound
may
be
loud
and
frightening,
may
use
headphones
for
child.
b. The
cast
blade
runs
back
and
forth
and
not
around,
so will
not cut
 through
padding.
c. Hold
the
cast
saw in
the
middle,
and go
up/down
to cut;
do not
hold
blade
down
in
material
for
long
periods
or the
blade
will
heat
up. Do
not
 run
the
blade
across
materials,
only
up/down.
d. When
a
“give”
is felt
with
the
cast
saw
going
down
in the
material,
lift the
cast
saw
back
up. Do
not
leave
 the
blade
down
in
material,
or that
position
will
heat
the
blade.
e. If the
blade
feels
overheated,
stop
cutting;
may
require
a new
blade
or
need
to cool
off.
f. After
 cutting
the
cast
use
the
cast
spreader
to
open
the
cast.
g. Cut
the
padding
first,
running
the
cast
scissors
on the
stockinette.
h. Lift the
stockinette
off the
skin,
and
 cut the
stockinette.
Prevent
running
the
scissors
on the
client’s
skin.
5. Documentation
A. The OT will document in the
medical chart the cast
application and observations of
how the client tolerated the
casting procedure.
B. The OT will document status
before casting, changes and
status on removal of cast, and
goals.
CIMT, Constraint-induced movement therapy; FCT, functional cast
therapy; MCP, metacarpophalangeal; OT, occupational therapist,
occupational therapy; OTR, occupational therapist, registered; QA,
quality assurance; UE, upper extremity.
Rigid Circular Wrist Cast
Rationale for Use
The rigid circular wrist cast is indicated for the wrist that exhibits
spasticity, muscle imbalance, or weakness, as well as contractures
where wrist flexion is more dominant and may lead to myostatic
contracture. The wrist cast may be positioned in flexion, extension, or
deviation depending on the clinical problem and alignment concerns.
As the wrist ROM improves, the hand can be properly fitted and
maintained by a lightweight, low-temperature thermoplastic orthosis.
By improving the balance between wrist flexion and extension and
stabilizing the wrist in a functional hand position, the wrist cast may
promote fine motor control of the thumb and fingers. This cast
stabilizes the wrist for the client to actively coordinate thumb and
finger movement with the wrist in a better alignment. Poor wrist
strength requires a wrist orthosis and active wrist strengthening to be
incorporated after the casting program. Gradual improvement into
wrist extension may occur over time as the client practices hand
function and strengthening.
The wrist cast is generally left in place for 5 to 7 days unless
contraindicated. The upper extremity should be reevaluated after each
cast, according to the goal and aim of the casting program.

Wrist Cast Application Using Plaster Material

(Table 19.8)
1. Measure stockinette from the olecranon to the PIP joint.
2. Cut a small ¼-inch slit approximating the placement of the
thumb, and apply the stockinette (Fig. 19.10).
3. Apply the felt strips to the following: one over the ulnar styloid
and the two smaller strips for the thumb piece. Fold the larger
strip in half lengthwise, and cut a half circle one-third from the
top. Place the smaller felt strip through the hole of the larger
strip, and place the felt strip piece through the thumb slit,
covering the web space. The longer piece is placed along the
radial border of the forearm. Tape the felt pieces in place (Fig.
19.11A–B).

FIG. 19.6 A and B, Initially there are two layers of padding over
the olecranon with the application of padding in a figure-of-eight
manner.

FIG. 19.7A-B Padding should crisscross at the anterior elbow

crease and overlap approximately 1 inch over the olecranon;
wrap again to overlap by 1 inch over the olecranon. There are
initially two layers of padding over the olecranon.
 FIG. 19.8 Apply plaster from ½ inch below the top of the
padding at the axilla, down the humerus to ½ inch proximal to the
ulnar styloid.
FIG. 19.9 Completed rigid circular elbow cast.
 FIG. 19.10 Cut a small ¼-inch slit in the stockinette for the
thumb.

4. Apply padding proximally approximately 2 inches below the

olecranon to wrap circumferentially, overlapping by one-third
on each wrap. If bulking occurs on the narrow side of the
forearm while wrapping the distal forearm, hold the padding
and tear at the opposite end of the bulking to contour the
forearm shape.
5. When wrapping around the thumb, pull the padding going
radial to ulnar on the dorsum of the hand above the wrist, and
then from ulnar to radial on the volar surface to reinforce wrist
extension. Place the middle of the padding in the middle of the
web space (Fig. 19.12). Tear the padding horizontally at the
third metacarpal on the dorsal surface. Wrap the lower half of
the padding around the metacarpal joint of thumb. Wrap back
around the carpometacarpal (CMC) and MCP joint of the
thumb. Repeat as needed.

TABLE 19.8

Wrist Cast Materials Using Plaster or Semirigid Material

Wrist Cast Materials Using Plaster or Semirigid Material

FIG. 19.11 A, Fold the larger strip in half lengthwise, and cut a
half circle one-third from the top. Place the smaller felt strip
through the hole of the larger strip, and place the felt strip
through the thumb slit covering the web space. Apply the felt
strips—the longer piece is placed along the radial border of the
forearm. B, Apply the felt strips—the longer piece is placed along
the radial border of the forearm.
 FIG. 19.12 Place the middle of the padding in the middle of the
web space.

6. Begin application by applying the plaster ½ inch below the

proximal end of forearm and unrolling, leaving ½ inch of the
padding at the distal and proximal ends. If bulking occurs
with the plaster, take the extra piece of plaster and tuck (Fig.
19.13). Apply the plaster again, radial to ulnar, on the dorsal
side and ulnar to radial on the volar side to reinforce the pull
into extension.
 FIG. 19.13 Begin application by applying the plaster ½-inch
below the proximal end of the forearm and unrolling, leaving ½
inch of padding at the distal and proximal ends.

FIG. 19.14 A and B, Angle the plaster on the dorsum of the

hand, and tuck to continue unrolling in a radial-to-ulnar direction.
 FIG. 19.15 Forming a palmar arch.

7. To apply plaster through the web space, squeeze the plaster

together so that it lays in the middle of the padding. Angle the
plaster on the dorsum of the hand, and tuck to continue
unrolling radial to ulnar (Fig. 19.14A–B). Come through the
web space with the plaster only two to three times, or it may
become too bulky and cause difficulty using the thumb for
prehension.
8. After applying two to three rolls of plaster, form a palmar arch.
(Fig. 19.15). Use only the palm, and not the thumb or
fingertips, when applying counterpressure on the dorsum of
the cast to prevent indentation into the cast material.
9. Turn the stockinette over the plaster edge distally and
proximally, and secure with the plaster cast or plaster strips.
The felt strip at the thumb can be folded over and secured with
the stockinette for the web space.
10. Check for tightness at the distal and proximal end of the cast.
The completed wrist cast is shown in Fig. 19.16.
Cast Application for Soft Wrist Cast Using
Semirigid Soft Cast Material (Similar to the
Wrist Cast Procedure)
1. Measure stockinette from the olecranon to the PIP joint.
2. Cut a small ¼-inch slit approximating the placement of the
thumb, and apply the stockinette.

FIG. 19.16 Completed wrist cast.

3. Apply the felt strip to the following: one over the ulnar styloid.
4. Apply padding proximally approximately 2 inches below the
olecranon, and wrap circumferentially, overlapping by one-
third on each wrap. If bulking occurs at the narrow end while
wrapping the distal forearm, hold the padding and tear at the
opposite end to contour the forearm shape.
5. When wrapping around the thumb, pull up on the padding
going radial to ulnar on the dorsum of the hand above the
 wrist, and then from ulnar to radial on the volar surface to
reinforce wrist extension. Place the middle of the padding in
the middle of the web space. Tear the padding horizontally at
the third metacarpal on the dorsal surface. Wrap the lower half
of the padding around the metacarpal joint of the thumb.
Wrap back around the CMC and MCP joint of the thumb.
Repeat as needed. The padding around the thumb is required
to keep the sticky casting material away from the skin.
6. Apply the soft cast ½ inch below the proximal end of the
forearm, and unroll, leaving ½ inch of the padding at the distal
and proximal ends. Apply the soft cast again radial to ulnar on
the dorsal side and ulnar to radial on the volar side to reinforce
the pull into extension.
7. Wrap through the web space by cutting a slit, starting at the
third metacarpal on the volar surface of the soft cast and
moving toward the index finger on the dorsal side on the
distal third portion of the wrist cast material. The smaller third
portion of the cut cast material should lay on the web space as
the thumb is placed through the opening of the cast (Fig.
19.17).
FIG. 19.17 Wrap through the web space by cutting a slit for the
thumb to slide into.

FIG. 19.18 Forming a palmar arch.

 8. Apply the soft cast material through the web space, wrapping
two to three times depending on the size of the hand. Turn the
stockinette back over the edge on the distal and proximal end,
and secure the cast.
9. Form a palmar arch (Fig. 19.18). Using the palm to avoid
pressure from the thumb or fingertips, apply counterpressure
on the dorsum of the cast.
10. Check for tightness at the distal and proximal ends of the cast.
The completed wrist cast is shown in Fig. 19.19. Finish the
thumb area by removing the padding so that the thumb can be
incorporated into activities requiring prehension.
Long Arm Cast
Rationale for Use
The long arm cast can be effectively used for clients with minimal to
moderate involvement and spasticity of the arm. The long arm cast
may reduce the dominance of spasticity and assist with rebalancing
the antagonistic motor group. Furthermore, a common pattern of
clients with poor postural alignment is the forward shoulder, with an
abducted or downwardly rotated scapula. This position
biomechanically places the humerus into internal rotation, and the
upper extremity into elbow flexion, pronation of the forearm, and
flexion or ulnar deviation of the wrist with flexion of the fingers and
an adducted thumb or thumb-in-palm. The client often demonstrates
difficulty with dissociation of the wrist and forearm during active
grasp, decreased ability to extend the wrist using thumb-finger
opposition for grasp, and difficulty supinating the forearm during
lifting the object with the fingers. The malalignment of the joints and
tightening of muscles often prevent activities that require thumb-
finger opposition for fine prehension.
 FIG. 19.19 Completed wrist cast.

The long arm cast includes the elbow, forearm, and wrist. It is used
to simultaneously manage problems with alignment of the humerus,
elbow, forearm, and wrist. The long arm cast is the only cast effective
in controlling alignment of forearm rotation by incorporating the
wrist, as well as the elbow, into extension. This cast may be
inappropriate in the presence of extreme tightness throughout the
arm. Microtearing of the soft tissue may occur when tight muscles are
stretched over multiple joints. It is also contraindicated for use with a
client with a subluxed shoulder.
Clients can simultaneously work on proximal stability and improve
scapular control as they increase the strength of their shoulder girdle.
55 As the forearm and elbow soft tissue is gradually lengthened,

improvement may be seen in active forearm control and reach into

extension.
The long arm cast has also been used for children with brachial
plexus birth palsy, which affects the upper plexus involving the fifth
and sixth cervical nerve root. The long arm cast assists with
improving shoulder girdle alignment and strengthening shoulder
girdle and scapula stabilizers from the muscle imbalance. Often
children with brachial plexus injury posture the affected arm into
humeral internal rotation and compensate by lifting the affected arm
into humeral abduction, elbow flexion, and forearm pronation. The
long arm cast may reduce the habitual dominance of the arm posture
and assist with rebalancing the antagonistic motor group. Muscle
reeducation is important in facilitating isolated control, because
muscle weak ness is a common problem.

TABLE 19.9

Long Arm Cast Materials

In cases with muscle paralysis, such as a client with spinal cord

injury C5-6, the unopposed biceps may develop into a supination
contracture as the forearm is pulled into supination during elbow
flexion. Early positioning and long arm casting into pronation is
critical for assisting the client to work on hand-to-mouth patterns and
to eventually use an orthosis to facilitate a functional tenodesis for
tabletop skills. The bicep relaxes in the cast as the arm is positioned
into forearm pronation and the elbow is gradually extended. 18
To position the arm before the cast the therapist gently holds the
involved hand and positions the elbow into extension and forearm in
the desired position. The therapist then feels for the decrease in the
tension or pull of the arm. The therapist typically holds the arm at the
submaximal range while applying the padding and casting material.
Cast Application for Long Arm Using
Semirigid Soft Cast Material (Table 19.9)
1. Measure stockinette from the acromion, and on the posterior
aspect of the olecranon to accommodate for the length of the
material to the fingertips (Fig. 19.20), and approximate
placement of the thumb. Apply the stockinette (Fig. 19.21).
When the elbow is flexed 45 degrees or more, cut a slit in the
stockinette at the anterior elbow crease to prevent wrinkling of
the stockinette, similar to the elbow cast instruction.
2. Apply the felt strips to the following: one over the ulnar
styloid, and the two smaller strips for the thumb piece, similar
to the wrist cast.
3. Note: If the elbow is flexed 45 degrees or more, apply felt strips
similar to the elbow cast vertically across the olecranon, up on
the humerus, and down along the ulna. The horizontal strip is
across the olecranon covering the medial and lateral
epicondyles.
4. Apply padding as described for the elbow and wrist cast. If
applying semirigid soft cast, fewer layers of padding can be
used as the material can be unraveled and peeled off.
 FIG. 19.20 Measure the stockinette from the acromion to the
fingertips.

FIG. 19.21 Applying stockinette.

5. Apply the soft cast material ½ inch below the top of padding at
the axilla, down the humerus to ½ inch of padding at the distal
end.
6. Apply the soft cast material ½ inch below the proximal end of
the forearm and unroll, leaving ½ inch of padding at the distal
and proximal ends. Apply the soft cast again radial to ulnar on
 the dorsal side and ulnar to radial on the volar side to reinforce
the pull into extension.
7. Wrap the soft cast through the web space similar to the wrist
soft cast procedure. Cut a slit in the material so that the distal
width (one-third portion) of the cast material lays in the web
space as the thumb is placed through the opening of the cast.
Cut a slit in the soft cast to place the thumb through the
opening.

FIG. 19.22 Completed long arm cast.

8. Wrap the soft cast through the web space two to three times,
depending on the size of the hand. Turn the stockinette back
over the edge on the distal and proximal ends, and secure with
soft cast.
9. Form a palmar arch. Use one’s palm to avoid pressure from the
thumb or fingertips, and apply counterpressure on the dorsum
of the cast to prevent indentation.
10. Check for tightness at the distal and proximal end of the cast.
Finish the thumb area by removing the padding or leave in
place. The completed long arm cast is shown in Fig. 19.22.
Wrist Cast with the Thumb Included
Rationale for Use
The alignment of the wrist and forearm influences the ability of the
thumb to oppose the index and middle finger for prehension and
manipulation of objects. When the wrist is pulled into flexion and
ulnar deviation, the thumb is held in adduction and flexion, which
eventually develops into a shortened and tight web space. Improving
the muscle balance and joint alignment gained through a casting
program may stretch the tightness of the thumb and lead to improved
ability to use the thumb for functional activities.
A thumb-in-palm deformity is caused by abnormal muscle pull of
the flexor pollicis longus or brevis, adductor pollicis, and/or the first
dorsal interossei, which can lead to a fixed myostatic contracture. This
deformity prevents the thumb from participating in grasp and pinch.
The tightness and contracture of the thumb may cause shortening of
the web space, an unstable MCP joint, or an overstretched extensor
pollicis longus and brevis.
A wrist cast with the thumb included can improve the range into
thumb abduction and extension and gradually improve palmar
expansion. Opening the hand and bringing the thumb out of the palm
assists with the development of the transverse or carpal arch, as well
as the oblique arch, formed when the thumb moves toward the fingers
for opposition.
It is important to contour the casting material at the thenar
eminence, supporting the MCP and interphalangeal (IP) joint of the
thumb. The thumb should be gradually stretched and the material
molded in the web space to assist in providing palmar expansion and
stability. Gradual positioning of the thumb in a stretched position is
provided at submaximal range to elongate the thumb extensors and
abductors, with the wrist in neutral or in 10 to 15 degrees of extension.
A series of casts that provides a slow, gradual stretch prevents
overstretching or pain in the thumb. This is key for rebalancing
muscle forces and controlling the opposing muscle groups. Follow-up
after casting may include a night orthosis to maintain the thumb in
good alignment and strengthening to optimize functional use of the
hand and thumb.
A wrist cast with the thumb enclosed may assist with stabilizing a
dystonic thumb with hyperextension at the IP or MCP joint and
tightness of the thenar eminence. The client practices grasp and
release of objects with the wrist and thumb stabilized in the cast. The
distal IP joint is stabilized with the enclosed cast, or the cast can be
wrapped proximal to the IP joint or IP crease to allow the client to
practice distal IP control.
Careful evaluation and palpation is needed to assess the best
position of the thumb to promote a gentle stretch, or to provide
stability, as indicated.

Casting Materials
A moldable material is needed for wrapping around the thumb,
providing contour of the palmar arch, thenar eminence, and enclosing
the thumb. Plaster cast material or polyester soft cast is recommended.
Fiberglass material will not conform to the thumb or provide the
needed molding of the hand (Table 19.10).

Cast Application for Thumb-Enclosed Wrist

Cast Using Polyester Soft Cast
1. Apply the stockinette and felt strips as described for wrist cast.
2. Wrap the forearm as described for padding the wrist cast.
3. Another method for wrapping the thumb is to go up the center
of the web space with the padding and tear horizontally to
angle the padding toward the thumb. Wrap snuggly around
the thumb beyond the IP joint two times. On the third time
around come up through the web space; check that the CMC
joint and thenar eminence are covered with the padding (Fig.
 19.23). Continue to wrap around the thumb, covering the
thenar eminence.
4. Apply this cast similar to the wrist cast, using the polyester soft
cast material or plaster.
5. Wrap the material between the web space, angle slightly
toward the MCP joint of the thumb, and wrap the material two
to three times around the thumb, depending on the size of the
hand (Fig. 19.24). Bring the material up through the web space
on the dorsal side of the hand and around the volar surface
and back up through the web space.
6. Turn the stockinette back over the soft cast, and secure the
edges with the material.
7. Form the palmar arch, and contour the thenar eminence,
supporting the MCP and IP joint of the thumb.
8. Allow the tip of the thumb to be seen, and trim the padding on
the edges of the thumb for the skin to be monitored. The
completed thumb-enclosed wrist cast is shown in Fig. 19.25.

TABLE 19.10

Thumb Enclosed Wrist Cast Using Plaster or Polyester Soft Cast Material
FIG. 19.23 An alternate method: Wrap the thumb from the center of
the web space with the padding, and tear horizontally to angle the
padding toward the thumb.
 FIG. 19.24 Wrapping the material between the web space and
angling slightly toward the metacarpophalangeal joint of the thumb.
FIG. 19.25 Completed thumb-enclosed wrist cast.
Metacarpophalangeal Wrist Cast
Rationale for Use
When weakness of the intrinsic muscle or spasticity of the lumbricals
causes flexion contractures of the MCP joints, this inhibits the client
from fully extending at the distal PIP and IP joints of the fingers. For a
client with spasticity the pull of the intrinsics into flexion at the MCP
joint can lead to an intrinsic plus hand and further lead to a myostatic
contracture. The MCP cast can be applied just distal to the MCP or PIP
joint to allow the client to actively work on end-range finger
extension. This cast positions the wrist and finger MCP into extension
and facilitates active finger extension. The support of the distal cast
beyond the MCP joint or PIP joint assists with gradual elongation of
the intrinsic musculature to facilitate active extension of the IP joints
when the MCP joints are extended.
End the distal portion of the cast where the fingers require the
support, to gradually assist with active end range of finger extension,
or to lengthen the long finger flexors in the presence of intrinsic
muscles tightness.
The MCP cast is used to gradually improve the tightness of the
intrinsic muscles to improve finger extension, thus improving the
ability of opening of the hand for grasp-and-release functional
activities.

Casting Materials
Any casting materials can be used for the MCP cast (Table 19.11).
Refer to the wrist cast materials, and apply the cast according to the
procedure.

Cast Application for Metacarpophalangeal

Wrist Cast Using Semirigid Soft Cast
1. Apply the stockinette from the olecranon to the DIP joints and
approximate placement of the thumb. Cut a straight slit for the
thumb.
2. Apply the felt strips as described for the wrist cast, to the ulnar
styloid and thumb.
3. Wrap the forearm as described for padding the wrist cast.
4. Wrap padding around the thumb to prevent the sticky material
from adhering to the skin of thumb. Apply the padding
proximally extending three-fourths the length of the forearm
and distally beyond the MCP joint or PIP joint depending on
your assessment.
5. Apply the soft cast similar to the wrist cast. Apply the cast
material ½ inch below the padding proximal, and end the
material ½ inch distal to the padding.
6. Apply the soft cast material radial to ulnar on the dorsal
surface of hand, and ulnar to radial on the volar surface. Cover
the thumb CMC joint wrap radial to ulnar on the dorsal
surface. Lay the soft cast going up through the web space so it
lies partially in the trough formed by the padding and past the
MCP joints (Fig. 19.26). Continue the soft cast ½ inch to the
distal padding
7. Turn the stockinette back over the soft cast, and secure the
edges with the material.
8. Form the palmar arch.
9. Finish the thumb area by removing the padding or leave in
place. The completed MCP wrist cast is shown in Fig. 19.27.
FIG. 19.26 Application of soft cast material in a radial-to-ulnar
direction on the dorsal surface of the hand.
 FIG. 19.27 Completed metacarpophalangeal wrist cast.

TABLE 19.11

Metacarpophalangeal Wrist Cast Using Plaster or Semirigid Soft Cast Material

Metacarpophalangeal Wrist Cast to
Increase Flexion of the
Metacarpophalangeal and Proximal
Interphalangeal Joints
Rationale for Use
In an intrinsic minus hand there is hyperextension of the MCP joints
and flexion of the PIP joints, referred to as a claw hand. The claw hand
is caused by paralysis of the interossei and lumbrical muscles. The
client can flex and extend the fingers with the MCP joints in
hyperextension or extension but is unable to flex at the MCP for fine
prehension. For example, a client with significant burns on the
dorsum of the hand with scarring can pull the fingers into
hyperextension at the MCP, which leads to an intrinsic minus hand
with myostatic contractures.
The MCP wrist cast can be applied just distal to the MCP or PIP
joint to work on increasing range into MCP and PIP flexion. When
using the soft cast material, it is difficult to position the MCP into
flexion, because of the flexibility and sponginess of the material. After
applying the padding, a piece of Aquaplast is draped over the dorsum
of the forearm and MCPs. The Aquaplast is pulled to hold the MCP
joints in the position needed to improve flexion. The soft cast material
is then applied, similar to the MCP wrist cast. The MCP cast for the
intrinsic minus hand is used to gradually improve the tightness of the
MCP for improved hand grasp and release and fine prehension.

Casting Materials
Semirigid Soft Cast Materials
This technique is used when working with a client when you want the
client or caregiver to be able to remove the cast at home if issues arise
(Table 19.12).

Cast Application for Metacarpophalangeal

Wrist Cast Using Soft Cast
1. Apply the stockinette from the olecranon to the DIP joints and
approximate placement of the thumb. Cut a straight slit for the
thumb.
2. Apply the felt strips as described for the wrist cast.
3. Wrap the forearm as described for padding the wrist cast.
4. Wrap padding around the thumb to prevent the sticky material
from adhering to the skin of the thumb. Apply the padding
distally, extending three-fourths the length of the forearm and
distally beyond the MCP joint or PIP joints, depending on
needs per assessment.
5. Drape the Aquaplast on the dorsum of the hand over the
padding, and pull the MCP and PIP joints into flexion while
holding the splint material (Fig. 19.28).
 FIG. 19.28 Drape the Aquaplast on the dorsum of the hand over
the padding, and pull the metacarpophalangeal and proximal
interphalangeal joints into flexion.

TABLE 19.12

Metacarpophalangeal Wrist Cast Using Semirigid Soft Cast Material and

Aquaplast

6. Apply the cast similar to the MCP wrist cast over the
Aquaplast to position in place. Apply the cast material ½ inch
 below the padding proximal and end the material ½ inch
distal to the padding.
7. Turn stockinette back over the soft cast, and secure the edges
with the material.
8. Form the palmar arch. The completed MCP wrist cast to
increase MCP flexion is shown in Fig. 19.29.
Functional Cast Therapy
Functional cast therapy (FCT) is a casting method using Delta-Cast
Conformable Polyester Cast Tape to apply a form-fitting orthosis that
is molded directly onto the client’s hand. The knitted polyester
material is easy to apply and molds similar to plaster or semirigid
polyester soft cast. The material provides the rigidity needed to
support specific joints and also offers the flexibility for areas where
immobilization is not required. The material is easy to apply and is
used for a variety of orthotic needs. Further information on the
different types of functional cast therapy applications is described in
the application manual using Delta-Cast Conformable by BSN
Medical, Inc.
Thumb Spica with Functional Cast
Therapy Materials
Rationale for Use
The thumb spica orthosis is used to decrease movement and provide
support and comfort through stability of an injury. It is often used for
clients with de Quervain tenosynovitis, traumatic thumb injuries, or
rheumatoid arthritis. Stabilizing the thumb and wrist can also be used
to manage dystonia or hypertonicity, which positions the thumb in
palmar flexion and adduction. By positioning the thumb in abduction
and opposition of the index and middle fingers, motions for
functional prehension are possible. The position of the thumb in a
thumb spica orthosis varies depending on the client’s diagnosis.

FIG. 19.29 Completed metacarpophalangeal wrist cast.

Functional Cast Therapy Materials
(Table 19.13)
Cast Application for Thumb Spica Using
Delta-Cast Conformable
1. Apply the thumb stockinette liner with the padded side on the
client’s skin.
2. Apply sticky-back foam over the ulnar styloid on the
stockinette.
3. Insert the cutting strip under the stockinette on the dorsal side
of the forearm and hand, covering the area to be casted (Fig.
19.30).
4. Before applying the FCT cast decide what part of the wrist
splint requires stabilization to support the hand (three to four
layers to provide stability) and what part of the splint can
remain flexible.

TABLE 19.13

Functional Cast Therapy Using Delta-Cast Conformable

 FIG. 19.30 Insert the cutting strip under the stockinette on the
dorsal side.

a. Measure the desired length from palm to proximal

third of the forearm. Place the three to four layers
on the volar surface of the hand (Fig 19.31). The
holder can assist with holding in place. Note: The
layers do not need to be placed in the water.
5. Place the remaining roll in the water, and begin to unroll. Start
at the proximal end unwrapping around the forearm with two
layers. Overlap each layer by half the width of the material,
unwrapping the cast down to the CMC joint. Remember
overlapping by half, and continue in a radial-to-ulnar direction
(Fig. 19.32). Continue up through the web space.
6. Wrap around the thumb to the IP joint two times while having
the holder maintain the position of the thumb in abduction.
Come back up around the dorsum of the hand over the MCP
joint.
7. Form the palmar arch and thenar eminence, and rub the
remaining cast (Fig. 19.33). Place gloves in the water before
rubbing in the cast. Once the tackiness is gone, then the cast is
 ready to be cut off.
8. To remove the cast, place the scissors on top of the cutting
strip. Gently squeeze the cast in the area you are cutting and
work your way down the cast (Fig. 19.34).

FIG. 19.31 Measure the desired length from palm to proximal

third of the forearm, placing three to four layers on the volar
surface.
 FIG. 19.32 Overlap the casting material by half in a radial-to-
ulnar direction.

9. Reposition the cast on the client’s hand, and decide what area
needs to be trimmed to improve the fit of the splint. Mark
directly on the cast the areas on the dorsal and volar surface
(e.g., palmar crease) that can be trimmed to provide MCP
flexion to all of the fingers (Fig. 19.35). If some areas are too
difficult to trim, use the special small tin snip–like scissors for
the rigid areas.
FIG. 19.33 Form the palmar arch and thenar eminence, and rub
the remaining cast.

FIG. 19.34 Gently squeeze the cast in the area you are cutting,
 and work your way down the cast.

FIG. 19.35 Mark directly on the cast the areas on the dorsal and
volar surfaces to trim to allow metacarpophalangeal flexion.
 FIG. 19.36 Apply the Velcro stretch loop to complete the
orthosis.

10. Complete the orthosis by placing the adhesive fleece edger

around the edges of the orthosis. Once the orthosis is totally
dry, apply the adhesive hook. Use a heat gun to heat the sticky
side of the adhesive hook before applying to the orthosis.
Once the heated hook Velcro is applied to the orthosis, rub the
Velcro with the blunt edge of the scissors to secure it to the
material. Apply the 1-inch or 2-inch Velcro stretch loop to
complete the orthosis. The completed thumb spica is shown in
Fig. 19.36.
Cast Removal
As discussed, some types of casting material require removal with a
cast saw or cutter, and others constructed of materials, such as the
FCT, that can be cut off with scissors. With respect to the cast saw, the
therapist must (1) be knowledgeable about how to safely operate the
cast saw, (2) be familiar with the cast removal techniques, and (3) be
knowledgeable about use of the equipment. Staff must complete
competency training by a qualified staff member who is experienced
in the use of a cast saw. A system of checking for equipment
maintenance must be established to ensure that the cast saw and blade
are in proper working condition.
The most common cast saw is the electrically motorized cast cutter.
Some of the cast cutters are attached to a cast dust vacuum that has a
strong airflow, facilitating hygienic surroundings. Safety glasses are
worn to protect the eyes of the client and therapist during the cutting
procedure. The blade of the cast saw does not rotate but rather
oscillates back and forth for an excursion of approximately ⅛ inch.
The therapist should explain to the client by demonstrating how the
blade oscillates and touch lightly on their own hand to show how the
saw works (Fig. 19.37). The blade is designed to cut through plaster or
fiberglass and is not intended to cut through padding or stockinette.
When properly used, the cast saw should not cause damage or
abrasion to the skin. The sound of the cast saw can be loud; therefore
when working with children, headphones can be used to muffle the
sound of the saw.
The technique for using the saw requires the therapist to grip the
cast saw securely by the handle and hold it perpendicular to the cast
using a down-and-up motion to cut. When cutting down into the cast
material with the saw, the therapist will feel a “give.” Pull the saw up
as soon as a “give” in the material is felt (Fig. 19.38). Do not leave the
saw in the casting material for an extended period as the blade
becomes hot. If there is more than one cast saw, dedicate one cast saw
for cutting fiberglass and one for removing plaster. The blade for
cutting the fiberglass may require more frequent changes, and the use
of a vacuum attachment assists with control of airborne fiberglass
material.

FIG. 19.37 Explain to the client how the cast saw works by
demonstrating on your own hand.
 FIG. 19.38 Pull the saw up as soon as a “give” in the material is felt.

When using the cast as a bivalve orthosis, determine and mark the
cut line before cutting. Avoid cut lines over the antecubital fossa and
olecranon (Fig. 19.39).

Use of a Cast Cutter

Hold the cast cutter securely by the handle in the middle of the saw.

1. Press down firmly until a “give” is felt in the material. When

there is less resistance, the saw has cut through the plaster or
fiberglass. Lift the saw up, then place the saw back down,
going only up/down.
2. Do not leave the saw down in the cast for extended periods or
use the saw to cut or run parallel across the cast. This
overheats the blade and may cause a burn to the client. If the
cast saw is hot, allow the motor to cool.
3. Insert a cast spreader between the cut area of the cast, and
spread the edges apart (Fig. 19.40).

FIG. 19.39 When using the cast as a bivalve orthosis,

determine and mark the cut line before cutting, and avoid lines
over the antecubital fossa and olecranon.
 FIG. 19.40 Insert a cast spreader between the cut area of the
cast to spread the edges apart.

4. Use bandage scissors to cut the padding, gliding the scissors on

the stockinette (Fig. 19.41).
5. Pull up the stockinette so there is no pressure from the bandage
scissors felt on the client’s skin, and cut the stockinette (Fig.
19.42).

Removing Semirigid Soft Cast

The soft cast materials can be removed by unwrapping the layers or
cutting off with bandage scissors (Fig. 19.43). The use of a cast saw is
not recommended as this material is flexible and less padding is used.
When the cast is completely dry, demonstrate how to unwrap the soft
cast material by unraveling a small amount and then trimming the
edge. If the cast feels too tight, inform the caregiver that a small
amount of the casting material can be unwrapped instead of removing
the entire cast.
FIG. 19.41 Use a bandage scissors to cut the padding while gliding
the scissors on the stockinette.
FIG. 19.42 Pull up the stockinette to avoid pressure on the skin from
the bandage scissors.
FIG. 19.43 Soft cast materials can be removed by unwrapping the
layers or cutting with a bandage scissors.
Summary
A thorough assessment of underlying tissue causing joint restrictions
is critical to determine the effectiveness of any casting program. The
evaluation assists clinicians with determining what type of cast to use.
Furthermore, the assessment findings guide the therapist with sound
clinical reasoning for cast implementation.
References
1. Ahmed S.S, Carmichael K.D. Plaster and synthetic
cast temperatures in a clinical setting: an in vivo
study. Orthop . 2011;34(2):99.
2. Autti-Ramo S.J, Anttila H, Maimivaara A, et
al. Effectiveness of upper and lower limb casting and
orthosis in children with cerebral palsy: an overview
of review articles. Am J Phys Med Rehabil
. 2006;85:89–103.
3. Bennett G.B, Helm P, Purdue G.F, et al. Serial casting:
a method for treating burn contractures. J Burn Care
Rehabil . 1989;10(6):543–545.
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Appendix 19.1 Case Studies
Case Study 19.1 a

Read the following scenario, and answer the questions based on the
information in this chapter.
Ella is a 10-year-old girl who has spastic cerebral palsy (CP) and is
dependent on her parents to assist her with most of her daily care. Her
family includes her parents and a younger brother. She has moderate
to severely increased muscle tone in all four extremities with reduced
tone in her trunk. She takes oral baclofen in the morning to assist with
managing her tone. Ella’s functional use of her upper extremities is
limited because of limited active control and both hands present with
increased tone. Mother reports that during the winter months it is
extremely difficult to position her wrist through the sleeves of her coat
because of the flexed and myostatic contracture of her wrist. Her
range of motion at both wrists is 100 degrees flexion to 60 degrees
wrist flexion. Modified Ashworth Scale of her wrist flexors is 3, with
considerable increase in muscle tone, and passive movement is
difficult. Ella displayed severe hypertonicity with a stretch reflex felt
at the beginning of range, at 85 degrees of flexion. Functional
classification is 0, she does not use. Ella has been unable to be
positioned in a night orthosis because of her tightly fisted hands. Ella
is scheduled to be seen by her physiatrist to receive a botulinum toxin
type A (BtA) injection. The physician will place the BtA into her wrist
to relax the flexors and long finger flexors and to decrease the pull
into flexion.
You will be following up with Ella’s intervention program to
address the tightness in both of her hands.

1. What are three baseline evaluations that should be used?

2. What are two different types of cast that you may consider?
What is the rationale for each?
3. In what position should the wrist be placed in the initial cast?
 4. How long should each cast be applied in the series?
5. What follow-up should be provided after casting?
6. What is the primary goal for casting Ella?

Case Study 19.2 a

Paul is a 25-year-old man who was injured in a motor vehicle
accident. He was hospitalized for 6 weeks and in a coma for 4 of the 6
weeks. When he was admitted for rehabilitation, Paul showed only
localized response to visual and auditory stimuli. He responded to
simple yes/no questions inconsistently, and displayed a mass flexor
response with imposed movement with his arms.
Paul’s posture was markedly asymmetrical, with his head rotated
and laterally flexed to the left. The left upper extremity exhibited a
strong flexor pattern, and the right was moderately involved, with
minimal active movement. Minimal passive motion could be achieved
with relaxation and positioning techniques, but increased
spasticity/stiffness and myostatic upper extremities deformities were
present bilaterally. No spontaneous motion in the upper extremities
was present with the exception of the mass flexor synergy pattern of
flexion at the elbow, wrist, and hand.
Treatment goals were to decrease the spasticity, correct deformities,
and mobilize the upper extremities using casting and
neurophysiological treatment techniques. The typical resting position
of the left extremity was 105 degrees of elbow flexion, with the wrist
and fingers flexed. The right elbow is positioned in 60 degrees of
elbow flexion, with the wrist flexed, and tightness of the lumbricals.
Bilateral casts were indicated, but the casting schedule needed to be
coordinated to avoid simultaneous casting of the upper extremities.
Significant range-of-motion gains, as well as increased volitional
movement, were achieved after the casting program, right more than
left upper extremity.

1. Because of the severe increased tone of the left arm, which two
casts are the most appropriate to use initially?
 a. Rigid circular elbow cast
b. Rigid circular wrist cast
c. Long arm cast
d. Rigid circular elbow cast with use of a cone or roll
orthosis to position hand
2. The right arm was moderately involved. Which cast is the most
appropriate to use initially for the right upper extremity?
a. Rigid circular elbow cast
b. Rigid circular wrist cast
c. Metacarpophalangeal wrist cast
d. Wrist cast with thumb enclosed
3. Which of the following is/are the most appropriate baseline
assessment(s) during the initial inpatient rehabilitation stay?
Select all that apply.
a. Range of motion
b. Modified Ashworth Scale
c. Stereognosis
d. Manual muscle test
e. Functional arm and hand placement
4. Between the series of casts, which of the following should be
focused on? Select all that apply.
a. Remove and replace cast to incorporate gains from
one cast to the next.
b. Remove cast and let the skin breathe overnight, and
cast the next morning.
c. Measure range of motion.
d. Evaluate the skin for any red areas or breakdown.
Appendix 19.2 Laboratory Exercise
Laboratory Exercise 19.1
Choose one of the casts described in the chapter, and ensure that you
have the necessary materials to apply and remove the cast. Before
starting, determine the correct position to place your partner’s hand,
wrist, forearm, elbow, etc. After fitting the cast, practice educating
your partner on the cast care and precautions using Table 19.4.
Appendix 19.3 Review a
Upper Extremity Casting Competency
Checkout
Therapist ________________________________________ Date:
________________________

1. Why are casts applied?

2. What are two contraindications for application of a cast?
3. What three factors may necessitate special consideration in
application and monitoring?
4. What type of cast would you choose for the following
problems?
a. Ninety-degree elbow contracture, moderate muscle
tone
b. Humeral internal rotation, elbow flexion, pronation
contracture, mild spasticity
c. Wrist contracture with thumb-in-palm
d. Spasticity/tightness/weakness of the lumbricals and
posturing in metacarpophalangeal flexion
e. Hypertropic scarring at anterior crease of elbow,
elbow flexion contracture from burns
5. Indicate the removal technique for each of the materials listed.
Options are cast saw, unravel, cutting strip, bandage scissors.
a. Fiberglass ______________
b. Semirigid soft cast _______________
c. Delta-Cast Conformable (functional cast therapy)
______________
d. Plaster _______________
6. Match the number with the letter with the use of the casting
saw procedure.
1. Explanation of cast cutter procedure
2. Holding cast cutter and cutting
3. Use of cast spreader
4. Cutting padding
5. Cutting stockinette
6. Bivalve technique for elbow bivalve
a. Place the bandage scissors onto the stockinette to
assist with cutting so the bandage scissors do not
contact the skin.
b. Press firmly down and in.
c. Insert in the cut area of the cast, and spread apart.
d. Pull up the stockinette so there is no bandage
scissor felt on skin.
e. Draw on the medial and lateral epicondyles.
f. The cast saw blade oscillates back and forth.
Appendix 19.4 Checkout Procedure
Name: ___________________ Date: __________________
Laboratory: Application procedure staff checkout.
Choose one of the following casts to be checked out:

• Rigid circular elbow cast

• Rigid circular wrist cast
• Long arm cast
• Wrist cast with thumb enclosed
• Metacarpophalangeal (MCP) wrist cast—intrinsic plus
• MCP wrist cast—intrinsic minus
• Functional cast therapy (FCT)
• Precast evaluation documented, physician’s order,
nursing notified (if inpatient)
• Preparation of materials

a See Appendix A for the answer key.

a See Appendix A for the answer key.
a See Appendix A for the answer key.
20
Upper Extremity Prosthetics
Debra Latour, and Kris M. Vacek

CHAPTER OBJECTIVES
1. Differentiate between various levels of upper extremity
amputation as it relates to function.
2. Describe the many causes of an upper extremity amputation.
3. Differentiate the roles of the prosthetic team members.
4. Explain the unique role of the occupational therapist as a team
member in upper extremity prosthetic rehabilitation.
5. Identify the characteristics of numerous upper extremity
prosthetic devices.
6. Identify advantages and disadvantages of various upper
extremity prosthetic devices.
7. Describe the phases of rehabilitation from an occupational
therapy (OT) perspective.
8. Provide examples for OT intervention.
9. Explain why individuals with upper limb acquired loss or
congenital difference are likely to develop secondary conditions.
10. Describe the physical and psychosocial disparities often
experienced by the population.
11. Discuss strategies for marketing upper extremity prosthetics
specialty area to the wider community.
KEY TERMS
biofeedback
body-powered prosthesis
componentry
contralateral limb
electrodes
externally powered prosthesis
grip force
harness
hook rubbers
hybrid prosthesis
myoelectric prosthesis
nerve entrapment
osseointegration
overuse syndrome
pattern recognition
phantom pain
phantom sensation
prosthesis
“prosthosis”
psychosocial-emotional impact
radio-frequency identification (RFID)
residual limb
socket
targeted muscle reinnervation (TMR)
terminal device (TD)
3-D printed device
voluntary closing
voluntary opening

Gary is a 52-year-old man who owns and works on his farm.

Unfortunately, the drawstring to Gary’s sweatshirt hood got caught in
an auger and pulled his left, nondominant hand into the auger. The
surgeon completed a transhumeral-level amputation. The team of
physicians caring for him sent a referral to occupational therapy to see
Gary. What does the occupational therapist do? What should be expected
of the occupational therapist’s contribution to Gary’s rehabilitation?

Orthotics and prosthetics are closely interrelated fields. This chapter

serves as a resource for those therapists who serve this historically
underserved population. There are approximately 2 million people in
the United States who are living with a limb loss. 60,61 Approximately
185,000 amputations occur in the United States each year. 60 The
incidence of upper extremity amputation is lower than the incidence
of lower extremity amputation (1:4 ratio). 5 In the population with
upper limb loss, the most common loss is a partial amputation of one
or more digits, with loss of one upper extremity as the next most
common loss (60% at the transradial level). Every year approximately
2000 Americans experience new upper limb amputations at, or
proximal to, the wrist. 4
Approximately 50% of individuals with amputations are fitted with
prostheses. 58 Of the 50% fitted with prostheses, only half actually
wear the device. Experts cite numerous reasons for this trend. 76 Fit
and prosthetic training appear to be the most salient factors that affect
prosthetic wear. 13 Prostheses may be heavy and awkward to use. If
the fit is not tolerable, or if the potential wearer has not been properly
trained to use the device, the prosthesis may end up on the closet
shelf. The purpose of an upper limb prosthesis depends on the client’s
goals. However, most prostheses assist in restoring participation in
meaningful functional activities, as well as improving body image and
cosmesis. 86 In collaboration with the health care team, the role of the
prosthetist is to provide well-fitting prosthetic devices. It is the role of
the occupational therapist (OT) to assist individuals in becoming
independent users of their devices. In addition, the OT can be
instrumental in helping to determine the most appropriate technology
to be provided and in assisting the client with developing realistic
expectations of the technology. 2,3
Unfortunately, only a small number of health care providers have
extensive knowledge of the rehabilitation of the person with an upper
extremity amputation. Typically, therapists may encounter few
individuals with upper extremity amputations. Thus it is difficult to
remain abreast of the current prosthetic trends and technological
developments that affect how therapists promote the maximal level of
independence for clients with upper extremity amputations.
However, OTs can make a substantial difference in the lives of
individuals with amputations if they possess knowledge of the
various factors that impact the life of a person with an amputation.
Individuals with upper limb loss or congenital difference (ULL/D)
are at risk for experiencing further disparity due to overuse of the
sound side. Several studies have documented the presence of pain
and musculoskeletal conditions affecting the function of the sound
arm in individuals with unilateral ULL/D. 9,46,62 Gambrell 38
conducted a review of the literature noting the consequences and
importance of prevention of overuse syndrome with
recommendations for a team approach, emphasizing practitioner
responsibility to educate patients to the likelihood of overuse and
methods that impede development.
Many individuals who experience acquired limb loss report that
they were given little to no information by medical professionals. 4,5
Recently Sheehan and Gondo 74 reported on the effect of limb loss in
the United States, recognizing that each well-trained member of the
specialized amputee rehabilitation team has a specific and important
role in the care and recovery of people with limb loss. They cited the
need for interventions to address secondary conditions affecting
physical and mental health because current standard medical
treatments often exclude psychosocial interventions. The authors
emphasized that “those with limb loss in America have been forgotten
in the health care system” 74 (p. 9) because there is no active medical
surveillance.
Therapists who treat persons with orthotic needs will naturally be
called upon to provide services to persons with upper extremity
amputations. Thus it is important for therapists to know how to access
the information needed to provide OT to individuals with upper
extremity amputations.
This chapter addresses the following content:

• Reasons and causes for amputations

• General knowledge of upper extremity amputations and their
impact on function
• Roles of team members and the importance of collaboration
• Various prosthetic options and components
• Goals for OT intervention throughout the prosthetic
rehabilitation process
• Psychological and social issues of clients with amputations
• Upper extremity prosthetic intervention for children
• Marketing strategies and recommendations

:
Reasons and Causes for Upper
Extremity Amputations
The causes of upper extremity amputations differ from lower
extremity amputations. Lower extremity amputations are largely a
result of vascular disease. Most of upper extremity amputations result
from trauma (69%), and a majority of these are due to war causalities
30,31 with other causes attributed to disease (27%) or congenital

malformation (4%). 30 It is estimated that the number of individuals

living with limb loss will more than double by 2050. This is largely
due to the rise of vascular disorders. 30,89
General Knowledge of Upper Extremity
Amputations and their Impact On
Function
Amputation Levels
Fig. 20.1 provides an outline of the various amputation levels, along
with their abbreviations. Older terminology included above elbow
(AE) and below elbow (BE); however, newer terminology cites the
anatomical level of amputation. 40,77 For example, AE is referred to as
transhumeral, and BE is referred to as transradial. The level of
amputation directly impacts function.
With levels of amputation there is an inverse relationship between
the amputation level and function. The more distal the amputation,
the greater the functional ability of the extremity remains.
Consequently, less is demanded of the prosthesis with increasingly
distal amputations. 40 For example, an individual who has an
amputation at the midhumeral level may be functionally able to use
shoulder internal and external rotation along with other shoulder
motions. However, the individual lacks the functional motions of
elbow flexion/extension and forearm supination/ pronation, causing
functional limitations. In addition, amputations through the joint,
such as at the shoulder, elbow, or wrist, present challenges of fit with
componentry to provide the function of the particular joint. For
example, if the residual limb is amputated through the elbow (or too
close to it), there is not enough space for a prosthetic elbow
component; the concern is that the prosthetic device will appear to be
asymmetrical to the contralateral limb. Regardless of level, prostheses
help to compensate for the lost motions, but limitations remain. For
example, when an individual with a midhumeral amputation wants to
receive money from a cashier, more effort is required because of the
functional limitations in motion. Compare this with someone whose
limb loss is at the transradial level, where often some forearm motion
is retained, allowing greater functional capacity of the upper
extremity. More specifically, positioning and locking the elbow in
flexion is necessary for the individual with the transhumeral loss.
Next, the person manually rotates the terminal device (TD) to the
palm-up position with the sound side. Finally, the person is ready to
perform the act of receiving the money. Conversely, an individual
with an amputation at the wrist level is functionally able to pronate
and supinate, flex and extend the elbow, and retain full shoulder
function in the completion of activities of daily living (ADLs). The
ability to pronate and supinate serves as a substantial advantage.
Supination and pronation enable the person with the amputation to
turn the prosthetic hand palm up as if to receive money from a cashier
without the substitution movements of shoulder external rotation.
 FIG. 20.1 Levels of upper extremity amputation.

If an individual chooses to wear a prosthesis, the level of

amputation appears to impact satisfaction. In a survey conducted in
2006, 93% of 109 respondents with an upper extremity amputation
reported owning a prosthesis, whereas 12% of those respondents
reported they did not wear it regularly. 4 A majority of those surveyed
reported satisfaction with their prosthesis, but one-third reported
dissatisfaction with it. 4 Contributing factors to dissatisfaction
specifically include socket fit, comfort level, appearance, weight, and
ease of use. Additionally, one-fourth of those surveyed received
therapy, and the average number of visits was 25. Twenty percent of
those who did not receive therapy reported cost as the leading factor
preventing them from receiving the services they needed. 4
Role of Team Members and the
Importance of Collaboration
The team treating clients with amputations must have knowledge of
the diverse upper extremity prosthetic technology to facilitate success.
The key team members consist of the client with the amputation, the
prosthetist, and the therapist. Other important members include the
surgeon, case manager or life care planner, psychologist, physical
therapist, and the insurer/reimbursement source. A team approach
combines expertise and experience, creating a synergy of
professionalism, with team members working together and promoting
the maximal level of independence for the individual. The primary
goal of therapy is to provide the individual with the proper tools and
techniques to regain independence; however, OT is only one
dimension of the entire process. The best results in upper extremity
rehabilitation include interdisciplinary collaboration. 12

The Client
The most important member of the team is the person with the
amputation. Throughout the assessment and intervention process,
several key factors of the client are considered, including specific
abilities, characteristics, or beliefs. 3 Factors such as the level of
amputation, musculature, skin condition, range of motion, ability to
learn, motivation, and values all contribute to the degree of
participation in occupations.
The client’s goals, desires, and needs establish the foundation for
which the team develops the intervention plan. Clients’ priorities for
rehabilitation vary. It is important to ensure that clients are realistic
with their expectations and are well educated in the prosthetic options
available to them. Education can come from both the prosthetist and
OT. The prosthetist discusses the various prosthetic options available,
whereas the OT discusses the functional aspects of each device. This
process is important because it helps the key team members formulate
the individual intervention plan necessary for successful prosthetic
delivery and use. 55 For example, an individual with a transhumeral
amputation who works full-time in a factory and desires to return to
work will have different needs from an individual with a transradial
amputation who is a homemaker. The type of prosthesis selected
differs, depending on a precise analysis of the client’s desire to
participate in meaningful occupations. 3

The Prosthetist
Orthotics and prosthetics are closely interrelated fields. Forty-one
percent of practitioners certified by the American Board for
Certification in Orthotics, Prosthetics and Pedorthics hold credentials
in both orthotics and prosthetics, and fewer practitioners specialize in
upper extremity prosthetic fabrication. 2 Because the incidence of
upper extremity amputations is less than lower extremity
amputations, it is important for the prosthetist to have specialized
training and experience in fabricating and fitting upper extremity
prostheses. Prosthetists have knowledge of the technology and
prosthetic componentry available. Technology for upper extremity
prosthetics has significantly evolved since 1976 due to research and
development in related technology, such as cell phones, computers,
and video games. 17 Prosthetists are experts when it comes to fit and
fabrication. Upon prosthetic delivery, prosthetists introduce, educate,
and orient the clients about the controls and functions, all of which
should be reinforced by the OT. In an ideal setting, prosthetists and
therapists collaborate throughout the entire intervention process from
assessment of prosthetic needs to return to occupational performance.

The Occupational Therapist

Unfortunately, only a small number of therapists have extensive
knowledge of the rehabilitation of the person with an upper extremity
amputation. In many practice settings, therapists rarely treat clients
with upper extremity amputations. Thus, it is difficult to remain
abreast of the current prosthetic and technological developments.
Such advances affect how therapists promote the maximal level of
independence for these clients. However, OTs can make a substantial
difference in individuals with amputations when they possess
knowledge of prosthetic intervention.
Occupational therapists’ expertise relates to function and
occupational performance. Therapists typically work with clients
throughout the entire prosthetic rehabilitation process. Each phase of
recovery presents its own challenges and demands. Without proper
therapy the benefits of prosthetic use may be limited. For example, the
therapist may see the client immediately following surgery to address
postsurgical issues, including pain, edema, wound healing, and
shaping of the residual limb. In addition, OT interventions may
beneficially impact successful transfer of hand dominance, awareness
and prevention of secondary conditions, and changes in body image.
The OT plays an important role as the client explores the various
prosthetic devices. Finally, the therapist provides prosthetic
rehabilitation upon delivery of the prosthesis and assists the client in
achievement of occupational performance. 50
The therapist reinforces and builds on residual movement,
developing functional applications of the prosthesis to address the
distinct ADLs (e.g., brushing teeth) and instrumental ADLs (IADLs;
e.g., driving) of everyone. 80 The therapist is responsible for ensuring
that the client knows how to clean and maintain the prosthesis. In
addition, the therapist provides opportunities for the client to practice
using the prosthesis in specific daily activities. The therapist focuses
on bilateral activities. Often after amputation the individual becomes
successful in performing some ADLs unilaterally. Thus therapy must
begin early in the rehabilitation process to facilitate use of the
prosthesis in bilateral activities. 73
Initial prosthetic training begins with a reorientation to the
prosthesis and basic open-and-close control. Training then includes
controlled grasp, such as opening the close control in small increments
to grasp small items and then more fully to grasp larger items.
Training emphasizes grasping objects of varied texture and density to
be handled. Sessions incorporate work on prehension and timing of
release. Functional and appropriate tasks are encouraged and require
the client to use the prosthesis for gross and fine motor activities.
Training also emphasizes drills and tasks to achieve these skills at
different heights and in a variety of planes and positions. 47,63 With the
combined efforts of the team members, the appropriate prosthetic
components are chosen so that the individual can achieve goals
through therapy, practice, and education.
Prosthetic Options and Components
A prosthetic device cannot mechanically duplicate the amount of
function, reliability, and aesthetic quality that the human upper
extremity naturally provides. However, prostheses can improve
functional abilities. To provide the appropriate prosthesis, a
fundamental understanding of the components is necessary. Health
care providers must continually stay abreast of prosthetic
developments.
Generally six categories of prosthetic options are available for the
person with an upper extremity amputation. The options include (1)
no prosthesis; (2) a passive functional aesthetic prosthesis; (3) activity-
specific prosthesis; (4) a cable-driven body-powered prosthesis; (5) an
externally powered, electrically controlled prosthesis with myoelectric
sensors and specialized switches; and (6) a hybrid prosthesis that
may combine types of control. Table 20.1 outlines the pros and cons of
each prosthetic option.

No Prosthesis
Wearing no prosthesis is one approach, and for some individuals it is
the best option. For example, an individual may not be able to tolerate
the prosthesis for reasons such as residual limb hypersensitivity, soft
tissue adhesions, and excessive scarring. 9 Reasons documented in the
literature for prosthetic rejection include limited usefulness, weight,
and residual limb and socket discomfort. 54,87 Individuals choosing not
to wear prostheses may find advantages and disadvantages with this
option, which are found in Table 20.1.
Advantages of no prosthesis include increased proprioceptive and
sensory input. Disadvantages include limited functional ability,
bimanual task difficulty, and the potential for development of overuse
syndrome, nerve entrapment, or vascular damage in the contralateral
limb. 68 Some individuals do not wear prostheses because (1) they do
not know their options, (2) they had a negative first prosthetic
experience, (3) they lack funds, or (4) they are reluctant to undergo
surgery for a prosthetic fit and reduction of hypersensitivity. 4

Passive Functional Aesthetic Prosthesis

A passive prosthesis option is common for individuals who have had
amputation distal to the elbow in that they may maintain elbow
flexion and extension and forearm pronation and supination. In this
case the obvious purpose may appear to be aesthetic. However, a
passive prosthesis provides some degree of function, such as to
support and stabilize objects, and digits of a passive prosthesis can be
adjusted to assist with activities, such as typing, carrying a purse or a
document, or operating the gearshift in an automobile. 67 This type of
prosthesis is often used as a first prosthesis for children as young as 4
months of age. A passive prosthesis has many benefits, including its
light weight, minimal (if any) harnessing, no cables, and low
maintenance. Disadvantages include lack of active grasp and
difficulty in performing some bimanual tasks. 52

TABLE 20.1

Advantages and Disadvantages of Prosthetic Options

Prosthetic Option Advantages Disadvantages
No prosthesis Maintain full proprioception and sensation Limited functional ability
Difficult to perform
bimanual tasks
Passive prosthesis Lightweight Prosthesis has no
Minimal (if any) harnessing prehension abilities
No cables; low maintenance Difficult to perform
Static function: support, stabilize bimanual tasks
Social function
Activity-specific Lightweight
prosthesis Minimal (if any) harnessing
No cables; low maintenance
Static function: support, stabilize
Quick disconnect
Crossover functional purposes
Robust
Reduced maintenance, costs
Body-powered Heavy-duty construction and function Restrictive/uncomfortable
prosthesis Reduced maintenance cost harness
 Proprioception Poor cosmesis
Refer to specifics of VC vs VO terminal Restrictive functional
devices work area
Limited grip force (VO)
Externally Unlimited work area Battery maintenance
powered Function cosmetic restoration Increased weight
prosthesis Increased grip force Susceptible to damage
Harness system reduced or absent from moisture
Increased comfort Increased cost
More modern, high-tech appeal Battery life
Interchangeable components
Development of technology to provide for
individual custom fabrication
VC, Voluntary closing; VO, voluntary opening.

Activity-Specific Prosthesis
Many individuals are interested in completing a specific activity.
Sometimes the OT fabricates a tool of thermoplastic material or other
material that can be attached to a cuff or to the existing TD to serve a
specific function. At other times, collaboration with the prosthetist is
necessary to obtain a specific TD or a sophisticated adaptation.
Activity-specific upper limb prosthetic technology is typically static.
The TD attaches to the forearm unit and allows for function to
perform specific activities that may include personal care tasks (e.g.,
feeding and grooming), instrumental tasks (e.g., cooking,
woodworking, and gardening), and diverse recreational activities. 67
Some of the devices have “crossover” functions. For example, a device
used for bicycling may also be used to grasp the handles of a
shopping cart, a stroller, or even a lawnmower, thus enhancing the
functional envelope of the technology. This technology often is robust
and lightweight and offers quick release. It typically does not require
harnessing or cables and is low maintenance. The activity-specific
prosthesis is often suspended with a pin-lock style of liner or a
Neoprene sleeve.

Body-Powered Prosthesis
The body-powered prosthesis is sturdy and allows for prehension.
Body-powered upper limb prostheses are actuated by body motion,
which generates tension in a cable. The cable courses from a shoulder
harness through a housing to a prosthetic component, such as a hook
or elbow. In other words, the active movements of the shoulder and
arm cause the tension in the cable to open and close the hand or hand-
like component (hook) as shown in Fig. 20.2. Therapists help
individuals with the amputation learn the names of the basic
components, such as the figure-eight harness, cable, elbow unit, wrist
unit, and TD.
 FIG. 20.2 Body motions used to transmit force to terminal device
(TD). A, Glenohumeral flexion. B, Biscapular abduction. C, Scapular
adduction/retraction.

Benefits of a body-powered prosthesis include its heavy-duty

function and construction, decreased maintenance cost, and increased
proprioceptive input. Disadvantages may include the restrictive
uncomfortable harness, potential for nerve entrapment or
compression, decreased aesthetic appearance, restricted functional
work area (Fig. 20.3), and limited grip force (see Table 20.1). Body-
powered TDs generally weigh less than the externally powered
prostheses because they lack the heavy motors and circuitry placed
within them to operate the myoelectric signals.
The Harness
The purpose of the harness is to suspend the prosthesis on the
residual limb. It transmits force from the body to the prosthesis for
independent operation of the prosthetic components. 57 The body-
powered prosthesis always requires harnessing. There are two
primary types of harness: a figure-eight and a chest strap. The figure-
eight harness passes over the shoulder, across the back, and under the
contralateral axilla. “The ring lies flat in the back, inferior to C7 and
just to the sound side of the center of the spine.” 76
The standard figure-eight shoulder harness for the upper extremity
has an axilla loop on the sound side that is commonly uncomfortable
and can cause numbness and nerve damage. 24 The chest strap offers
an alternative method of harnessing. It travels across the back, under
the contralateral axilla, and across the chest. It is important that the
harness, most commonly figure-eight, figure-nine, or chest strap, be
tight enough to activate the TD without excessive effort and loose
enough to be comfortable, allow freedom of movement of both arms
and shoulders, and not entrap the thoracic outlet.
 FIG. 20.3 Components of a body-powered prosthesis.

Long-term wear and inappropriate fit may cause discomfort or

physical damage. The harness has been found to limit the functional
work envelope, which is the space in front of the person who is able to
use the prosthesis successfully for functional tasks. Harness systems
limit successful prehension when the TD is outside the functional
work area. With the body-powered prosthesis, function can be limited
above the head, behind the back, and near the ground, primarily
because of the restricting harness (see Fig. 20.3). The prosthesis
functions because of the ability to move in these planes.
An alternative to traditional harnessing is the Scapular Cutaneous
Anchor technology, developed by an OT who also presents with
upper limb congenital difference and who is a long-term prosthesis
user. The Scapular Cutaneous Anchor is simple technology that
adheres to the back in the area between the spine and the scapula on
the same side as the limb difference or loss. This location on the back
allows movement of the scapula and shoulder to control the TD, thus
displacing discomfort or damage in the opposite axilla. It also permits
function above the head, at the waist, behind the back, and near the
ground.
Discomfort and neurological and musculoskeletal disorders can
result from inefficient harness design 21 and long-term wear. After the
user has worn a harness for years, the axilla of the sound side
experiences increased force and pressure to operate the prosthesis
repetitively throughout the day. This can result in neurological and/or
vascular damage. A strong case can be made for providing an
externally powered prosthesis that either eliminates or reduces the
harnessing. This prevents the risk of long-term nerve damage on the
sound side. More importantly, use of diverse prosthetic technologies
adds to the functional toolkit of the user as no one prosthesis can
replicate the diverse functions of the hand.
The prosthetist is responsible for fabrication of the harness, and the
therapist occasionally may make minor adjustments to improve
function. Sometimes several harness options are attempted to find the
type of system that best fits the amputee. It is often a trial-and-error
process. Another important factor is the awareness of the increased
workload in the remaining arm, which may produce symptoms
ranging from minor aches to serious conditions, such as nerve
entrapment and overuse syndrome. 46

The Socket
The socket is the part of the prosthesis that intimately fits over the
individual’s residual limb. It is the connection between the prosthesis
and the individual’s body. The socket is fabricated from an exact mold
of the residual limb, and it is fabricated from various types of laminate
or thermoplastic material. Development of high-temperature rigid
plastic materials has made it possible to have total contact on the skin
and allow decreased weight and increased durability. The use of
carbon graphite and the introduction of flexible thermoplastics have
resulted in sockets that are more comfortable, lighter, and more
durable and have made soft sockets with windows possible. The
prosthetist makes modifications over bony prominences and areas
susceptible to torque and shear forces. 6 Typically three to four sockets
will be fabricated before the final one is delivered.
Intimate socket fit provides a stable foundation of support
necessary to transfer forces from the TD. It provides evenly
distributed pressure on the residual limb, which prevents skin
breakdown or pressure sores. In the past decade a multitude of design
innovations have been incorporated, which have resulted in
developing better comfort, suspension, stability, and range of motion.
The new fitting techniques and socket designs appear to be more
efficient for force of transmission and motion capture and more
functionally consistent than traditional sockets. 1 Occasionally the
prosthetist instructs the individual to wear the socket before all
components are attached because it increases wearing tolerance and
facilitates reshaping of the residual limb.
As the person with the amputation ages, physical and physiological
changes occur. The person may experience weight loss or gain or
muscle bulk increase or decrease. These changes have an impact on
the size and condition of the residual limb, and the socket may no
longer fit as it should. A new socket must be fabricated to fit the exact
shape of the residual limb when changes occur. When a new socket is
fabricated, it replaces the poorly fitting one in the individual’s current
prosthesis. An entirely new prosthesis is not needed because the
socket is removable and replaceable. This saves on cost. The wearer of
a body-powered prosthesis may benefit from using a second sheath or
sock made of either a fabric or a gel-like substance to manage poor
skin integrity, prevent breakdown, absorb moisture, or provide
padding.

The Liners
Liners may be used for comfort and/or for suspension. Liners may be
as simple as a sock or fabricated from silicone or other such materials.
Depending on several factors, including the level of limb
loss/difference, and other componentry, liners with a pin-lock system
help to keep the prosthesis on the residual limb. Some individuals opt
to not wear a liner or sock and prefer what is called a “skin fit.”

The Cable
The harness allows placement of the cable, which is the transmitting
force that operates the prosthesis. Body-powered prostheses are
operated by body motion that generates tension in the cable. The cable
is routed from the harness through a housing to the TD or elbow. 21
The primary movement to operate the prosthesis is glenohumeral
flexion. As the individual flexes the humerus, the TD opens. As the
individual returns the humerus to neutral, the hook rubbers cause the
TD to close. When the individual wishes to open the TD closer to the
body, biscapular abduction is used, and adduction or retraction of the
scapula allows the TD to close (Fig. 20.4). The following quotation
from a client with an upper extremity amputation who uses a
voluntary-opening (VO) TD highlights the importance of the cable
system for functional tasks:
 FIG. 20.4 Functional work area (body-powered prosthesis).

The rubber bands on my hooks regulate tension I put on objects. To force

the hook open, I first lock the elbow in the desired position. Then I
proceed to bring my shoulder forward, putting tension on the cables.
After I have grasped the desired object, I bring my shoulder back to the
original position. 27

Cables need periodic replacement when they fray or break. Cable

replacement is generally the most common repair needed for the
body-powered prosthesis wearer. 27 The OT and the client should
know how to replace an old cable with a new one. The process is
simple, involving removal of the old cable and reattachment of the
new cable to the TD and the harness. It is beneficial for the client to
have two or three spare cables at home so that replacement is
convenient.

Terminal Device
The TD is the hand component and appears in the form of a hand or a
hook. Most body-powered prosthetic hands open and close in a three-
point prehension pattern. The prosthetic hooks open and close in a
lateral or tip pinch prehension pattern, depending on positioning of
the TD. Therapists should be familiar with TD options because they
will most likely introduce the person with the amputation to the
available options and provide education in their use.
Generally the initial goals of the prosthetist are to fit the person who
has had an amputation with a standard prosthesis. The person with
the amputation then requires time to adjust and become an
independent user of the prosthetic device. There are two basic TD
options, and each is available in two different control systems.
Typically an individual has some form of a hand and/or a hook, which
can be interchangeable if using the same control system. For example,
the client uses the hand-like TD for basic ADLs and uses the hook-like
TD for more challenging activities such as quilting or changing a tire.
Every TD has its pros and cons. Differences exist between the hand
and hook TDs (Table 20.2). The hand-like TD may appear to some to
be more aesthetically pleasing. However, digits 3, 4, and 5 are not
movable, often occluding vision, impairing function, and providing
increased bulk. The hook-like TD allows for successful fine motor
prehension, access to visual input, less bulk, and more durability.
However, it may be less aesthetically appealing than the hand-like
TD.

Voluntary-Opening and Voluntary-Closing Terminal

Devices
Important to the type of function is the method of control. The TD
may be voluntary opening or voluntary closing. VO devices are
positioned in a closed position, and the user works to open it against
the resistance of elastic bands. Closure is implemented by relaxing the
control and allowing the elastic bands to pull the opened TD closed.
Grip strength with this technology is dependent on the number of
elastic bands being used. Each elastic band is equivalent to
approximately 1 to 1.5 pounds of force. One must remember that the
user has to work against this force to open the TD. For example, five
bands might lead to more than 5 pounds of pinch strength, but the
user must consistently and repetitively resist the force to access use of
the device. Voluntary-closing (VC) devices are positioned in the open
position, resembling the at-rest position like the natural hand. The
user works to close the device and can regulate the amount of grip
strength exerted. The user can control the device to use a light grasp
(such as when holding a child’s hand) or stronger grasp (such as to
hold a shopping bag). For sustained closure the user might use a
locking system that conserves energy. VC systems appear to offer
greater efficiency because they exert less load on the user to access
function.

TABLE 20.2

Advantages and Disadvantages of the Hand and Hook Terminal Devices

Terminal Device Advantages Disadvantages
Hand Cosmetically appealing Digits 3, 4, and 5 are nonfunctional
Tendency to impair fine motor
manipulation
Vision obstruction
Hook Superior fine motor May be aesthetically unappealing
prehension
Less bulky
Durable
No vision obstruction
Voluntary- Must resist force to open
opening Limited grip strength

Voluntary- Efficient, ergonomic

closing operation
Grip strength control
More intuitive control
 Using a body-powered VO device, the grip can vary from 5 to 20
pounds, depending on the number of hook rubbers used. Hook
rubbers are like thick, wide rubber bands providing resistance to the
grip of the TD. Each rubber band provides 1 pound of grip force,
consequently increasing the amount of pressure placed in the axilla on
the contralateral side. VC devices can generate grip strength of 60
pounds or greater and are often actuated using bungee-type cords or
springs. New technology is emerging that incorporates the features of
both VO and VC devices.

The Glove
The glove is the cosmetic covering of the hand-like TD. Gloves are
made of either latex or silicone substances and are removable and
replaceable. Differences exist between the two types of glove. Latex
gloves are sturdy and come in 10 to 15 shades of color. Individuals are
matched to the shade that corresponds to their skin tone. Latex gloves
easily absorb stains that do not wash off. However, latex gloves are
more durable than silicone gloves.
A silicone glove is custom fabricated to match the individual in
terms of shape, size, and coloring. It is difficult to differentiate
between a silicone glove and a human hand by sight. Such a glove is
truly a work of art. Silicone gloves are more costly and fragile than
latex gloves. It is more difficult to permanently stain a silicone glove.
However, they tear easily. Persons who have had an amputation
generally request the silicone glove because of its life-like appearance.
Because silicone gloves are more expensive, funding for a silicone
glove is difficult to obtain.
 FIG. 20.5 Functional work area (externally powered prosthesis).

Externally Powered Prosthesis

The externally powered prosthesis is another prosthetic option. The
externally powered prosthesis is also called a myoelectric prosthesis
because it operates from the electromyographic (EMG) signal
transmitted from the muscles of the residual limb. An externally
powered prosthesis has several differences from the body-powered
prosthesis, which are outlined in Table 20.1. Beneficial characteristics
of a myoelectric prosthesis include an unlimited work area (Fig. 20.5),
25 functional cosmetic restoration, increased grip force, elimination of
harnessing, increased comfort, interchangeable componentry, and
individualized custom fabrication. Thus myoelectric control is most
commonly used when possible. 26,43 Disadvantages of a myoelectric
prosthesis include increased weight, increased cost, increased
maintenance, and increased risk for damage.
The externally powered prosthesis is composed of various
components, as shown in Fig. 20.6. The components include a socket,
a forarm shell, electrodes, battery, glove, and TD.

The Harness
Most myoelectric prosthetic devices do not require a harness.
Occasionally a harness system is required if it is difficult to fit and
maintain contact between the electrodes and the muscle signal or if
the socket is loose because of weight loss or other factors. Because the
harness system is either eliminated or reduced, the functional work
area is expanded to include the areas above the head, behind the back,
and near the ground compared with the body-powered prosthesis.
The Scapular Cutaneous Anchor can also be used to secure electrodes
and linear transducers and may be a compelling option because it
does not limit the functional envelope. 45,46
 FIG. 20.6 Components of an externally powered prosthesis.

Externally Powered Prosthetic Controls

The externally powered prosthetic socket is unique in that it has
electrodes that detect the EMG signals of the muscle. The electrodes
are mounted directly in the walls of the flexible socket. The EMG
signal stimulates the motor in the prosthesis to produce a desired
motion. Prosthetic technology for clients with upper extremity
acquired loss or congenital differences has dramatically changed over
the past decade. The main changes have occurred in components,
socket fabrication, fitting techniques, suspension systems, and sources
of power and electronic controls. 34,51
There are a variety of electrodes available. Some are more sensitive
than others in detecting the muscle EMG and controlling the
movement of the TD. Through the collaborative effort of the team, the
best-suited electrodes are determined. Single- or dual-site control
systems are available as well as pattern recognition and radio-
frequency identification. A single-site system is used if the client
cannot differentiate and isolate control of two separate and opposing
muscles for electrode sites. This may be beneficial for persons who are
cognitively unable to control the dual-site system, such as with young
children. For example, the TD remains in the closed position when the
individual’s muscles are relaxed and open when the muscle contracts.
Thus if the individual wanted to grasp an object, he or she would
contract the muscle to open the TD, position it around the desired
object, and relax. Upon relaxation the TD automatically closes and
remains closed until the next muscle contraction. 66
Commonly a dual-site control system is preferred over a single-site
system. The dual-site control system is activated by two separate
muscle contractions. For example, the individual with a transradial
amputation will most likely contract the wrist extensor muscle group
to open the TD and the wrist flexor muscle group to close the TD. The
TD can remain in any position if the muscle signals are absent. For
example, the same individual can open the TD with contraction of the
wrist extensors. Once the muscles are relaxed, the TD will stay open
as if to shake the hand of a friend. As soon as the wrist flexors are
contracted, the TD will close. With this system electrodes can be
embedded in the liner to offer contact, suspension, and comfort. A
sheath or sock cannot be worn because it would interrupt the
connection between the muscle and the electrode.

Pattern recognition
Many muscles work in concert to move the arms and hands. The
muscles contract in unique ways and generate small amounts of
electrical activity called myoelectricity. The patterns of electrical
activity are unique for each movement and can be detected by
electrodes placed on the surface of the skin. For example, the pattern
of myoelectric activity recorded on the forearm during hand opening
is different than the pattern recorded while the hand is closing. 15 For
those with upper limb loss or difference, remaining muscles can
produce these signal patterns. This is called pattern recognition.
Specialized software interprets the signals to control the arm and
hand movement of a prosthesis. Because the command signals can be
unique to each user, the technology provides intuitive control of
multiple prosthetic movements. 23
 Pattern recognition works best when it has many myoelectric
signals to listen to and to interpret. Thus electrode placement is not
the same as with conventional single- or dual-site prostheses. For
example, there is not an exclusive “hand open” or “hand close”
electrode; rather, the system interprets the information from all
electrodes. It then accurately decodes the user’s intent for movement.
The system currently reads eight myoelectric signals using passive
electrode dome contacts (sometimes called remote electrodes) and a
single wire harness to connect them all. 23
Like traditional myo-systems, pattern recognition requires (1) the
ability to achieve good skin-electrode contact within a prosthesis and
(2) the ability of the user and practitioner to learn and understand the
mechanism of control. Pattern recognition is currently used by
individuals with upper limb loss or congenital difference at the levels
of shoulder disarticulation, transhumeral, and transradial.

Radio-frequency identification
Some externally powered TDs are controlled by using wireless
communication known as radio-frequency identification (RFID).
This system involves an RFID reader and a tag. The tag has
information stored in its memory, and the reader (using an antenna)
interprets this information. RFID technology is used by the public in
many ways, such as to control building access, manage stock, and bill
for use on toll roads. It is now applied to control the upper limb
myoelectric prosthesis. Each tag is programmed with a specific grip
pattern. The tag is strategically placed in an area where the user will
implement the particular grip. For example, a tag programmed with a
trigger grip pattern will be placed on a bottle of window cleaning
solution. The RFID system works well with multiarticulatingTDs. 44

Terminal devices
Like body-powered TDs, myoelectric TDs are available in hand- and
hook-like presentations and may be VO or VC. The standard
myoelectric hand offers a basic open-close function with a three-jaw
chuck type of grasp. The fourth and fifth digits do not move. Electric
hooks are available in different styles and configurations. Generally
these devices are not waterproof, although some manufacturers may
offer a protective sleeve. Externally powered TDs have a greater
opening range, allowing for the ability to grasp objects of larger size.
The externally powered prosthesis provides the ability to use
prehension capabilities in all planes. This contributes to the expansion
of the functional work area to include space above the head, behind
the back, and near the ground. The externally powered TD generally
provides grip strength of approximately 20 to 30 pounds.

Multiarticulating terminal device

Advancements in technology offer exciting options in the form of
multiarticulating hands. Although these prosthetic hands cannot
replicate all the functions of the natural hand, they do offer access to
more grip patterns with greater articulation. All the digits in these
hands move and are integrated into the diverse patterns. These hands
integrate with the pattern recognition and RFID control systems.

The battery
The battery provides the energy for the externally powered prosthesis.
Lithium-polymer battery technology advancements have improved
the ease of externally powered prostheses. The lithium-polymer
batteries are 80% lighter and 70% smaller and offer 30% more storage
capacity than nickel-cadmium batteries. 17

Other joints
The singular prosthesis is made up of many components and is
relative to the level of loss or difference experienced by the user. The
individual with transradial difference will likely benefit from
componentry that offers wrist function and hand function. This
chapter is focused on the TDs, but other joint movements are
important for the total function of the upper limb. Individuals with
higher levels of loss need elbow flexion and extension and shoulder
movement. These functions are vital to being able to accomplish ADLs
and IADLs. It is important that the OT incorporate these movements
and functions of the prosthetic components into the plan of care.

Elbow
Elbow components offer flexion and extension and are available for
body-powered and myoelectric control. The body-powered options
may require a shoulder shrug or a ballistic forward flexion to activate,
or there may be a pull switch or locking mechanism. Although the
body movements described may seem unnatural, it may be
inconvenient to use the intact hand to actuate the elbow control,
particularly during bimanual tasks. Electric options may offer
smoother and more efficient movement, but the components add
weight to the prosthesis.

Shoulder
Shoulder joints are available for body-powered and myoelectric
control, but the movement offered is limited primarily to forward
flexion/extension and internal/external rotation. There are different
ways to control the body-powered technology, such as a nudge switch
or scapular movement. Although the electric options may offer
smoother and more efficient movement, the components add weight
to the prosthesis. Cumulatively, the externally powered prosthesis
could weigh more than 10 pounds.

New Technologies
Emerging technologies impact the performance and the functional
outcome for users of prosthetic devices. One such intervention is
osseointegration. 56 Osseointegration is a surgical procedure that
provides “the structural linkage made at the contact point where
human bone and the surface of a synthetic, often titanium based
implant meet.” 56 A type of pin is implanted into the end of the bone
and extends through the skin to lock into a prosthesis.
Another intervention is targeted muscle reinnervation (TMR), in
which residual nerves from the amputated limb are surgically
transferred to reinnervate new muscle targets that have otherwise lost
their function. The results of this procedure work well with pattern
recognition and improve the control of the upper limb prosthesis. 22

3-D Printing
Advances in upper limb prosthetic technology offer the consumer
added options that may even include access to the technology itself.
Additive manufacturing (AM), also known as 3-D printing, has many
benefits as well as limitations. AM permits the production of shapes
that are complex and that would likely be expensive, if not cost-
prohibitive, to reproduce. It has the potential to reduce both the costs
and the time associated with manufacturing. There are many forms of
AM; one method, fused deposition modeling, has been used to create
technology for children with upper limb differences. With this
method, plastic is heated and transferred through a hose to create a
model one layer at a time. The temperature and humidity of the
manufacturing environment must be strictly controlled to manage the
structural integrity of the device. If the plastic cools too quickly, the
model becomes brittle; however, if it does not cool quickly enough,
the model’s shape can deform. In either case these factors can
negatively affect the quality of the device and its usefulness. 88
3-D printing technology is referred to as “disruptive” because the
impact of reduced costs and decreased time from design to production
has disturbed the manufacturing process. This technology has been
disruptive to the providers and users of prostheses. Medical devices
must meet U.S. Food and Drug Administration (FDA) regulations to
help ensure patient safety. Prosthetic componentry are medical
devices approved by the FDA and are fit to the user by a prosthetist
who has undergone the rigors of academic and clinical preparation as
well as national professional certification. 3-D printed devices are not
always fabricated or fit by such professionals. The orthotics and
prosthetics (O&P) organizations, with the FDA, are addressing areas
related to:
 1. “Provision of clinical O&P services by untrained, uncertified,
and unlicensed individuals;
2. Manufacturing and distribution of unregulated 3D-printed
medical devices; and
3. Lack of institutional review board (IRB) oversight for human
subjects testing of 3D-printed investigational medical devices.”
11

Although these devices are not typically provided by OTs,

practitioners may be requested to train its usage with particular
relevance to addressing ADLs. As with a more traditionally fabricated
prosthesis, the OT practitioner should check the fit of the device and
inspect the functionality of it. Clients should be advised and
counseled about issues such as independent donning and doffing,
care of the device, and skin inspection. Depending on the fabrication
and features of the device, the OT may use different techniques, such
as tenodesis-type action, to control the 3D-printed hand. Should the
device offer a body-powered or an externally powered feature, the
relevant training strategies would apply. Users of the device should
immediately contact the fabricator if there are any problems with fit or
function of the device. 11
The Prosthetic Rehabilitation Process
The educational background of OTs includes motor control, motor
learning, and movement as they relate to the upper extremity function
required for occupational performance. Education in the
psychological and social adjustment to disability is also the OT’s area
of expertise. The sooner therapy is initiated, the faster the client will
be prepared for prosthetic fitting and the chances of engaging in
bimanual activities will increase. Many long-lasting deficits are
prevented with early intervention from therapy.
Phases of Rehabilitation
Prosthetic rehabilitation is categorized into nine phases of evaluation
and intervention (Box 20.1). Each phase contains specific items to
evaluate along with typical areas to address. 33 The phases are:

1. Preoperative
2. Amputation surgery and dressing
3. Acute postsurgical
4. Preprosthetic
5. Prosthetic prescription and fabrication
6. Prosthetic training
7. Community integration
8. Vocational rehabilitation
9. Follow-up

Preoperative Phase
Ideally the assessment and intervention process begins before the
amputation. The health care team forms a plan and educates the client
in what to expect after surgery and during rehabilitation. Therapists
ensure realistic expectations and outline the typical rehabilitation
process. Phantom pain and phantom sensation are explained because
they are common occurrences for individuals post amputation. The
preoperative phase is a good time to assess hand dominance and
determine the need for adaptive equipment. Adaptive equipment is
provided on an as-needed basis only, because clients will eventually
use their prostheses with daily activities, and adaptive equipment
may interfere with the transition to prosthetic use. 33

Amputation Surgery and Dressing Phase

Surgeons determine residual limb length before and during the
surgery. Myoplastic closure of the wound is completed, ensuring soft
tissue coverage of any distal bone. A rigid dressing or removable rigid
dressing can assist in controlling pain. 33

BOX 20.1 Nine Phases of Prosthetic

Rehabilitation and Intervention Focus

1. Preoperative phase
• Team formulates a plan
• Educate client on expectations
• Provide adaptive equipment
2. Amputation surgery and dressing phase
• Surgery
• Determine length of residual limb
• Wound care
• Dressing wound
• Pain control
3. Acute postsurgical phase
• Pain control
• Range of motion
• Wound healing
• Contracture prevention
• Emotional support
• Address phantom sensation/pain
4. Preprosthetic phase
• Limb shrinkage and shaping
• Increase muscle strength
• Foster sense of control
• Realistic expectations
5. Prosthetic prescription and fabrication phase
• Prosthetic options considered
• Prosthesis is delivered
6. Prosthetic training phase
• Prosthetic fitting and training
 • Desensitization of residual limb
• Unilateral independence
• Educate client in prosthesis controls, etc.
7. Community integration phase
8. Vocational rehabilitation phase
9. Follow-up phase
• Purposeful activities
• Participation in meaningful activities and occupations
• Bilateral activities

Acute Postsurgical Phase

The goals after surgery for the team are pain control, maintenance of
range of motion, and wound healing. Postsurgical therapy often
incorporates wound care and contracture prevention. Emotional
support to the client is essential. Discussions about phantom sensation
and phantom pain continue. 33

Wound Healing and Contracture Prevention

In addition, therapists assist persons in adjusting to the amputation in
many ways. Postsurgical goals include early motion, wound healing,
scar management, desensitization, pain management, edema
reduction, limb shrinkage/shaping, and unilateral independence
(change in hand dominance). Many interventions for motion, wound
healing, scar management, desensitization, and pain management are
the same interventions as used with other diagnoses. Interventions for
edema reduction, limb shrinkage/shaping, and change in hand
dominance are more specific to this population.

Phantom Pain and Phantom Sensation

Clients with amputations often experience phantom sensation and
phantom pain. The role of the health care team is to prepare clients
and assure them that these phantom sensations and pain are to be
expected and are normal. 29 Phantom sensation occurs when the
individual feels as if the nonexistent limb is still present. The
amputated extremity may feel exactly like the original limb in terms of
shape, size, position, and ability to move. Rings or watches that were
previously worn may be part of the sensation. Phantom sensation is
described as a pins-and-needles or tingling sensation. Phantom
sensation diminishes over time.
Phantom pain is different from phantom sensation. The
phenomenon of phantom pain is not completely understood. It is
common for an individual to experience pain in the phantom limb
early on after amputation and have it fade over time. It is reported
that 80% of individuals with an amputation experience phantom pain.
4
Intervention related to phantom sensation and phantom pain is
implemented as soon as possible. One study surveyed 65 individuals
with upper amputations about phantom pain. Results suggested the
best intervention for phantom pain was active participation in
functional activity. 81 Other interventions include gentle massage,
prosthetic wear, and transcutaneous electric nerve stimulation
(TENS). As therapists, we are well equipped to work with clients to
optimize the functional use of the extremity with an amputation. 29

Preprosthetic Phase
The primary goals during the preprosthetic phase are to shape the
residual limb, increase muscle strength, and restore the person’s sense
of control over what is happening. 33

Limb Shrinkage and Shaping

Limb shrinkage and shaping is addressed for this population. Custom
compression garments are available for the client. Edema can be
controlled through wrapping the residual limb in a diagonal design,
so as not to compromise circulation. Compression garments or wraps
should be worn as much as possible to ensure proper shaping of the
residual limb. Compression has a direct impact on residual limb
shrinkage and shaping. Elevation and retrograde massage are useful
alternatives to decrease edema. It is important for the therapist to
reinforce the importance of edema management because it has a direct
impact on socket fit and comfort. The reduction of edema is a
prerequisite for prosthetic fitting. 29
Time during the preprosthetic phase is crucial for reinforcement of
realistic expectations. Individuals with amputations may be under the
assumption that they will perform all activities at the same level of
independence they had before the amputation. This assumption needs
to be discussed. Therapists explain that the prosthetic device will not
replace the arm. Rather, it is an assistive tool used to stabilize,
support, and hold objects during bimanual activities.

Prosthetic Prescription and Fabrication Phase

The prosthetic prescription and fabrication phase is the time when the
team comes to consensus on the type of prosthesis that will best meet
the client’s needs and condition. 33 The preprosthetic period begins
when the individual with the amputation begins exploration of
prosthetic devices. The phase concludes upon prosthetic delivery.

Prosthetic Training Phase

During the prosthetic training phase, individuals frequently visit the
prosthetist for fittings and modifications of the socket. Clients also see
therapists for rehabilitation services. Individuals receiving body-
powered prostheses move much more quickly through the fabrication
and rehabilitation process because electrodes are not required and
muscle sites and signals do not need to be identified. Therapy
continues to address any lingering issues from the acute postsurgical
phase. Additional goals of therapy during this phase include
preparation of the individual to tolerate wearing the prosthesis and
using it independently for daily activities. Specifics include electrode
training; desensitizing the residual limb to pressure, pain, and weight;
maintaining range of motion; eliminating contractures; and unilateral
independence. 33

Electrode Training
If individuals receive an externally powered prosthesis, the best
muscle sites are identified and trained to operate the prosthetic
features. 38 Finding the sites and training the muscles for electrode
placement are primarily the responsibility of the therapist. During this
phase, therapists provide extensive training using biofeedback to
teach individuals to contract the identified muscle or muscles on
command. The therapist facilitates the improvement of muscle site
control and focuses on isolated muscle contraction, strength, and
endurance. Special biofeedback machines are available from
prosthetists. It is important for clients to practice muscle contractions
in a variety of positions, including lying, standing, and sitting.
Practicing muscle contractions in different positions with the
extremity in various planes enhances maximal success after delivery
of the prosthesis.
Once electrode sites are established, the prosthetist is informed of
the exact and most appropriate electrode location for the individual to
obtain the most function. Locating and training for electrode sites is
often a lengthy, rigorous, and trial-and-error process. Once the socket
and electrode sites are sufficient to work the prosthesis, the prosthesis
is ready for final fabrication. There may be a period after the
preprosthetic phase when the individual is discharged from therapy
with a home program until the prosthesis is delivered and therapy can
resume.

Desensitizing the Residual Limb to Pressure, Pain, and

Weight
Clients may experience disappointment when the prosthesis is
delivered and they are unable to use it as they imagined. It is the duty
of the health care team to inform individuals of the advantages and
disadvantages of the various prosthetic components to provide a
realistic picture of rehabilitation. Clients are usually surprised when
they realize that the prosthesis is hard, cold, heavy, and not an exact
replacement for the hand. With establishment of realistic expectations
and acceptance, use of the device greatly improves. 7
Clients commonly experience residual limb sensitivity. Therapists
intervene by teaching and implementing the following desensitization
techniques: wrapping, massage, weight bearing, and pain
management. Desensitization and pain management are additional
components of therapy. Therapists provide modalities for pain and
educate clients in managing their pain independently. Each client
presents with different complaints, and the treatment is
individualized.
In some instances, prosthetists provide clients with sockets to wear
as precursors to full-time prosthetic wear. Sockets reshape the residual
limb and allow clients to experience how the devices feel. Weights can
be added to the distal ends of sockets for increasing tolerance to the
weight of the devices as well as readjustment to extended limb length.
Prosthesis simulators can be used to help the client adjust to the
changes in limb length and to the prosthesis weight and can also be
used to initiate controls training toward functional application.

Unilateral Independence
Unilateral independence involves using environmental adaptations
and one-handed techniques. It may be necessary to teach clients to
switch hand dominance if the dominant hand was amputated.
Generally therapists work to promote the maximal level of
independence for the individual. Assistive devices and adaptive
strategies are often used. For clients with amputations, it may
promote better prosthetic success if therapists do not issue adaptive
equipment until after prosthetic training, because clients may become
efficient with the adaptive equipment and may not be motivated to
learn to use the prosthesis. However, many assistive devices used in
tandem with prosthetic technology can augment and improve
function.

Bilateral Involvement
Clients with bilateral involvement present with unique challenges that
are dependent on multiple factors. It is important to understand that
the individual’s presentation may not be symmetrical and that
differing technology—or no technology—may be used. Many
individuals with bilateral loss or difference, particularly at a high level
(such as shoulder disarticulation) engage in footwork using the toes to
accomplish dexterous tasks.

Orientation and Control Training

Upon prosthetic delivery the prosthetist educates clients about the
prosthesis and its components. Therapists reorient clients to their
prostheses. Prostheses are complex devices, and they cannot be
mastered in one therapy session. Clients will not be independent with
use of the prosthetic unless there is a complete understanding of all
the components.
Client orientation includes education in donning, doffing, operating
switches and batteries, and caring for the prosthesis. Therapists
ensure that prosthetic fit and function are adequate. Therapy includes
evaluation of independence with prosthetic donning and doffing.
Clients must be able to properly care for their prosthesis to prevent
damage and maximize its potential.

Community Integration, Vocational

Rehabilitation, and Follow-Up Phases
The final three phases of community integration, vocational
rehabilitation, and follow-up 33 are composed of purposeful activities
and participation in meaningful occupation-based activities. 3 These
phases are intensive. Clients’ visits to other members of the team
decrease, and therapists act as liaisons to the teams. These final phases
are progressive and evolve as clients’ skills develop. During this time,
clients learn to operate the controls of their prostheses and practice
until they become proficient. Depending on the prosthetic features,
clients practice tasks, such as opening and closing the TD, elevating
and lowering the elbow, and rotating the wrist on command.
Practicing such activities is graded (e.g., controlling the TD to open in
three, four, or five separate steps).

Purposeful Activity
With purposeful activity, clients learn how to operate prostheses by
engaging in repetitive tasks to facilitate eventual functional use and
endurance. Purposeful activity includes using the prostheses to grasp
and release objects of various sizes, textures, and weights in different
planes and positions. Objects above the head can be difficult to grasp
because individuals must relax the wrist extensors and contract the
flexors while the hand is elevated. Overhead grasp is difficult to
accomplish because of the prosthetic weight. Examples of other
activities practiced during this stage include holding and placing a
tomato on a counter without crushing it or playing a card game with
the cards held by the TD.
Bilateral activities are also a focus in therapy. Often after
amputation individuals become successful in performing some ADLs
unilaterally. Thus therapy must begin early in the rehabilitation
process to facilitate use of the prosthesis in bilateral activities.
Training includes controlled grasp, such as opening in small
increments to grasp small items and then more fully to grasp larger
items. Training emphasizes grasping objects of varied textures and
density. Sessions incorporate work on prehension and timing of
release. Functional and appropriate tasks are encouraged and require
clients to use their prostheses for gross and fine motor activities in
various planes.

Occupational-Based Activity
Occupational-based activity involves engaging the client in
occupations that match clients’ goals. Clients practice skills related to
their lifestyle and interests. Training may include grooming and
hygiene, meal preparation, dressing, child care, return to work
activities, or other meaningful tasks. Tasks may also include
preparation for return to employment or recreation.
The primary focus of therapy should include bilateral activities for
occupational performance. Box 20.2 lists examples of bilateral tasks. 54
Individuals with amputations usually do not realize the functional
benefits of their prostheses until they experience success with bilateral
tasks. Bilateral task training may be difficult for some clients who
became proficient with one-handed techniques early in rehabilitation.

BOX 20.2 Examples of Bilateral Activities

• Insert a garbage bag into a trash receptacle

• Dry dishes with a towel
• Use cell phone
• Butter bread
• Put toothpaste on a toothbrush
• Lace and tie shoes
• Access currency (coins, bills) from a wallet
• Fold a letter and seal envelope
• Use power tools
• Use scissors to cut along a line and shapes
• Crack eggs and separate the yolks from the whites
• Fold laundry
• Wash dishes in a sink
• Remove lids from jars
• Manage separating zippers or buttons
• Peel oranges
• Sweep and use a dustpan
• Rake and bag leaves
• Peel and cut vegetables/fruits
• Cut meat
• Sewing on buttons
• Thread needles
• Use screw drivers
• Hammer a nail
• Drive a vehicle
 • Play sports or card games

As stated earlier, clients are active participants in the rehabilitation

process. Therapists design home programs for clients. The programs
are continually updated as individuals progress to greater function
and independence. Scheduling periodic follow-up visits with the
client to review progress and prosthesis function is important. Often
therapy will be reinitiated when clients find new skills they need or
desire to learn. Therapists are resources for clients, enabling them to
achieve maximal function and independence for participation in
meaningful activities during a lifetime.
Secondary Conditions
Individuals who experience unilateral ULL/D are likely candidates for
experiencing secondary conditions related to overuse of the sound
upper limb. Several studies documented the presence of pain and
musculoskeletal conditions affecting the function of the sound arm in
individuals with unilateral ULL/D. 19,46,62 Their findings agree that
continual patient follow-up is essential to prevent further disparity
and that more studies should be conducted to investigate the effects of
prosthesis wear and to determine possible preventive measures.
Gambrell 38 conducted a review of the literature noting the
consequences and importance of prevention of overuse syndrome
with recommendations for a team approach, emphasizing practitioner
responsibility for educating patients about the likelihood of overuse
and methods that impede development.
Psychological and Social Issues of
Clients with Amputations
At any of the rehabilitation stages, psychological and social issues
may arise, and it is important to make appropriate referrals to
specialists as necessary. Persons with amputations voiced that they
experience more difficulty dealing with their social worlds than with
their physical worlds. 29 Common issues can center around
relationships with family, friends, coworkers, and significant others.
Specific issues may include posttraumatic stress, body image
concerns, loss of sense of wholeness, social isolation, decreased sexual
activity, and depression. 71 One of the most common secondary
conditions associated with limb loss is depressed mood. 4
Some research suggests that the valued personal identities and the
self-management of patients’ ability status should be a priority for the
health professionals involved in prosthesis users’ medical care and
personal development. 59 To users, prostheses may be more than
tools, which is suggested by the industry. When embodied, the
prostheses represent deeply personal meanings that revolve around
mastery of the technology, management of personal information, and
self-identity. Earlier research explored factors toward adjustment and
social meanings surrounding the use of prostheses and particularly
sought perceptions of limb users. 58 Several themes emerged,
including actual prosthesis use, social rituals, the perceptions of social
isolation, the reactions of others, social implications of whether to
conceal or disclose the limb difference, and perceptions or experiences
relative to social and intimate relationships. Factors that influence
adjustment and successful rehabilitation were early prosthetic fitting,
prosthetic satisfaction associated with increased self-esteem, increased
social integration and absence of emotional challenges, and the need
for individual expression, including social expression, person-first
language, societal acceptance, and personalizing the appearance of the
prosthesis. Exploration into the psychosocial aspects of persons with
amputations serves as the impetus for development of a platform to
heighten health care professionals’ consciousness of social challenges
faced by the population of individuals with ULL/D, to raise the voices
of the consumers, and to heighten the hearing of the funding
stakeholders.

Family Dynamics
The dynamics of the family may be altered when a family member
loses a limb. Significant others or direct family members of the injured
person experience a series of losses and adjustments. Family members
may fear that the individual is suffering and at risk of dying. Fear and
anxiety may become overwhelming at times. Family members may
worry about how the individual will adjust to his or her changed
body. Issues about intimacy and dependency are common concerns.
The therapist should encourage a reconnection between the person
who has sustained an amputation and his or her partner. 48,49

Impact on Rehabilitation
The rehabilitation team should become knowledgeable about the
individual’s response to the injury. Psychosocial aspects include
change in self-image and body image, acceptance of the residual limb,
and feeling comfortable in society as a person with an amputation.
Some clients may be medically prepared to begin rehabilitation, but
they are not psychologically ready. Health providers should not label
the client as uncooperative and unmotivated. Rather, they should
facilitate and reinforce good communication among the client and
health care team. The client should be an active partner in establishing
rehabilitation goals.

Counseling People Who Have Amputations

According to Price and Fisher, issues addressed during counseling
sessions include depression, distress, sleeplessness, anxiety, changed
body image, effects on relationships and intimacy, and feelings of
anger and resentment 65 . According to Kohl, 48,49 complaints of
emotional distress in the early stages of rehabilitation seemed to be
most apparent from 6 to 24 months after surgery. As stated
previously, researchers suggest the importance of psychosocial-
emotional health 48,49 and that behavioral health issues are often
overlooked and unaddressed in this population. 64
Upper Extremity Prosthetic Intervention
for Children
Early gross motor movements in children (such as prone and sitting)
emerge between 4 and 6 months. 28 These movements directly involve
the use of hands to balance, support, and stabilize the trunk. As a
result, fitting children with prostheses is considered necessary to
maintain and preserve normal development. 73 Exner 35 stated that
“[t]he development of visual perception and eye-hand coordination
skills in conjunction with cognitive and social development allow the
child to engage in increasingly complex activities.”

Early Fitting
According to Hanson and Mandacina, 39 “The single most important
advantage of early fitting is the immediate acceptance of the
prosthetic arm by the child.” The most beneficial age range to receive
a prosthesis is from 2 months to 2 years. 36,72,78 Children fitted with
prostheses at a young age who wear their prostheses regularly will
demonstrate spontaneous use in daily activities.
Children fitted at later ages are less spontaneous and more inclined
to use the prosthesis passively. 8,16,39 In addition, because hand skills
develop gradually, children should be fitted early so that the
prosthesis becomes naturally integrated with bilateral activities. While
wearing their prostheses, children must practice activities that require
crossing midline, hand position in space, grasping, bilateral tasks, and
bringing hands to midline. 8 Table 20.3 suggests types of prostheses,
goals, assessments, and interventions for children of different age-
groups.

Family Involvement
Acceptance of the prosthesis involves the family. The family should be
involved in donning and doffing the prosthesis, playing with the child
while the prosthesis is on, and developing wearing schedules. The
family should be educated about the importance and advantages of
early and consistent prosthetic use. Furthermore, children who have
myoelectric prostheses require substantial one-to-one training and
attention. 8,32

TABLE 20.3

Suggestions for Age-Appropriate Prostheses, Goals, Assessment, and

Interventions

PUFI, Prosthetic Upper Extremity Functional Index; U-BET, Unilateral Below Elbow Test.

Data from Shaperman, J., Landsberger, S. E., & Setoguchi, Y. (1996).

Early upper limb prosthesis fitting: When and what do we fit, Journal
of Prosthetics and Orthotics 15(1):11–17, 2003; Stocker, D., Caldwell, R.,
& Wedderburn, Z. (1996). Review of infant fittings at the Institute of
Biomedical Engineering: 13 years of service, ACPOC News 2,1–5.
Marketing Strategies and
Recommendations
To specialize in upper extremity prosthetic rehabilitation, therapists
must be motivated and persistent, just as in any area of practice. There
are many avenues for gathering basic information on upper extremity
prosthetics, such as journals, books, agencies, other therapists, and the
Internet (see the Evolve website for information about client
resources, manufacturer resources, and tests and measures).
Important information from these resources augments basic prosthetic
knowledge. Therapists should establish relationships with prosthetists
who specialize in upper extremity prosthetics. Because the number of
upper extremity amputations is generally low, it may be difficult for
therapists to work full-time in this area unless they are willing to
travel regionally or nationally. Some companies employ therapists
who cover a designated region and provide prosthetic rehabilitation
exclusively. If travel is not an option, therapists can network with
prosthetic providers to be the primary referral for prosthetic
rehabilitation in a geographical area. Typically therapists who take
this route work in an outpatient upper extremity rehabilitation
facility.
Spending a week with a prosthetist to learn about the process of
reimbursement, fabrication, and orientation to various prosthetic
options is valuable. The reimbursement process can take much time,
depending on the source of reimbursement and the insurance
company’s specific benefits regarding prostheses. It is important to
remain focused on clients and to serve as advocates for individuals
with the amputation. Phone calls and letters from health care
professionals may expedite approval of prosthetic devices. Therapy
can proceed without approval for the prosthetic devices to accomplish
goals from the preprosthetic phase.
In addition, it is important to locate area case managers and
physicians who work with this population. Case managers and
physicians assist in establishing a referral base. It has been the
experience of the author that physicians, prosthetists, and case
managers are happy to know that therapists exist who want to work
in upper extremity prosthetic rehabilitation. They are also often happy
to refer clients. Upper extremity prosthetics is a rewarding field.

a
Self-Quiz 20.1
Answer the following questions.

1. The term above elbow (AE) amputation is now called

a. Transfemoral
b. Transhumeral
c. Transradial
d. Transtibial
2. The term below elbow (BE) amputation is now called
a. Transfemoral
b. Transhumeral
c. Transradial
d. Transtibial
3. The primary cause for an upper extremity amputation is
a. Congenital malformation
b. Disease
c. Trauma
d. Vascular disorders
4. Which prosthetic option allows individuals to maintain grasp
and release within an unlimited work area with full range of
motion of the proximal upper extremity?
a. Body-powered prosthesis
b. Externally powered prosthesis
c. No prosthesis
d. Passive prosthesis
5. Which prosthesis allows individuals to maintain proprioception
for grasp and release?
 a. Body-powered prosthesis
b. Externally powered prosthesis
c. No prosthesis
d. Passive prosthesis
6. Which prosthetic option typically allows for increased
grip/pinch strength?
a. Body-powered prosthesis
b. Externally powered prosthesis
c. No prosthesis
d. Passive prosthesis
7. Often therapists establish electrode sites and provide
myoelectric training to use externally powered prostheses. In
which phase of the rehabilitation process does this typically
occur?
a. Acute postsurgical
b. Preoperative
c. Preprosthetic
d. Prosthetic training
8. A therapist receives an order to evaluate and treat an individual
with a transhumeral amputation. The prosthetist indicates the
client received the prosthesis 1 week ago. Rank in order the
steps of the therapy intervention:
Step 1: _________
Step 2: _________
Step 3: _________
Purposeful activity
Occupation-based activity
Orientation and control training
9. In which phase of postprosthetic training does the client learn to
operate the controls of the prosthesis and practice until
proficient?
a. Purposeful activity
b. Occupation-based activity
c. Orientation and control training
10. Which secondary condition is most commonly associated with
 limb loss?
a. Depressed mood
b. Isolation
c. Loss of sense of self
d. Posttraumatic stress disorder

a
See Appendix A for the answer key.

Review Questions
1. What is the relationship between the level of amputation
and functional ability? List three reasons for prosthetic
dissatisfaction.
2. What are the primary causes for upper extremity
amputation?
3. Clarify the specific roles of the client, prosthetist, and OT
when treating a person with an amputation?
4. What are the six types of prosthetic options available for
people with upper extremity amputations?
5. How would you explain in lay terms the advantages and
disadvantages of passive aesthetic functional, activity-
specific, body-powered, and externally powered
prostheses?
6. What is one therapy goal for each phase of prosthetic
rehabilitation? What is one specific intervention for each
phase?
7. What are the psychosocial impacts of an amputation that
may arise?
8. What are the diverse types of secondary conditions that are
likely to arise, and why is it important to advise the client
about protective/preventative strategies?
9. How might peer networking be helpful to individuals with
either congenital difference or acquired loss of the upper
limb(s)?
10. What are some barriers individuals with upper limb
acquired loss/congenital difference experience when trying
to access specialized intervention?
References
1. Alley R.D. Advancement of upper extremity
prosthetic interface and frame design, From “MEC
‘02 The Next Generation. Proceedings of the 2002
MyoElectric Controls/Powered Prosthetics
Symposium Fredericton New
Brunswick. Canada: Copyright University of New
Brunswick; 2002 Retrieved
from. http://dukespace.libduke.edu/dspace/bitstream/handle/10
sequence=3.
2. American Board for Certification in
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Appendix 20.1 Case Studies
Case Study 20.1 a

Read the following scenario, and answer the questions based on the
information in this chapter.
Michael is a 6-month-old baby who sustained a vascular trauma
resulting in the amputation of his right wrist and hand at the age of 3
days. Recently Michael began sitting and trying to hold his bottle. He
was seen by the prosthetist for consideration of his first prosthesis.
Michael was referred to occupational therapy for input and
recommendations regarding his developmental milestones.

1. What did the occupational therapist advise?

2. What were the considerations?

Following delivery of the prosthesis, Michael and his caregivers

were referred to occupational therapy for prosthetic training.

3. What might have been included in the occupational therapist’s

plan of care?

Case Study 20.2 a

Amy is a 13-year-old girl who presents with a unilateral congenital
left upper limb difference at the transhumeral level. She has been
wearing a body-powered prosthesis that is cumbersome to wear and
to operate. She complains about the traditional harnessing used to
suspend and to control the components of the device. The prosthetist
is planning to provide Amy with an externally powered device and
would like occupational therapy to work with her before delivery for
readiness with this technology.

1. What goals will occupational therapy address in the plan of

 care?

Case Study 20.3 a

Nick is a 22-year-old man who works as a butcher. His left dominant
hand was caught in a meat grinder. The surgeon who was scheduled
to perform the amputation of the hand called the Department of
Occupational Therapy to have an occupational therapist quickly
consult on the best level of amputation for function.

1. What did the occupational therapist advise?

After the amputation surgery, Nick was referred to an occupational

therapist for preprosthetic intervention.

Case Study 20.4 a

Matt is a 64-year-old man with a right congenital upper limb
difference (transradial level). He wears and uses his prosthetic
technology daily and for different purposes. For example, Matt uses
an activity-specific device that allows him to fish and to shoot archery.
He uses an externally powered multiarticulating hand to accomplish
tasks at work, where he is a salesman. He uses a body-powered
voluntary-closing device for home and property maintenance. Despite
all of this, he has been experiencing pain in the left upper limb, neck,
and trunk. In addition, he reports that he sometimes feels
uncomfortable socially because of the stares and questions asked by
strangers in the community. His primary care physician referred him
to occupational therapy with the order that states, “Evaluation and
Treatment.”

1. What might be included in the occupational therapist’s plan of

care?
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
a See Appendix A for the answer key.
21
Professional Development in
Upper Extremity Rehabilitation
Tara Ruppert

CHAPTER OBJECTIVES
1. Describe the practice settings where upper extremity
rehabilitation occurs.
2. Define hand therapy.
3. Identify the knowledge and skills required to become a certified
hand therapist.
4. Describe the process for certification.
5. Identify the benefits of obtaining a specialist credential.
6. Identify the resources available for preparing for the hand therapy
credential.
7. Identify pathways of service for experienced therapists to
continue professional development.

KEY TERMS
certified hand therapist (CHT)
fellowship program
hand therapy
mentoring
Threaded Case Study A: Owen took a full-time position with a
rehabilitation company that served a four-county rural area near his
small hometown upon graduation from his occupational therapy
program. His job duties consisted of treating clients in a subacute
rehabilitation facility, an acute care hospital, an outpatient rehabilitation
clinic, and in home health. Owen enjoyed treating clients in these
medical settings because he followed many people through the
rehabilitation continuum. Within the first year of employment, Owen
developed a strong interest in upper extremity orthopedic rehabilitation,
especially in fabricating custom orthotics. He enjoyed helping people
recover from traumatic or degenerative conditions and return to
fulfilling occupations.

Threaded Case Study B: Nicole began a full-time position in an

outpatient multidisciplinary rehabilitation clinic attached to a large
hospital immediately after graduation. She had the opportunity to work
with a variety of clients in that setting: people with neurological,
orthopedic, and degenerative conditions. This clinic had a wide variety
of referral sources both internal and external to the hospital, and the
physical and occupational therapists worked side by side. This
environment allowed her to learn from experienced therapists in both
disciplines. After practicing for 2 years, Nicole had developed a good
relationship with a hand surgeon who had recently joined the orthopedic
group. The surgeon approached the rehabilitation team about providing
walk-in services for custom orthotic provision for his patients. Nicole
took on this role with some trepidation but soon found an interest and
aptitude in custom orthotic fabrication.
Entry-Level Practice in Upper Extremity
Rehabilitation
Entry-level occupational therapists are trained in the rehabilitation
process of common upper extremity orthopedic conditions and in the
art of custom orthotic fabrication. This skill set is an important part of
the identity of occupational therapy and has been part of the
occupational therapy scope of practice since the 1970s. 1 However, like
many other skills, becoming proficient at fabricating a custom orthosis
requires practice. Knowing what to do for someone with an
orthopedic impairment also involves experience. Therefore entry-level
occupational therapy practitioners who work with clients with upper
extremity impairments—whether from orthopedic, neurological, or
some other cause—should focus on expanding knowledge and skills
throughout their career.
There are multiple medical settings in which an entry-level
occupational therapist would be expected to treat people of any age
with upper extremity orthopedic conditions. Some of these settings
include acute care hospitals, subacute rehabilitation centers,
outpatient therapy clinics, home health services, and long-term care
facilities. An occupational therapist working in any of these settings is
expected to treat a variety of conditions that impair upper extremity
function (Box 21.1) and needs to provide effective interventions to
help clients return to their daily activities. Provision of custom
orthotics is one intervention that is commonly indicated for many
upper extremity impairments. 2

BOX 21.1 Common Upper Extremity Conditions

for Entry-Level Practice
Common Upper Extremity Orthopedic Diagnoses
 Arthritis
Joint trauma or instability
Burns
Peripheral neuropathy
Connective tissue disorders
Tendinopathy
Cumulative trauma disorders
Tissue contractures
Fractures
Wounds

The Accreditation Council for Occupational Therapy Education

(ACOTE) sets the standards for entry-level education. Standard B.5.11
requires that master’s degree and doctorate occupational therapy
programs teach “design, fabrication, application, fitting, and training
in orthotic devices used to enhance occupational performance and
participation.” 3 Occupational therapy assistant education programs
have a similar standard; “Provide fabrication, application, fitting, and
training in orthotic devices used to enhance occupational performance
and participation.” 3 Occupational therapy programs decide to what
degree this standard is met, so the actual content and exposure to
orthotic fabrication varies among programs. The majority of entry-
level education programs address only the tip of the iceberg in regard
to treating upper extremity impairments. The pursuit of continual
education beyond initial certification is an essential piece of
professional development.
Threaded Case Study A: Within the first year of practice, Owen was
surprised by the number of referrals he received to treat people with upper
extremity orthopedic conditions. He enjoyed working with this population
because clients were often able to return to their previous level of function
after occupational therapy interventions. However, Owen quickly realized
that he needed more education to treat this population. He attended
continuing education courses that addressed upper extremity rehabilitation.
At one of these courses he met Cindy, a certified hand therapist who worked
in an outpatient rehabilitation clinic 50 miles away from him. At the end of
the course they exchanged contact information, and Cindy invited Owen to
contact her whenever he had questions about upper extremity rehabilitation.
Owen was glad to have found a mentor in this specialty area.
Specialty Areas in Occupational
Therapy
With greater experience comes the opportunity to specialize.
Occupational therapists have many potential specialty areas, both
internal and external to the profession. The American Occupational
Therapy Association (AOTA) developed pathways for board
certifications in four different practice areas: pediatrics, mental health,
gerontology, and physical rehabilitation. Occupational therapists must
have 5 years and 5000 hours of experience in the specific practice area,
including at least 500 hours of direct therapy service provision, to
apply for the board certifications. AOTA also developed specialty
certifications for occupational therapists and occupational therapy
assistants in specific intervention areas: driving and community
mobility; environmental modification; feeding, eating, and
swallowing; low vision; and school systems. The process for obtaining
these certifications involves peer review of professional portfolios as
evidence of advanced knowledge in the designated practice area. The
specialty certifications require various lengths of practice experience. 4
AOTA offers fellowship programs and mentoring programs in
specific practice areas. The intent of these programs is to allow
graduates to continue didactic education immediately after entry-level
certification while working under a clinician mentor. These programs
may involve a research and scholarship focus. The areas of fellowship
offered under AOTA are geriatrics, low vision, neurorehabilitation,
pediatrics, physical rehabilitation, burn recovery, and hand therapy.
Fellowship programs last from 9 to 12 months. Graduates are eligible
to sit for AOTA specialty certification in the related field with 3 years
of experience rather than 5 years after successful completion of a
fellowship program. 5
Occupational therapists are eligible for other specialty certification
areas outside those offered by AOTA. A nonexhaustive list of
potential rehabilitative specialty areas includes 6 :
 • Assistive technology (Assistive Technology Professional
([ATP])
• Stroke rehabilitation (Certified Stroke Rehabilitation Specialist
[CSRS])
• Ergonomics (Board of Certification in Professional Ergonomics
[BCPE], Certified Ergonomic Evaluation Specialist [CEES], or
Certified Ergonomic Assessment Specialist [CEAS])
• Lymphedema therapist (Lymphology Association of North
America [LANA] Certified Lymphedema Therapist [CLT])
• Neurodevelopmental treatment (NDT)
• Upper extremity orthopedic rehabilitation (certified hand
therapist [CHT])
• Women’s health (Pelvic Rehabilitation Practitioner
Certification [PRPC])

These specialty areas are available for occupational therapists or

physical therapists. Each clinical specialty identifies the specific
requirements for entry, which typically include clinical experience
before eligibility and some form of competency assessment, such as a
certification examination.

Hand Therapy Certification

Occupational or physical therapists who demonstrate advanced
knowledge in upper extremity orthopedic rehabilitation can pursue a
certified hand therapist (CHT) credential (Box 21.2). The CHT
credential is overseen by the Hand Therapy Certification Commission
(HTCC), which sets eligibility requirements, administers the initial
certification examination, and tracks the recertification process. The
CHT credential originated in 1991 after years of work by the founders
of the American Society of Hand Therapists (ASHT) to establish and
define the field. 7 Now hand therapy is a recognized specialty in the
United States, Canada, Australia, and New Zealand. The HTCC
reports that 85% of all CHTs are occupational therapists, 14% are
physical therapists, and 1% have both occupational therapy and
physical therapy licenses. As of 2017 there were 6284 certified hand
therapists in the world. 8 This specialty is somewhat misnamed
because these practitioners are experts in treating conditions of the
entire upper extremity, not just the hand.

BOX 21.2 Definition of Hand Therapy

Hand therapy is the art and science of rehabilitation of the upper
limb, which includes the hand, wrist, elbow, and shoulder girdle. It is
a merging of occupational and physical therapy theory and practice
that combines comprehensive knowledge of the structure of the
upper limb with function and activity. Using specialized skills in
assessment, planning, and treatment, hand therapists provide
therapeutic interventions to prevent dysfunction, restore function,
and/or reverse the progression of pathology of the upper limb in
order to enhance an individual’s ability to execute tasks and to
participate fully in life situations.
From Hand Therapy Certification Commission. (2017). Recertification.
https://www.htcc.org/recertify.

Hand therapists practice in a variety of settings, but the majority

work in outpatient therapy clinics in urban or suburban areas. 8 The
outpatient therapy setting allows a hand therapist to develop a close
working relationship with orthopedic surgeons who specialize in the
upper extremity. Some hand therapists work alongside a hand
surgeon, providing multidisciplinary treatment in a single clinic
setting, whereas others work in clinics near the surgeons’ clinics and
are able to provide walk-in services. This close interprofessional
relationship between surgeon and therapist benefits everyone
involved, especially the client, and creates an environment of mutual
respect. Hand surgeons often rely on their associated hand therapists
to further educate the client in the rehabilitation processes and
timelines, and the hand therapists consult with surgeons on complex
cases.
 The HTCC published a nonexhaustive list of diagnoses that hand
therapists can treat within the hand therapy scope of practice (Box
21.3). This information is beneficial to include in the scope of practice
because it further clarifies and explains the level of expertise of
therapists with the CHT credential. Hand therapists use a wide
variety of interventions to treat clients, including but not limited to
orthotic fabrication, manual therapy, physical agent modalities,
therapeutic exercise, scar management, edema reduction, work
hardening, and occupation-based therapy. This level of care requires a
solid foundation in many areas, including anatomy, physiology,
kinesiology, ergonomics, psychosocial development, learning styles,
and research principles.

a
BOX 21.3 Hand Therapy Scope of Practice

a
Printed with permission from the Hand Therapy Certification
Commission, Scope of Practice and Domains of Hand Therapy.
Hand Therapy Certification Commission. (2017). Recertification.
https://www.htcc.org/recertify.

An occupational or physical therapist who has at least 3 years of

clinical experience and 4000 hours of practice with upper extremity
rehabilitation is eligible to apply for the certification examination. The
examination is administered two times each year throughout the
United States. The 4-hour examination is computer based and consists
of 200 questions. The HTCC offers a blueprint that outlines the
domains addressed by the examination. Applicants must demonstrate
knowledge of evaluation, treatment planning, therapeutic
interventions, and basic scientific concepts related to the upper
extremity. 9 HTCC conducts field research every 5 years to ensure that
the examination reflects current practices, skills, conditions, and
evidence. Examination pass rates for each testing period over the past
15 years are posted by the HTCC, and the average pass rate for the
CHT examination is 56.8%, with a range of 51% to 63%. 10 The pass
rate indicates that the examination is thorough, rigorous, and requires
a high level of knowledge, all of which are necessary to protect the
integrity of the CHT credential.

Benefits of the Hand Therapy Credential

A practitioner with the CHT credential has proven advanced
knowledge in the realm of upper extremity rehabilitation. The CHT
credential informs referral sources, clients, and payers that the
therapist is an expert in the rehabilitation of a wide variety of issues
related to the complex upper extremity. The HTCC website offers this
quote from a hand surgeon: “In my experience, those with the CHT
certification are more experienced, more knowledgeable about
anatomy and are willing to ‘work outside the box’ with complex
patients.” 8 Hand surgeons rely on hand therapists to provide patient
education, fabricate custom orthotics, and use manual therapy
interventions. Surgeons especially value the rapport that a hand
therapist can build with a patient. As one hand surgeon stated, “A
certified hand therapist has demonstrated their commitment, over
many years, to develop their fund of knowledge and skill set focused
entirely on improving the lives of patients with hand dysfunction. The
synergy of a hand therapist and hand surgeon working together is a
beautiful and necessary team approach to optimize the outcomes for
our patients.” 11
Becoming a clinical specialist can potentially assist with career focus
and advancement. The HTCC reports the results of a salary survey
every 5 years, which outlines the salaries, benefits, and practice
settings of CHTs in the United States. The survey results are beneficial
in salary negotiations. The 2017 survey reported that the average
salary of a hand therapist had a greater increase than the average
salary of a non–hand therapist. 12 The relative rarity of CHTs can
provide a competitive edge in the job market. Of course, the CHT
credential does not guarantee career or salary advancement.
Threaded Case Study B: Nicole enjoyed treating people with upper
extremity impairments and was proud of the improvements she was making
with fabricating custom orthoses. She met Dale, a certified hand therapist, at
an annual conference for her state’s occupational therapy association. They
discussed common interests and practices over lunch. As Nicole learned more
about the CHT credential, she began to appreciate the impact that
specialization could have on her career. She wanted to continue working in
the outpatient therapy setting with people who had orthopedic conditions.
What she was not sure of was how to begin preparing for specialization.

Becoming a Certified Hand Therapist

The requirements to apply for the hand therapy credential are
straightforward. The route to preparing for the certification
examination can vary significantly. There is no one preferred track for
preparation, so therapists who pursue the CHT must tailor an
approach to fit their personal learning styles. Some may choose an
independent track, using resources and self-study approaches. Others
may decide to seek out more directed guidance for their preparation,
such as fellowship programs and mentoring. In either case a critical
step for preparation includes pursuit of continuing education courses
that address topics related to hand therapy. Because entry-level
occupational therapy education must prepare graduates to be
generalists, there is not enough didactic time to cover clinical areas in
depth. Therefore occupational therapists must take it upon themselves
to advance their knowledge after graduation. Courses related to the
foundational content of the hand therapy certification examination are
critical for success. The ASHT, American Hand Therapy Foundation
(AHTF), and the Hand Rehabilitation Foundation (HRF) each hold
annual conferences that focus on upper extremity rehabilitation
practice and research. These multiday conferences are open to hand
therapists and nonspecialists alike and offer information on evidence-
based practice and current knowledge. The time spent pursuing
continuing education is invaluable for the future hand therapist.
There are a multitude of resources for the clinician who wants to
specialize in upper extremity rehabilitation. Textbooks related to
upper extremity rehabilitation are important components of a
clinician’s library and should be referred to frequently in early
practice. One essential piece for the developing hand therapist is
Rehabilitation of the Hand and Upper Extremity by Skirven and
colleagues. 2 This two-volume set addresses current research in upper
extremity conditions, surgical management, and treatment. Many
CHTs consider this resource to be the epitome of essential knowledge.
There are many other resources related to development of upper
extremity rehabilitation, and both the HTCC and the ASHT websites
offer suggestions. The HTCC offers a self-assessment tool that can
help applicants identify areas of strengths and areas that need further
study before taking the certification examination. The ASHT offers
CHT test preparation courses several times each year.
Joining a study group is an effective option for developing further
knowledge in a clinical specialty area. Some states have organizations
of hand therapists who meet regularly, and these groups can be
extremely beneficial for the novice therapist. If this type of specialty
group is not immediately available, a therapist can network to find
other practitioners interested in pursuing the CHT. The ASHT offers
an online community forum, and this type of virtual interaction can be
just as effective as meeting face-to-face. Study groups often conduct
journal reviews, hold case study discussions, or work through mock
examination questions together. Sharing clinical experiences and
working through the clinical reasoning process for treatment planning
is another powerful approach that study groups employ.
 Some practitioners may prefer a more directed approach to
mastering upper extremity rehabilitation concepts, rather than
preparing independently or with other nonspecialists. One path for
guided learning is through a formal fellowship program. Fellowship
programs at major U.S. hand surgery centers exist whereby licensed
occupational or physical therapists obtain experience in upper
extremity rehabilitation under the guidance of expert hand therapists
and hand surgeons. These full-time fellowships are typically a
minimum of 6 months in length and are highly competitive for entry.
Mentoring is an effective way to develop knowledge and advance
practice skills. Mentoring can be an informal or a formal partnership
between two or more people, where one practitioner serves as the
expert and helps the other practitioner gain a deeper understanding of
specific content, treatment practices, and skills. The HTCC supports
formal mentorship as part of its mission and has developed a self-
assessment tool for mentees and a handbook for mentors to facilitate
preparation to become a hand therapist. However, mentoring does not
have to be a formal process. Some of the most successful mentoring
environments are those that develop informally between coworkers or
acquaintances. Upon entering practice, new therapists gain
immeasurable benefit from working alongside and learning from
more experienced therapists. This type of informal mentoring allows
easy communication and idea exchanges when mentors work in close
proximity. In some instances, new therapists may work in more
isolated environments with limited contact with experienced
therapists. In these cases the new clinician must be more self-directed
and should find a mentor in the field with whom to interact with on a
regular basis. The ASHT facilitates mentoring by connecting willing
mentors with available mentees through an online community.
Mentoring offers mutual benefits for the involved parties. Mentors
can use their experience and knowledge to help mentees advance in
clinical practice but also benefit by learning through teaching.
Mentees can benefit from the experiences of their mentors, and
exploring new topics together can update the mentor’s knowledge.
Mentoring does not have to be profession-specific either—a new
physical therapist can learn from an experienced occupational
therapist and vice versa. This interprofessional exposure is especially
beneficial in hand therapy, where the two professions overlap and
complement the rehabilitation process. The field of hand therapy
developed as a result of mentoring when orthopedic surgeons began
to work alongside therapists in the treatment of complex upper
extremity cases. 1 Mentoring may be the most important step in
preparing to specialize in any area, but especially in hand therapy.
Whichever path a therapist chooses, there is an essential process
that should be used routinely to refine clinical reasoning. This process,
called experiential learning, was outlined by Kolb in 1984 and is well
supported throughout educational research. Kolb outlined four
distinct steps to complete when learning new concepts: concrete
experience, reflective observation, abstract conceptualization, and
active experimentation. 13 The first step is gaining authentic
experience related to specific concepts. For the new therapist these
experiences are a daily occurrence, but even a seasoned therapist
encounters new situations. The second step involves deliberate
reflection of the experience and the related outcomes. Specifically, the
learner notes any contradictions between prior knowledge and new
observations. Making connections from past experiences can then lead
to new understanding about how to approach similar situations in the
future. This process of active reflection and conceptualization is
essential for all practitioners to develop clinical reasoning, especially
when pursuing specialization. 14
Threaded Case Study A: After learning about the CHT credential, Owen
set a goal to become a hand therapist as soon as he met the application
requirements. For the next 3 years, he tracked the number of hours he spent
working with people who had upper extremity impairments. He met the 4000
hour requirement after 4 years of practice due to his mixed case load in the
rural setting. During these 4 years, Owen dedicated himself to advancing his
knowledge through multiple approaches. He joined the ASHT as a
nonspecialist and read the Journal of Hand Therapy routinely. He obtained
continuing education credit by completing the quizzes associated with the
articles and sought out as many continuing education courses as possible.
Owen focused on attending courses that focused on treatment of conditions
that affected the shoulder and the wrist and other courses that elaborated on
specific treatment interventions, such as manual therapy skills and custom
orthotic fabrication. He was fortunate that his employer had a generous
policy regarding reimbursement for continuing education courses and
clinical resources, but he also budgeted his own money to purchase books for
his professional library. He found an online study group consisting of other
clinicians who intended to take the CHT examination and became a leader in
suggesting activities for the group. Owen kept in contact with Cindy, a CHT,
via email and video chat due to the physical distance between them. He found
her input and guidance invaluable in his preparations. At her suggestion,
Owen attended a CHT examination preparation course 1 year before his goal
date for the examination. One of his proudest moments in his career was the
day he passed the CHT examination and could add “CHT” to his signature.
Threaded Case Study B: Nicole discussed her aspirations to pursue the
CHT with her direct manager at the outpatient clinic where she worked. The
manager was supportive of Nicole’s desire to specialize in hand therapy.
Together they agreed to direct all appropriate upper extremity orthopedic
referrals to her whenever possible, including shoulder diagnoses after Nicole
completed an in-depth continuing education course on the treatment of
common shoulder conditions. Nicole approached the orthopedic surgeons in
her facility and informed them of her developing knowledge in treating upper
extremity conditions, including shoulder conditions, and encouraged them to
refer appropriate patients to her for occupational therapy services. Her
confidence grew along with her case load, and she incorporated reflective
practice into her routine to ensure that she was delivering proper care. This
reflective practice included journaling, building her resource library,
dedicating time to reading peer-reviewed journals, and using the HTCC Self-
Assessment Tool. Her manager took notice of how often Nicole sought out the
more experienced physical and occupational therapists to gain their insight
into questions or problems she was encountering. Nicole’s greatest step was
applying for a fellowship at a renowned surgical center and research hospital
in her state. When she was selected for the fellowship, she had to make the
hard decision to leave her position with the outpatient clinic, but her manager
was supportive of the move. The 6-month fellowship offered Nicole a chance
to immerse herself in hand therapy, and although she felt mentally exhausted
at the end of each day, her understanding of complex upper extremity
rehabilitation grew exponentially. She applied for the CHT examination
within 3 months of completing the fellowship and proudly added “CHT” to
her credentials.
Professional Development for
Experienced Therapists
Upon successful completion of the hand therapy certification
examination, a therapist can begin a new path in his or her career.
However, certification is only the first step. The HTCC requires hand
therapists to recertify every 5 years by completing 80 hours of
continuing education and 2000 hours of work experience within the
realm of upper extremity rehabilitation. This recertification piece is
essential for ensuring that the hand therapist continues his or her
evolution of knowledge and remains current on best practices. 15
Therefore the dedication to ongoing continuing education and
refinement of knowledge is a critical factor for all therapists, specialist
or not.

BOX 21.4 Pathways of Service for Experienced

Therapists

Become a fieldwork educator Mentor new therapists at place of employment

Join local and national associations Mentor in an area of clinical specialty

Conduct and publish research Serve as an adjunct instructor in an OT education program

Present at conferences Volunteer with state or national associations

OT, Occupational therapy.

Once a therapist has obtained the designation of specialist in any

field, the onus shifts from self-directed learning to self-directed
service. The scope of occupational therapy is too great to fully cover in
entry-level education, so dedication to the profession predicates
sharing knowledge and assisting new generations of clinicians in their
progression from student to generalist. Fortunately, there are many
ways an established therapist can contribute to the education of future
therapists (Box 21.4).
Service to the field is mutually beneficial. When sharing clinical
experiences and verbalizing clinical reasoning, the experienced
therapist gains a deeper understanding of the concepts while
simultaneously assisting the novice therapist. One of the most direct
ways to support the discipline is to serve as a fieldwork educator.
Licensed therapists with 1 year of experience can become fieldwork
educators and directly assist occupational therapy students during
Level II Fieldwork experiences. 16 Experienced therapists can also
share their knowledge through presenting at local, regional, or
national conferences. These types of presentations do not have to
address groundbreaking content; what some therapists see as
commonplace may be completely new to another therapist, so sharing
that information has an impact. Agreeing to formally mentor
clinicians in an area of specialty is another path that can significantly
influence the mentee as well as contribute to the discipline. One
critical way to share knowledge is to instruct in an entry-level
occupational therapy education program. Occupational therapy is a
high-demand field with nearly 200 programs throughout the country,
17 and these programs are dependent on clinician educators to teach,

mentor, and influence students.

Choosing occupational therapy as a career has a multitude of
benefits and opportunities and should be viewed as a lifelong journey.
Becoming an occupational therapy professional entails a commitment
to developing deep understanding of ways to assist people in
recovery from ailments or conditions that impact their occupational
performance, and this understanding can only be achieved through
the pursuit of continual education. Many therapists choose to become
specialists in some form: either through long-term experience in a
specific practice area, with specific populations, or through formal
certifications. Those who choose to become hand therapists are
selecting a credential that communicates their level of knowledge to
all parties and allows focused practice with people experiencing
physical impairments of the upper extremity—from shoulder to
fingertip. This field is incredibly rewarding, and professionals who
obtain this level of specialization are highly sought and well-respected
within the medical community. No matter the credentials,
experienced therapists who are dedicated to professional
development are a wealth of knowledge and essential leaders for the
advancement of occupational therapy.
Threaded Case Study A: Owen went on to start a hand therapy
organization within his state, which completed quarterly virtual meetings for
journal reviews, case discussions, and advocacy work. He also agreed to
present at his state occupational therapy association conference, and although
he was nervous about speaking in front of other professionals, he found a
receptive audience when presenting on treatment of common upper extremity
conditions. This experience bolstered his confidence, and he continued to
present at regional and state meetings. Within 6 years of becoming a CHT, he
was approached by a local occupational therapy education program about
teaching a course on upper extremity rehabilitation, and soon found a new
passion for educating future occupational therapists.
Threaded Case Study B: Nicole was fortunate enough to return to her
original employer 2 years after obtaining the CHT credential, when the
hospital opened an outpatient orthopedic surgery center. Here Nicole worked
alongside two other hand therapists and had direct access to two hand
surgeons. She worked with people who had complex traumatic conditions
involving the upper extremity and provided in-house orthosis fabrication
during the hand surgeons’ clinic hours. Over the years, Nicole and the other
hand therapists participated in clinical research on various upper extremity
rehabilitation topics and had the research published in peer-reviewed
journals. When she was first approached about completing research, Nicole
was concerned about the time demands but soon found that it was
manageable with a team approach and with good support from their
administration. Over the years Nicole always made time to accept fieldwork
students from the regional occupational therapy education program and
enjoyed watching these students advance in their understanding of upper
extremity rehabilitation.
Review Questions
1. Do any of the specialization areas mentioned in this
chapter interest you?
2. Where do you see your career in 5 years? 10 years?
3. Which path of education interests you—self-directed or
guided?
4. Which path of service interests you? Which options do you
see yourself doing in 10 years?
References
1. Fess E. A history of splinting: to understand the
present, view the past. J Hand Ther . 2002;15(2):97–
132.
2.
Skirven T, Osterman A.L, Fedorczyk J, Amadio P. Rehabilitation
of the hand and upper extremity. . ed
6. Philadelphia: Elsevier; 2011:1565–1580.
3. American Occupational Therapy Association. 2011
Accreditation Council for Occupational Therapy
Education standards and interpretive
guide. 2011 Retrieved from. https://www.aota.org/
∼/media/Corporate/Files/EducationCareers/Accredit/Standard
Standards-and-Interpretive-Guide.pdf.
4. American Occupational Therapy Association. Board
and specialty certifications. 2011 Retrieved
from. https://www.aota.org/Education-
Careers/Advance-Career/Board-Specialty-
Certifications.aspx.
5. American Occupational Therapy Association. AOTA
fellowship programs. 2017 Retrieved
from. https://www.aota.org/Education-
Careers/Advance-Career/fellowship.aspx.
6. Lyon S. The ABCs of occupational therapy specialty
certifications and credentials. 2016 Retrieved
from. https://www.verywell.com/occupational-
therapy-degrees-and-training-2509970?
utm_source=pinterest&utm_medium=social&utm_campaign=m
7. Chai S, Dimick M, Kasch M. A role delineation study
 of hand therapy. J Hand Ther . 1987;1(1):7–17.
8. Hand Therapy Certification Commission. Consumer
information. 2017 Retrieved
from. https://www.htcc.org/consumer-information.
9. Hand Therapy Certification
Commission. Certification. 2017 Retrieved
from. https://www.htcc.org/certify.
10. Hand Therapy Certification Commission. Passing
rates for the CHT exam. 2017 Retrieved
from. https://www.htcc.org/certify/exam-
results/passing-rates.
11. Rhodes D. Personal interview via email . September 22,
2017.
12. Hand Therapy Certification Commission. Salary &
benefits survey. 2017 Retrieved
from. https://www.htcc.org/htcc/salarysurvey.
13. Atkinson G Jr, Murrell P. Kolb’s experiential learning
theory: a meta-model for career exploration. J Couns
Dev . 1988;66(8):374–377.
14. Lin S, Murphy S, Robinson J. Facilitating evidence-
based practice: process, strategies, and resources. Am
J Occup Ther . 2010;64:164–171.
15. Hand Therapy Certification
Commission. Recertify. 2017 Retrieved
from. https://www.htcc.org/recertify.
16. American Occupational Therapy Association. COE
guidelines for an occupational therapy fieldwork
experience – level II. 2013 Retrieved
from. https://www.aota.org/
∼/media/Corporate/Files/EducationCareers/Educators/Fieldwo
%20Level%20II–Final.pdf.
17. American Occupational Therapy Association. Find a
school. 2017 Retrieved
from. https://www.aota.org/Education-Careers/Find-
School.aspx.
SUPPLEMENT FOR
13
Mobilization Orthoses

Serial-Static, Dynamic, and Static-

Progressive Orthoses
Sharon Flinn, PhD, OTR/L, CHT, and Janet Bailey, OTR/L, CHT ∗
Dynamic Orthotic Provision for Flexor
Tendon Injuries
A flexor tendon orthosis can substitute for the loss of muscle function
and controlled movement while the tendon heals. A flexor tendon
mobilization orthosis is one of the least complicated orthoses to
fabricate because an outrigger is not required. However, it is a very
demanding orthosis, because initially it must be worn 24 hours per
day and removed only for therapy. Therefore, it must fit well to
ensure comfort and to prevent migration. The therapist should check
the physician’s preference for tendon repair protocols. Although no
one protocol is universally accepted,39 the most common approaches
are the Kleinert and colleagues26 and the Duran and colleagues15
methods. For novice therapists, it is advisable to review zones of the
hand and the protocols because there are many precautions. It is
strongly advisable to consult with a more experienced therapist. The
following steps are instructions for creating a dynamic orthosis using
modifications from both protocols.

1. To apply a nail hook to the client’s proximal portion of the

fingernail, use an emery board to roughen the fingernail.
Apply super glue to attach the hook to the nail bed. Allow the
glue to dry thoroughly before applying the force. Educate the
client on the reason for the hook application. Assure the client
that removal of the hook is possible. Before application of the
hook to the fingernail, the hook may require an adjustment
with two pairs of pliers to fit the contour of the nail (Fig.
13.1A). Position the hook so that the hooks point towards the
nail bed. Hooks should be applied to the proximal end of the
nail bed to prevent avulsion of the fingernail (see Fig. 13.1B).
When applying the hook, do not use an excessive amount of
glue. Glue that comes in a gel form may be easier to manage.
Give the client extra hooks and application instructions
 because hooks occasionally break free from the nail bed.
Alternatives to the nail hooks are adhesive Velcro loops
applied to the nail or sutures placed through physician-created
holes in the nail during surgery.
2. Construct the pattern for a dorsal wrist orthosis, similar to that
shown in Fig. 13.2 (refer to Chapter 7 for instructions). Select a
thermoplastic material with the property of drapability.
Remember to design the pattern to cover two-thirds the length
of the forearm. The distal end of the orthosis should extend
about 1 inch beyond the tips of the fingers.
3. The hand position varies according to surgeon preference.
Klein25 recommends 20 degrees wrist flexion and 40 to 50
degrees of MCP flexion. To maintain the wrist in a safe
position and for ease of application, rest the forearm and hand
on a foam wedge. This positions the wrist and fingers in the
suggested posture (Fig. 13.3A). Instruct the patient not to
extend the wrist to maintain the protective position. It can be
helpful to have the patient use the uninvolved hand to gently
prevent the wrist from extending. Since the orthosis is usually
made postoperatively and the patient is wearing a bandage,
cover the dressing with a stockinette sleeve (Fig. 13.3B) to keep
the warm thermoplastic material from sticking to the bandage
(Fig. 13.3C). Cutting the sleeve off to remove the orthosis when
cooled is easier than pulling the material off a bandage on a
likely sore and swollen hand. To create a bubble to prevent
pressure over the ulnar styloid, a small amount of therapy
putty over the ulnar styloid makes a good temporary pad
during the initial fabrication. Orthotic material with memory is
helpful if needed to reform the orthosis.
4. Apply straps with hook-and-loop Velcro at the following
locations: across the palmar bar, at the wrist, 3 inches proximal
to the wrist, and across the proximal forearm.
5. Attach a safety pin to the strap that crosses the wrist
approximately 3 inches proximal to the wrist crease. Make
sure that the pulley pulls more palmarly so that the DIPs are
 passively flexed (Fig. 13.4A).
6. Apply traction using elastic thread attached to the nail hooks at
the distal end and to the safety pin at the proximal end. Elastic
thread is used due to its ability to stretch while maintaining a
fairly constant tension. Apply the force to hold the fingers in
flexion, but allow the client to achieve full active extension of
the interphalangeal (IP) joints against the force of the elastic
(see Fig. 13.4B). Full IP extension may take a few days to
achieve if the client has been immobilized previously with the
fingers flexed. As IP extension improves, adjust the orthosis’
elastic tension to maintain passive finger flexion while
achieving full active extension.

FIG. 13.1 A, Pliers may be used to adjust the hook to fit the
contour of the fingernail. B, The nail hook is applied to the
proximal nail bed.
 FIG. 13.2 Pattern for a dorsal block orthosis that is used after a
flexor tendon repair.

7. Achieving full IP extension is important because flexion

contractures are common complications following flexor
tendon repair.24 If the client is unable to attain full IP
extension, a wedge may be placed on the dorsum of the
involved finger(s) inside the dorsal hood of the orthosis. The
purpose of the wedge is to increase MCP flexion, thus
decreasing flexor tension and increasing IP extension (Fig.
13.4C).
8. Due to the confined arrangement of tendons within the pulley
system, flexor tendon injuries in zone II are highly susceptible
to adhesions (Fig. 13.5).14 A palmar pulley provides greater
excursion of tendons by maintaining resting position with
composite flexion rather than primarily PIP flexion. The
palmar bar serves to maintain the palmar arch and prevent
orthotic migration. The pulley is created by firmly attaching an
additional piece of thermoplastic material with eyelets for each
finger. The referring physician may specify whether all digits
or only the injured digit(s) should be included (Fig. 13.6). The
therapist may apply a strap to the distal aspect of the fingers to
maintain full IP extension. This application may reduce the
loss of extension at the IP joints and is generally used for night
wear or if the person is developing an IP flexion contracture.
With an IP flexion contracture and with physician approval,
the person may alternate between flexion traction and the
extension strap during the day (Fig. 13.7).
Static-Progressive Approach for
Composite Finger Flexion
It is common for the fingers to become stiff after trauma to the hand or
wrist. Stiffness may be due to joint pain or swelling, which prevents
an ability to achieve full finger flexion.
Although clients may be actively participating in a therapy program
that focuses on edema control, range of motion, and tendon gliding to
achieve full composite finger flexion, an orthosis that aids in wound
healing or tissue remodeling through low-load prolonged stress to the
joints can maximize return to function.
For the hand to function optimally, the PIP joint needs to extend
and flex to the palm. Different types of grasps are important for
occupational activities, such as the ability to slip the hand into a
pocket, to put on a glove, grasp coins, or hold a wrench. The PIP joint
can lose extension from the following:

• Crush injury
• Burn or fracture around the PIP joint
• Flexor tendon injury
• Ligament injury
• Excessive swelling of the hand following injury elsewhere
• Immobilization and disuse

There are several different ways to mobilize PIP joints to gain

passive flexion with either custom fabricated or prefabricated
orthoses. The following steps are instructions for creating a custom
fabricated static-progressive orthosis for the hand. Static-progressive
tension allows the person to maintain the tissue at a maximum
tolerable stretch.36

1. Fabricate a volar-based wrist immobilization orthosis with the

wrist in 30 to 45 degrees extension to maximize finger flexion
 (refer to Chapter 7 for instructions).
2. To fabricate the finger cuff, use a thinner (1⁄16 inch)
thermoplastic material. Cut two pieces ½ inch to ¾ inch wide
and 1½ to 2 inches long. Mold one cuff halfway around
dorsum of proximal phalanx and the other cuff over distal
phalanx.
3. Punch small holes using a hole punch on either side of the two
cuffs. Cut a piece of monofilament line approximately 10 to 12
inches long. Tie the start of the monofilament line on one side
of the distal cuff (Fig. 13.8A). Thread it through one side of the
proximal cuff, and then through the other side of the proximal
cuff. Tie off on the other side of the distal cuff (Fig. 13.8B).

FIG. 13.3 With the forearm and hand resting on the wedge, the
ideal position after flexor tendon repair can be achieved with
minimal discomfort to the client (A, B, C).
FIG. 13.4 A, Straps are applied across the palmar bar, at the
wrist, 3 inches proximal to the wrist, and at the forearm. The
safety pin is fixed to the strap 3 inches proximal to the wrist
crease. B, The person must be able to attain full IP active
extension against the force of the tension. C, To attain full PIP
extension, a wedge may be inserted.
FIG. 13.5 A palmar pulley may be best for tendon injuries in
zone II.
FIG. 13.6 An attachment may be added to the palmar bar to
increase tendon excursion in zone II injuries.
FIG. 13.7 The person may use a strap to secure fingers in
extension for night wear.
 FIG. 13.8 The fishing line should start from the distal cuff
through both holes on the proximal cuff before ending on the
other side of the distal cuff, leaving enough fishing line to loop
through the Velcro tap and reaching mid way down the forearm
(A, B).

4. Find the center of the monofilament line, and slip it through

the small hole at one end of a Velcro loop ½″ × 2″ to create a
completed flexion cuff.
5. Repeat this for additional fingers as needed.
6. This cuff is applied to the stiff finger(s) when pulled toward the
forearm. The tension should cause the finger to flex first at the
DIP, then at the PIP, and finally at the MCP into the palm
(composite fist).
 FIG. 13.9 When completed, the fingers can be pulled into a
composite fist position, adjusting the Velcro loop as tolerated
every 5 minutes with a goal of wearing the orthosis 30 minutes at
a time (A, B).

7. Reapply the volar orthosis, and apply straps across the dorsum
of the hand, at the wrist and forearm.
8. Fit the individual finger flexion cuffs, and gently pull them
toward the forearm (Fig. 13.9A), to determine where to place
the Velcro hook on the volar aspect of the wrist orthosis (Fig.
13.9B).
9. The cuffs should be pulled tight enough to provide gentle
tension to the fingers. After each 5 minutes attempt to tighten
the tension as tolerated, with the goal of wearing the orthosis
30 minutes for two times a day.

There are other options for finger cuffs, including leather,

commercially available finger loops, or strapping material. Please
refer to Appendix Evolve web site for another option of detailed
instructions for fabrication of a composite finger flexion orthosis with
static-progressive tension.
∗ This material is an exert from the fourth edition of Introduction to
Orthotics: A Clinical Reasoning & Problem-Solving Approach. It
includes information on fabrication of traditional dynamic orthoses,
and a static-progressive approach for composite finger flexion.
Glossary

A
acromion Forms the summit of the shoulder and connects with the
clavicle to form the acromioclavicular joint.
activity-specific devices Terminal devices that are intended for a
function or types of functions; often oriented to activities of daily
living, work, and recreation.
adherence The extent that a client follows agreed-upon intervention
without close supervision.
agonist A muscle that contracts while the other muscle relaxes.
alignment Arranging of anatomical structures so that they are in
proper relative position.
AMBRI Multidirectional bilateral shoulder instability, caused by a
combination of microtraumas with rehabilitation being the
treatment of choice.
Antagonist A muscle that opposes the action of another muscle.
anterior elbow immobilization orthosis Elbow immobilization
orthosis positioned on the anterior aspect of the arm.
anterior instability of the shoulder Increased abnormal movement
of the humeral head anteriorly, partially displacing the humeral
head from the glenoid labrum.
anterior transposition of the ulnar nerve A surgical procedure with
two main methods to reposition the ulnar nerve. The procedure
includes subcutaneous and submuscular transposition. The
subcutaneous method includes moving the ulnar nerve anteriorly
medial to the median nerve and below subcutaneous fascia in the
forearm.
anticoagulants A substance that hinders the clotting of blood; blood
thinners.
antideformity position One positional option includes the wrist in 30
to 40 degrees of extension, the thumb in 40 to 45 degrees of palmar
abduction, the thumb interphalangeal (IP) joint in full extension,
the metacarpophalangeals (MCPs) at 70 to 90 degrees of flexion,
and the proximal interphalangeals (PIPs) and distal
interphalangeals (DIPs) in full extension.
aponeurosis A strong sheet of fibrous connective tissue that serves as
a tendon to attach muscles to bone or as a fascia to bind muscles
together.
appendicular skeleton Bones of the upper and lower extremity,
excluding the head, trunk, and vertebrae.
area of force application Area that force is supplied with an orthosis.

arteriovenous anastomosis A blood vessel that connects directly to a

venule without capillary intervention.
arteriovenous fistula Surgically created fistula are typically located
on the forearm and used for vascular access for hemodialysis.
arthrogryposis Or arthrogryposis multiplex congenita typically
involves all four extremities. A pronounced lack of muscle mass
and flexion creases is apparent. Joints have decreased ROM with
an inelastic end range. Typical posturing includes internally
rotated and adducted shoulders, extended elbows, pronated
forearms, flexed and ulnarly deviated wrists, partially flexed
 fingers, and adducted thumbs.
Assessment of Motor and Process Skills (AMPS) A functional
assessment that requires the client to perform an instrumental
activity of daily living (IADL) and assesses motor and process
skills.
axial skeleton Bones of the head, trunk, and vertebrae.
axonotmesis An interruption of the axon with subsequent
degeneration of the distal nerve segment.

B
Bankart An injury to the shoulder resulting in a detachment of the
anterior inferior glenoid labrum. This is most often caused by an
anteriorly dislocating humeral head.
biofeedback A training technique by which a person learns how to
regulate certain muscle functions; one example of usage is to
develop control of a prosthesis.
biofeedback machine Equipment used to identify muscle signals and
sites.
biomechanical Considering the mechanical aspect of the body such
as forces and muscle exertion.
biomechanical principles Principles that include assessment of
normal and pathological gait patterns in a clinically observable
evaluation.
biopsychosocial approach Involving the interchange of biological,
psychological, and social factors.
body-powered prosthesis Prosthesis activated and operated by body
movements.
boutonnière deformity A finger that postures with proximal
interphalangeal (PIP) flexion and distal interphalangeal (DIP)
hyperextension.
brachial plexus palsy Paralysis or paresis of the brachial plexus, a
nerve plexus originating from the anterior branches, including the
last four cervical and first four thoracic spinal nerves. Plexus
innervates the shoulder, chest, and arms.
buddy straps Soft straps used to promote motion and support an
injured digit to an adjacent digit.

C
camptodactyly Permanent flexion of one or more of the
interphalangeal finger joints usually caused by congenital factors.
Canadian Occupational Performance Measure (COPM) A client-
centered outcome measure used to assess self-care, productivity,
and leisure.
carpal tunnel syndrome (CTS) A common painful disorder of the
wrist and hand induced by compression on the median nerve
between the inelastic carpal ligament and other structures in the
carpal tunnel.
central slip This structure crosses the proximal interphalangeal (PIP)
joint dorsally and is part of the PIP joint dorsal capsule.
centralization D A surgical procedure to realign the wrist to correct a
wrist deviation.
cerebral palsy (CP) A condition resulting in a nonprogressive
movement and postural disorder because of abnormal neural
development or damage to the motor centers of the brain before,
during, or after birth.
certified hand therapist An occupational or physical therapist who
has demonstrated advanced knowledge in the treatment of upper
extremity impairments.
circumferential An orthosis that fits around the circumference of an
extremity.
clasped thumb Refers to a classification of thumb anomalies that
range from mild deficiencies of the thumb extensor mechanism to
severe abnormalities of the thenar muscles, web space, and soft
tissues.
clavicular facet Hollow articulation on the sternum that articulates
with the clavicle connecting the axial to the appendicular skeleton
for the upper extremity.
client-centered intervention Treatment that focuses on meeting
client goals as opposed to therapist-designed or protocol-driven
goals.
client safety Approach to client care that considers safety.
clinical considerations Presentations or conditions that must be
accounted for planning intervention (e.g., lack of sensation, skin
breakdown, etc.).

clinical reasoning The in-depth deliberation and decision process

that therapists apply in clinical practice involving several
approaches toward thinking.
clinodactyly A congenital condition resulting in permanent and
abnormal lateral or medial flexion of one or more fingers.
collateral ligaments Ligaments on each side of the joint that provide
joint stability and restraint against deviation forces. The radial
collateral ligament protects against ulnar deviation forces, and the
ulnar collateral ligament protects against radial deviation forces.
complex regional pain syndrome (CRPS) A chronic pain condition
thought to be a result of impairment in the central or peripheral
nerve systems.
componentry The compilation of components toward assembling a
prosthesis.
composite extension Extension of all fingers together.
compression socks Socks used to reduce swelling formation at an
amputation site.
concomitant injury Injury that occurs impacting two or more places
simultaneously.
congenital hand anomalies Hand deformities found at birth.
congenital trigger finger Condition found at birth in which the
finger is pulled into flexion.
constriction band syndrome A congenital disorder caused by
entrapment of fetal parts, usually a limb or digits, in fibrous
amniotic bands while in utero.
context A variety of interrelated conditions within and surrounding
the client that influence performance, including cultural, physical,
social, personal, spiritual, temporal, and virtual aspects.
contracture An abnormal, usually permanent, condition of a joint
characterized by flexion and fixation and caused by atrophy and
shortening of muscle fibers or by loss of the normal elasticity of the
skin, such as that from the formation of extensive scar tissue over a
joint.
contralateral limb Limb on the opposite side to the referent.
convection Transfer of heat between a surface and a moving medium
or agent.
coracohumeral ligament A ligament that forms a ridged support of
the anterior shoulder.
creep Response of soft tissue to prolonged stress. Can be with pain or
inflammation or can be managed with controlled stress.
cubital tunnel syndrome Ulnar nerve compression in the upper
extremity located between the medial epicondyle of the humerus
and the olecranon resulting in pain and paresthesias in the fourth
and fifth digits.
cumulative trauma disorder (CTD) Musculoskeletal disorder
resulting from repetitive motions (usually occupation) that
develop over time. Symptoms include pain, inflammation, and
function impairment.

D
degrees of freedom The number of planes in which a joint axis(es)
can move.
de Quervain tenosynovitis The most commonly diagnosed wrist
tendonitis that may be recognized by pain over the radial styloid,
edema in the first dorsal compartment, and positive results from
the Finkelstein test or other assessments for the condition.
distal humerus Fracture at the end of the humerus bone.
documentation Professional writing in a formal medical record.
dorsal Pertaining to the back or posterior.
double crush Nerves that are compressed at more than one site.
dual site The use of an externally powered prosthesis from two
muscle sites.
Dupuytren contracture A contracture characterized by the formation
 of finger flexion contractures with a thickened band of palmar
fascia.
dynamic orthosis A mobilization orthosis that has a stable static base
and an elastic mobilizing component.

E
ecchymosis A subcutaneous hemorrhage marked by purple
discoloration of the skin.
elbow arthroplasty The resurfacing or replacement of the elbow
joint.
elbow instability Injury that results from a dislocation of the
ulnohumeral joint and injury to the varus and valgus stabilizers of
the elbow and to the radial head.
electrodes Conductors through which muscle electricity is
transmitted to control prosthetic technology.
end feel Assessed by passively moving a joint to its maximal end
range.
Erb palsy Paralysis of the upper arm and shoulders but not hands
caused by a lesion of the upper trunk of the brachial plexus or
roots to the fifth and sixth cervical nerves.
Essex-Lopresti fracture Fracture of the radial head along with
dislocation of the distal radioulnar joint and accompanying issues
with the interosseous membrane resulting from a fall from a
height.
evidence-based practice The process of reviewing a body of
literature to select the most appropriate assessment or treatment
for an individual client.
extensor lag The joint can be passively extended but cannot be fully
 actively extended by the client.
externally powered prosthesis Prosthesis that is controlled or
powered outside the body; also referred to as myoelectric
prosthesis.

F
fellowship program Post-professional training programs that
advance a practitioner’s knowledge and skills in a focused area or
practice.
figure-eight orthosis Support straps used with injury to the clavicle
and/or acromioclavicular joint. It prevents upward migration of
the proximal clavicle and assists in alignment during healing.
finger loops A method of applying dynamic force to a joint.
finger sprain Stress or ligamentous injury to a joint. Occurs in
varying grades of severity.
flexion contracture A joint that cannot be passively extended to
neutral.
forearm trough A component of the wrist immobilization orthosis
that rests proximal to the wrist on one or more surfaces of the
forearm. It provides counterforce leverage to support the weight of
the forearm.
functional envelope Area of work in front and around a person’s
hands.
functional position A position that includes the wrist in 20 to 30
degrees of extension, the thumb in 45 degrees of palmar abduction,
the metacarpophalangeal (MCP) joints in 35 to 45 degrees of
flexion, and all proximal interphalangeal (PIP) and distal
interphalangeal (DIP) joints in slight flexion.
fusiform swelling Fullness at the proximal interphalangeal (PIP)
joint and tapering proximally and distally. Often seen following
finger PIP joint sprains.

G
glenoid fossa A shallow depression on the lateral scapula that
increases the surface area contact with the head of the humerus.

grasp The result of holding an object against the rigid portion of the
hand that the second and third digits provide. The flattening and
cupping motions of the palm allow the hand to pick up and handle
objects of various sizes.
grip force Strength applied by the terminal device to grasp objects.

H
handling characteristics The properties of thermoplastic material
when heated and softened.
hand therapy Hand therapy is the art and science of rehabilitation of
the upper limb, which includes the hand, wrist, elbow, and
shoulder girdle. It is a merging of occupational and physical
therapy theory and practice that combines comprehensive
knowledge of the structure of the upper limb with function and
activity. Using specialized skills in assessment, planning, and
treatment, hand therapists provide therapeutic interventions to
prevent dysfunction, restore function, and/or reverse the
progression of pathology of the upper limb to enhance an
individual’s ability to execute tasks and to participate fully in life
situations.
hard end feel An abrupt hard stop to movement when bone contacts
bone during passive range of motion (PROM).
harness Strapping used to suspend or to help to control the
prosthesis.
Health Insurance Portability and Accountability Act (HIPPA)
Health Insurance Portability and Accountable Act regulates
privacy standards that protect medical records and other health
information.
heat gun An instrument used to make adjustments to thermoplastic
materials.
hook rubbers Elastic bands used to control a voluntary-opening
terminal device.
hybrid prosthesis Prosthesis with components that are controlled or
powered by the body and external to the body.
hypertonicity Being hypertonic or having excess tone.
hypoextensibility Lack of ability for muscles to extend or stretch in a
typical manner.
hypoplasia Unfinished or underdevelopment of an organ or part.
hypothenar bar A component of the wrist immobilization orthosis
that palmarly supports the ulnar aspect of the transverse
metacarpal arch.

I
immobilization Orthoses designed to immobilize primary or
secondary joints.
integumentary system A system encompassing the integument (skin)
and its derivatives.
intervention process Process provided by therapist with
intervention.
L
lamination Hard, permanent finish of prosthetic socket.

lateral bands Contributions from the intrinsic muscles that join

dorsal to the proximal interphalangeal (PIP) joint axis. They
displace volarly in a boutonnière deformity and dorsally in a swan
neck deformity.
lateral epicondyle The tissue at the lower end of the humerus at the
elbow joint.

M
mallet finger A finger that postures with distal interphalangeal (DIP)
flexion.
McKie thumb orthosis A prefabricated Neoprene orthosis designed
to position the thumb in opposition and to which a supinator strap
may be added. The primary function is to provide biomechanically
sound weight bearing, grasp, and manipulation of objects.
mechanical advantage The ratio of the output force developed by the
muscles to the input force applied to the body structures the
muscles move, especially the ratio of these forces associated with
the body structures that act as levers.
mechanoreceptor Sensory nerve ending that responds to mechanical
stimuli, such as touch, pressure, sound, and muscular contractions.
medial epicondyle The part of the humerus that gives attachment to
the ulnar collateral ligament of the elbow joint, to the pronator
teres, and to a common tendon of origin (the common flexor
tendon) of some of the flexor muscles of the forearm.
median nerve One of the terminal branches of the brachial plexus,
which extends along the radial parts of the forearm and the hand
 and supplies various muscles and the skin of these parts.
memory The ability of thermoplastic material to return to its
preheated (original) shape and size when reheated.
mentor Experienced practitioner who assists in the professional
development of a novice practitioner.
metacarpal bar A component of the wrist immobilization orthosis
that supports the transverse metacarpal arch dorsally or palmarly.
minimalist design A basic simplified orthotic design.
mobilization orthosis Orthosis designed to move or mobilize
primary or secondary joints.
monteggia fracture Dislocation of the proximal radioulnar joint along
with a forearm fracture.
myoelectric prosthesis Prosthesis that is controlled or powered
outside the body; also known as externally powered prosthesis.
myostatic contracture Shortening of muscle typically due to
immobilization and without pathology.

N
Neoprene A soft orthotic material consisting of rubber with nylon
lining on one side and pile material on the other, thus making the
Velcro hook attachment quick. Neoprene retains warmth, has some
degree of elasticity, and has contour for a snug fit.
nerve entrapment A medical condition caused by direct pressure on
a nerve, also referred to as a trapped nerve, or may refer to nerve
root compression.
neurapraxia A condition in which a nerve remains in place after a
severe injury, with a short-term loss of nerve conduction.
neurophysiological Branch of physiology that addresses the nervous
system.
neurotmesis A peripheral nerve injury in which laceration or traction
completely disrupts the nerve.
normal gait Smooth, rhythmic patterns of motion requiring little
effort involving a gait cycle from initial contact of one foot to the
next initial contact of the same foot

O
oblique retinacular ligament (ORL) Also called the ligament of
Landsmeer, this structure is determined to be tight if there is
limitation of passive distal interphalangeal (DIP) flexion while the
proximal interphalangeal (PIP) joint is extended.
occupational deprivation A state wherein clients are unable to
engage in chosen meaningful life occupations due to factors
outside their control.
occupational disruption A temporary and less severe condition than
occupational deprivation that is also caused by an unexpected
change in the ability to engage in meaningful activities.
occupational profile The phase of the evaluation process that
involves learning about a client from a contextual and performance
viewpoint.
Occupational Therapy Code of Ethics and Ethics Standards The
professional code of ethics established by the American
Occupational Therapy Association (AOTA). This code sets forth
the minimal expectations for occupational therapists.
occupation-based orthotic intervention A treatment approach that
supports the goals of the treatment plan to promote the ability of
clients to engage in meaningful and relevant life endeavors.
occupation-centered An overarching paradigm for conducting
occupational therapy assessment and intervention that promotes
the ability of the individual with dysfunction to engage in desired
life tasks and occupations.
occupation-focused approach The attention to the occupational
desires and needs of an individual, coupled with knowledge of the
effects or potential effects of pathological conditions and managed
through client-centered interventions.
olecranon process A proximal projection of the ulna that forms the
tip of the elbow and fits into the olecranon fossa of the humerus
when the forearm is extended at the proximal extremity of the
ulna.
open reduction internal fixation (ORIF) Two-part surgical procedure
for a broken bone, including putting the bone back into place
(reduction), followed by using a means of internal fixation (screws,
plates, rods, pins) to hold the bone.
orthosis A device that can support, place in alignment, or help
correct the positioning of a body part.
orthotic design principles Principles that consider the interaction of
anatomical and mechanical structures as well as functional
considerations of orthotic components and materials.
orthotic terminology Terminology derived from the anatomical area
affected by the orthosis.
orthotic treatment objectives Objectives that establish short- and
long-term goals that enhance functional level with minimal
orthotic intervention.
osseo-integration The structural link at which human bone and the
surface of a synthetic, often titanium-based, implant meet.
osteoarthritis (OA) The most common form of arthritis, in which one
 or many joints undergo degenerative changes—including loss of
articular cartilage and proliferation of bone spurs.
osteoporotic fracture Low-trauma or fragility fracture, which occurs
from a fall from a standing height or less, affecting those with low
bone mineral density.
outrigger A projection from the orthosis base that the therapist uses
to position a mobilizing force.
overuse syndrome Type of injury common to the contralateral side
among individuals with upper limb acquired loss or congenital
difference, typically caused by repetitive movements or awkward
postures and also known as repetitive strain injury (RSI).
Symptoms include swelling, pain, and weakness in the affected
joints.

P
passive functional aesthetic device Static prosthesis that appears to
look like a hand; functions include stabilizing, supporting, and
social tasks.
pathological gait Abnormal gait that may develop from
neuromuscular deficits, joint instabilities, pain, disease, or
congenital impairment.
pattern recognition Control requires a set of myoelectric signals,
corresponding to each possible movement of the user’s prosthesis,
to be recorded and used to calibrate the control system.
pediatric trigger thumb Presentation typical in early childhood;
palpable nodule at the volar aspect of the metacarpophalangeal
(MCP) joint flexion crease, known as a Notta nodule.
performance characteristics The properties of thermoplastic material
after the material has cooled and hardened.
phantom pain Pain that feels like it is coming from a body part that is
no longer present; once believed to be a psychological problem, it
is now recognized that these real sensations originate in the spinal
cord and brain.
phantom sensation Sensation that an amputated or missing limb is
still attached.
physical agent modality (PAM) Modality that produces a
biophysiological response through the use of light, water,
temperature, sound, electricity, or mechanical devices.
plaster bandage Material used for casting.
plasticity The quality of being plastic or formative.
positioning Place a joint or extremity in a desired position for
optimal healing.
posterior elbow immobilization orthosis A custom-molded
thermoplastic orthosis positioned in 80 to 90 degrees of flexion.
posterior interosseous nerve syndrome A condition that includes
weakness or paralysis of any muscles innervated by the posterior
interosseous nerve and does not involve sensory loss.
prefabricated off-the-shelf (OTS) A commercially-purchased
orthotic device that is not custom-fitted.
preformed orthoses Factory-produced orthoses premolded to a
specific design.
prehension The use of the hands and fingers to grasp or pick up
objects.
pressure Total force divided by the area of application.
principles The universal nature of obligations and duties and their
application to moral decisions.
pronator tunnel syndrome The compression of the median nerve in
the forearm between the two heads of the pronator teres muscle.
prosthesis An artificial device to replace or augment a missing or
impaired part of the body.
prosthosis A hybrid device accessing the qualities and/or functions of
a prosthesis and an orthosis for a retained limb with lost/impaired
function.
protocols Written plans specifying the procedures for giving an
examination, conducting research, or providing care for a
particular condition.
psychosocial-emotional impact The effect caused by environmental
and/or biological factors on an individual’s social and/or
psychological aspects.

R
radial Pertaining to the radius or radial side of the forearm or hand.
radial head The disk-shaped portion of the radius closest to the
elbow.
radial longitudinal deficiency A longitudinal deficiency of the
radius associated with abnormal genetics resulting in missing or
malformed radius and a small or missing thumb.
radial nerve The largest branch of the brachial plexus, supplying the
skin of the arm and forearm and their extensor muscles.
radial nerve injuries Injuries commonly occurring from fractures of
the humeral shaft, fractures and dislocation of the elbow, or
compressions of the nerve.
radial tunnel syndrome A condition in which a nerve in the forearm
 is compressed, causing elbow pain and weakness of the wrist or
hand but without causing a loss of sensation.
radialization dA surgical procedure to move the hand closer to the
radial border of the forearm.
radio-frequency identification (RFID) A type of wireless
communication that typically involves an RFID reader and a tag.
The tag has information stored in its memory, and the reader
(using an antenna) can read this information.
reliability The consistency of an assessment.
residual limb The remnant limb of a congenital difference or
following amputation.
responsiveness An assessment’s sensitivity to measure differences in
status.
rheumatoid arthritis (RA) A chronic systemic disease that can affect
the lungs, cardiovascular system, and eyes. Joint involvement
resulting from inflammatory disease of the synovium is the
primary clinical feature. The disease may range from mild to
severe and can result in joint deformity and destruction of varying
degrees.

S
scaphoid fracture A break in the boat-shaped bone of the hand.
sensory system modulation The brain’s ability to regulate and
balance excitation and inhibition of sensory input.
serial casting Casting used to gradually increase range of motion.
serial-static orthosis A type of mobilization orthosis that positions a
joint near its elastic limits to overcome a loss in passive range of
motion.
single site The use of an externally powered prosthesis from one
muscle site.
socket A hard material (resin and plastic) used to make temporary or
permanent prostheses.
soft end feel Soft compression of tissue felt when two body surfaces
approximate each other.
soft orthosis Prefabricated or custom orthosis made from various soft
materials.
spasticity A form of muscular hypertonicity with increased resistance
to stretch.
splint Refers to casts and strapping applied for reductions of
fractures and dislocations.
stages of tissue healing Refers to wound healing stages, such as the
proliferative stage, which influence orthotic provision.
static-progressive orthosis An orthosis that uses nonelastic tension to
provide a constant force.
stress Any emotional, physical, social, economic, or other factor that
requires a response or change.
stretch reflex Reflex that is elicited through passive stretch used with
orthotic fabrication for a person who has muscle tone.
subcutaneous Under the skin.
subluxation A partial separation or dislocation of the articular
surfaces of a joint.
submaximum range of motion Placement of an orthosis 5-10 degrees
below maximum passive range.
submuscular Under the musculature.
superficial agents Heating agents or thermotherapy agents that
penetrate the skin to a depth of 1 to 2 cm. They include moist hot
packs, Fluidotherapy, paraffin wax therapy, and cryotherapy.
superior labrum tear from anterior to posterior (SLAP) An injury to
the glenoid labrum of the shoulder affecting the top of the labrum.
The injury can occur in front and back of the attachment of the
biceps tendon.
suspension systems Straps used to suspend or hold a prosthesis.

swan neck deformity A finger that postures with proximal

interphalangeal (PIP) hyperextension and distal interphalangeal
(DIP) flexion.
syndactyly Webbing between finger digits creating fusion of the
digits.

T
targeted muscle reinnervation (TMR) Surgical procedure in which
residual nerves from the amputated limb are transferred to
reinnervate new muscle targets.
task-oriented approach Approach toward intervention that
encourages hand use with functional tasks.
tendinopathy Injury to a tendon, including tendonitis, tendinitis,
tenosynovitis, and tendinosis.
tendinosis Noninflammatory degenerative condition of the collagen
tissue due to aging, microtrauma, or vascular compromise.
tendonitis An inflammatory condition of a tendon, usually resulting
from strain.
tennis elbow Also known as lateral epicondylitis, overuse of the
 forearm extensor muscles causing strain or microtears in the
extensor muscles, especially the extensor carpi radialis brevis.
tenosynovitis Inflammation of a tendon sheath caused by calcium
deposits, repeated strain or trauma, high levels of blood
cholesterol, rheumatoid arthritis, gout, or gonorrhea.
terminal device (TD) Hand, hook, or tool used at the end of a
prosthesis.
terminal extensor tendon This delicate structure is formed by the
uniting of the lateral bands and provides distal interphalangeal
(DIP) extension.
“Terrible triad” injury A coronoid avulsion fracture resulting in
elbow instability and dislocation of the ulnohumeral joint and
injury to the varus and valgus stabilizers of the elbow and radial
head.
thermoplastic material Material that softens under heat and is
capable of being molded into shape with pressure and then
hardens upon cooling without undergoing a chemical change.
3-D printed device A three-dimensional device that resembles a
prosthesis, fabricated from computer-aided manufacturing (CAM).

three-point pressure A system consisting of three individual linear

forces in which the middle force is directed in opposite direction to
the other two forces.
torque The effect a force has on rotational movement of a point. It can
be calculated by multiplying the force by the length of the
movement arm.
torque transmission Orthoses that create motion of primary joints
situated beyond the boundaries of the orthosis itself or that harness
secondary “driver” joint(s) to create motion of primary joints that
may be situated longitudinally or transversely to the driver joint(s).
transhumeral amputation Amputation across the humerus bone.
transradial amputation Amputation across the radius and ulna
bones.
transverse humeral ligament Forms a bridge between the lesser and
greater tubercle of the humerus enclosing the canal of the bicipital
groove.
transverse retinacular ligament This ligament helps prevent lateral
band dorsal displacement and thereby contributes to the delicate
balance of the extensor mechanism at the proximal interphalangeal
(PIP) joint.
treatment protocol Written plan specifying the procedures for
treatment.
trigger finger A condition when a tendon becomes inflamed and
swollen, limiting its ability to slide freely, and the finger locks
when attempting to extend the finger after making a fist. Bending
the finger or thumb can make a snapping or popping sound.
TUBS Acronym that stands for Traumatic etiology, Unidirectional
instability, Bankart lesion, whereby Surgery is required for the
shoulder instability.

U
ulnar Pertaining to the long medial bone of the forearm or ulnar side
of the forearm or hand.
ulnar collateral ligament (UCL) injury A common injury that can
occur at the metacarpophalangeal (MCP) joint of the thumb. This is
also known as skier’s thumb or gamekeeper’s thumb.
ulnar nerve One of the terminal branches of the brachial plexus that
supplies the muscles and skin on the ulnar side of the forearm and
 hand.
ulnarization dA surgical procedure to move the hand closer to the
ulnar border of the forearm.

V
valgus Deformed joint with the more distal of the bones deviating
from the midline of the body.
validity The extent to which an assessment measures what it is
intended to measure.
values The internal motivators for an individual’s actions.
varus Deformed joint that is bent inward with the angulation toward
the midline of the body.
verbal analog scale (VeAS) A scale used to determine a person’s
perception of pain intensity. The person is asked to rate pain on a
scale from 0 to 10 (0 refers to no pain, and 10 refers to the worst
pain ever experienced.)
viscoelasticity The skin’s degree of viscosity and elasticity, which
enables the skin to resist stress.
visual analog scale (ViAS) A scale used to determine a person’s
perception of pain intensity. The person is asked to look at a 10-cm
horizontal line. The left side of the line represents “no pain,” and
the right side represents “pain as bad as it could be.” The person
indicates pain level by marking a slash on the line, which
represents the pain experienced.
volar Also called palmar, this term pertains to the palm of the hand or
the sole of the foot.
volar plate (VP) A fibrocartilaginous structure that prevents
hyperextension of a joint.
voluntary-closing Terminal device oriented in the open position;
user must actuate to close the device.
voluntary-opening Terminal device oriented in the closed position;
user must actuate to open the device.

W
Wallerian degeneration When a nerve is completely severed or the
axon and myelin sheath are damaged, the segment of axon and the
motor and sensory end receptors distal to the lesion suffer
ischemia and begin to degenerate 3 to 5 days after the injury.
Wartenberg neuropathy Compression of the superficial radial nerve
that usually includes numbness, tingling, and pain of the
dorsoradial aspect of the forearm, wrist, and hand.
wearing schedules Planned schedules for donning and doffing
orthoses.
working memory The short-term storage of information in the brain.

Z
zones of the hand The division of the hand into distinct areas for
ease of understanding literature, conversing with other health
providers, and documenting pertinent information.
APPENDIX A
Answers to Self-Quizzes, Case
Studies, and Laboratory Exercises
Chapter 1
Self-Quiz 1.1
1. b
2. c
3. a

Case Study 1.1

1. c
2. a
3. 1: b; 2: c; 3: a
Chapter 2
Self-Quiz 2.1
1. The therapist should learn about the culture of the client, either
through a personal interview with the individual or family or
through reading. If the client speaks a language that you do
not speak, ensure that a translator is present so that
information is accurately transmitted between you and the
client. Different cultures may have views about illness and
disability that are unique. They may also be of a different faith
or have family obligations and responsibilities dissimilar from
those you are accustomed to. Wearing an orthosis during
certain ceremonies or religious events may not be acceptable to
your client. Discuss the orthotic plan, and appropriately
explain the importance of compliance. If you learn that
cultural difference may be a barrier to compliance, work with
the client to arrive at a workable solution.
2. The areas of occupation of play and education as well as
developmentally appropriate activities of daily living (ADLs)
and instrumental activities of daily living (IADLs) functions
should be considered. Personal context factors such as age and
gender may impact color selection and the level of
independence the child may have with orthotic
donning/doffing and care. A younger child may need to have
additional straps applied to prevent unwanted orthotic
removal or shifting. An older child may be able to
independently monitor an orthotic schedule.

Case Study 2.1

1. Natasha’s husband, who is her primary caretaker, has
accompanied her to treatment sessions. As an important part
 of her social context, and his role as caregiver, he can assist
Natasha with accurate completion of the intake interview. To
ensure that Natasha is empowered and her family role as
primary home and family caretaker is preserved to the fullest
extent possible within this traditional family, the therapist
should first address questions to Natasha and verify responses
with her husband, only if needed.
2. The orthotic care sheet should be written in large, bold font.
Instructions should be written in simple phrases and line
drawings used as appropriate to illustrate orthosis and strap
placement. Black-and-white or photocopied photos should be
avoided because they may not provide high contrast. High-
contrast color photos taken of the orthosis on Natasha’s hand
may assist with accurate placement but should not be used as
the only pictorial representation. Orthotic care instructions
must be reviewed with Natasha and her husband using the
orthotic care sheet before issuing the device. Natasha should
be asked to repeat instructions and precautions back to the
therapist with the assistance of her husband.
3. As with the orthotic care sheet, large font and line drawings
can be used to assist with low vision. Instructions should be
phrased simply, and the order of the exercises should be
clearly indicated. Line drawings can be effective, as can color
photographs of Natasha’s hand. Exercise instructions must be
reviewed with Natasha and her husband using the handout.
Natasha should be asked to demonstrate the exercises and
verbalize repetitions and frequency with the assistance of her
husband.
4. Following consultation with the treating physician, a
removable volar component could be added to the orthosis to
statically maintain the alignment of her digits with MCPs
secured in neutral. This volar component should be easily
removed and applied by Natasha and her husband frequently
throughout the day for active exercise regime. The volar
component will secure the delicate MCP joints if Natasha were
 to become unclear about the purpose of the dynamic outrigger
and attempt to remove it. The dynamic orthosis with volar
component will be replaced with a resting pan orthosis at
night. The resting pan orthosis has a lower profile and secures
joints for safety during sleep.

Case Study 2.2

1. Graysen indicated that he is not satisfied with his ability to
complete independent bill paying, use the computer to
communicate with friends and family or social networking
websites, and prepare his plate for independent eating. These
areas scored poor in performance and satisfaction. Despite
these issues being caused by limited hand function, they
should be addressed during the first treatment sessions to
enhance the quality of life for Graysen. Although these
functions should return eventually as hand function improves,
waiting for eventual hand movement, strength, and
coordination will create an unnecessary lack of ability to
complete meaningful life tasks. Computer use and social
communication and bill paying are reported to be the most
difficult and least satisfactory areas for Graysen.
2. A client-centered treatment model and a rehabilitative
approach will expedite Graysen’s return to function. The
client-centered model focuses attention on his immediate
concerns (bill paying, computer use and social communication,
eating/plate preparation). The rehabilitative approach uses
adaptations and modifications as treatment methods to
enhance function.
3. The Canadian Occupational Performance Measure (COPM)
was used to investigate the functional capabilities of the client
within all areas of daily functioning. Issues were discovered
within the patient’s social, personal, and virtual contexts.
4. A suggested orthosis would be one that facilitates his ability to
type and hold onto objects, such as flatware and pencils, as
 well as to provide digital support for typing. The dorsal hand-
based orthosis extending from wrist to PIP joints holds all
digits in flexion. The long, ring and small fingers would be
held in more flexion than the index finger to provide isolated
digit for typing and securing tools. This orthosis would be
applied to the dominant hand, a second orthosis could be
fabricated for the non-dominant hand to facilitate typing and
food management during eating.

Case Study 2.3

1. The therapist should conduct an occupational profile
(AOTA,2017) with the client to determine the impact that her
elbow fracture and current orthotic device are having on her
roles, habits and routines. It should also be determined what
aspects of her environment and context may be barriers or
supports for her current level of occupational participation.
The goals of the client should also be clearly identified during
this process.
2. The Canadian Occupational Performance Measure
3. A lightweight thermoplastic orthosis should be fabricated to
replace the plaster device provided by the physician. Why?
Due to the ongoing healing status of her elbow, it is important
to continue with intermittent immobilization during
occupations and other activities that are meaningful to the
client. In addition, due to the heavy and ill-fitting nature of the
plaster orthosis, a custom thermoplastic splint can reduce the
potential for further harm to the wrist and shoulder.
4. The intervention itself would not change, a custom elbow
orthosis must be fabricated. However, the ability of the client
to engage in her desired leisure occupation of swimming and
attending church activities should be considered. In other
words, the device should be created to enable her to safely
swim in her pool with her friends, and independently engage
in ADLs required to attend church activities. Not engaging in
 these meaningful activities may lead to isolation, lack of
physical activity and detrimental changes to her daily routine.
Citation for occupational profile:
American Occupational Therapy Association. (2017). AOTA
occupational profile template. American Journal of Occupational
Therapy, 71(Suppl. 2), 7112420030.
https://doi.org/10.5014/ajot.2017.716S12

Matching
1. E
2. C
3. J
4. I
5. G
6. A
7. F
8. D
9. B
10. H
Chapter 4
Self-Quiz 4.1
Part I

1. d
2. a
3. b
4. a
5. c

Part II

1. Distal palmar crease

2. Proximal palmar crease
3. Thenar crease
4. Distal wrist crease
5. Proximal wrist crease

Part III

1. Longitudinal arch
2. Distal transverse arch
3. Proximal transverse arch

Self-Quiz 4.2
1. F
2. F
3. T
4. T
 5. F
6. T
7. F
8. T
9. T
10. F
Chapter 5
Self-Quiz 5.1
1. F
2. T
3. T
4. F
5. F
6. T
7. F
8. T
9. F
10. F
11. T
12. F
13. T
14. F
Chapter 6
Self-Quiz 6.1
1. F
2. T
3. T
4. T
5. F
6. T
7. F
8. F
9. F
10. T
11. T
12. F
13. F
14. T

Case Study 6.1

1. Steven has a radial nerve injury, which he sustained from
falling asleep with his arm positioned over the top of a chair.
2. Never hesitate to call the physician’s office. If the physician is
not available, leave your question with the nurse.
3. The therapist should suggest an orthosis for radial nerve and
research orthoses for that condition. He or she should review
both textbooks and evidence-based practice articles, time
permitting.
4. Steven should be educated about orthotic precautions, such as
monitoring the orthosis for pressure sores, and about an
orthotic-wearing schedule, including removal for hygiene and
exercise, so the orthotic provision is safe and effective.
 5. As discussed, adherence can be complicated because so many
factors need to be considered for why a person is nonadherent.
Is Steven’s nonadherence related to a self-image problem with
the orthosis or for some other reason that he has not stated?
Refer to Box 6.2 for ideas of factors contributing to
nonadherence. The therapist should provide open-ended
questions to get Steven’s perception about his nonadherence
and what it would take for him to become adherent with
orthotic wear. More specific education, including sharing of
research evidence about the importance of orthotic wear with
a radial nerve injury for regaining function, would be helpful.
This education would also help Steven understand the slow
process of nerve regeneration. Due to Steven’s history of
alcohol abuse leading to the development of the condition, he
may need psychosocial support beyond the therapy clinic.
Psychosocial support can be tactfully suggested by the
therapist, and Steven can request a referral from his primary
physician for intervention.

Case Study 6.2

1. Many areas were missing from the charting. Charting initially
did not specify the extremity. It did not include client history
of having de Quervain tenosynovitis or prior level of function.
It did not mention prior treatment of receiving a prefabricated
orthosis and did not specify where the reddened area was on
the thumb. It provided an opinionated comment about client
adherence. It would have been better to have provided factual
information, such as a direct quote from Marie. The inclusion
of normal measurements for range of motion, grip, and pinch
strengths would make it easier for the reader to have a better
understanding of deficits. It did not address the impact of the
condition on doing work and home occupations. It did not
address Marie’s current level of pain. It should include the
type of orthosis, position, and location. It should include a
 statement on fit, comfort, and function of the fabricated thumb
immobilization orthosis. Goals are vague and not related to
function. It would have been helpful to involve Marie with the
goal setting, perhaps through administering the Canadian
Occupational Performance Measure (COPM).
2. In every situation, questions using the interactive clinical
reasoning approach will be different. The following are a few
of many suggested questions:
• What questions do you have about wearing this fabricated
orthosis? (This question may open up discussion, considering
that Marie did not continue to wear the prefabricated orthosis
due to developing some chafing on the volar surface of the
thumb interphalangeal [IP] joint.)
• How will you go about following an orthotic-wearing
schedule based on the home and work demands in your life?
(This question may be helpful, considering Marie’s history of
nonadherence with the first orthosis.)
• What type of support do you need to help you with your
orthosis and hand injury? (This question may help you better
understand how Marie is coping with her condition.)
3. For this discussion, respect Marie’s confidentiality by moving
to a private area if in a large therapy room. You might assume
that one reason Marie was nonadherent with the prefabricated
orthosis was because it caused a reddened area on the thumb
IP joint due to fitting improperly. However, you should
tactfully question Marie for her reasons for nonadherent,
which might be different from your assumption. Refer to Box
6.2 for ideas of factors that contribute to nonadherence and to
Box 6.3 for ideas for open-ended questions to ask Marie. In any
case, you should fabricate a well-fitted comfortable orthosis
and monitor the fit carefully for potential pressure sores. Clear
education about the reason for orthotic wear along with any
evidence from research may help Marie’s adherence. It will be
important to check with Marie regularly about follow-through
with the orthotic-wearing program. Consider making a phone
 call or emailing Marie to check on her level of compliance and
to answer any questions.
4. Marie likely has workers’ compensation insurance.
Chapter 7
Self-Quiz 7.1
1. T
2. T
3. F
4. T
5. T
6. F
7. F
8. T
9. F
10. F
11. F

Case Study 7.1

1. (1) The thermoplastic strip was not the best choice because it
was not providing enough wrist support. (2) The
thermoplastic strip may have placed the wrist in the wrong
wrist position.
2. The wrist should be positioned as close to neutral as possible.
3. There are a variety of options for an orthotic-wearing schedule.
The American Academy of Orthopaedic Surgeons (AAOS)
suggests nighttime wear at the minimum and daytime wear
during activities that aggravate the condition.
4. The therapist should observe areas such as the ulnar styloid,
the first web space, and the volar and dorsal aspects of the
hand over the metacarpal bones for skin irritation. Angela
should notify the therapist immediately if irritation occurs. In
addition, Angela should be educated to not perform full finger
flexion in the orthosis due to that motion causing increased
 pressure on the carpal tunnel.
5. In this case, trust was violated because Angela dutifully
followed a wearing regimen for an orthosis that did not
correctly fit and was exacerbating her condition. As McClure45
suggests, providing research evidence specific to her situation
might help her better understand the rationale for a custom-
fabricated orthosis in a neutral position. Conservative
management with using an orthosis may help because the
condition was caught early.53
6. A custom orthosis may provide more stability to the wrist and
overall a better fit. A pre-fabricated orthoses may not position
the wrist in neutral.

Case Study 7.2

1. The therapist should use an orthosis to put Diane’s wrist in
neutral to provide a low-load stretch.
2. The therapist should continue to use a serial orthosis to get
Diane’s wrist into a functional wrist extension position.
3. This decision for discontinuation is made in collaboration with
Diane’s physician based on her progress. Discontinuation of
using an orthosis could occur when Diane obtains more
functional wrist extension because wearing the orthosis too
long will result in muscle weakness and/or joint stiffness. Once
the orthosis is removed, the therapist will continue to work on
obtaining increased active wrist extension and normal wrist
motions for function.

Laboratory Exercise 7.2

Orthosis A

1. The wrist is positioned in extreme ulnar deviation. The wrist

strap is placed incorrectly.
 2. This extreme position stresses the wrist joint and possibly
contributes to the development of other problems, such as
wrist pain, pressure areas, and de Quervain tenosynovitis.

Orthosis B

1. The wrist is positioned in flexion instead of a functional hand

position of extension. Positioning in wrist extension helps with
digital flexion. If the wrist is flexed, the client loses functional
grasp. The wrist strap is placed incorrectly.

Orthosis C

1. Metacarpophalangeal (MCP) flexion is inhibited because the

orthotic metacarpal bar is too high. The wrist appears to be
radially deviated. The wrist strap is placed incorrectly.
2. Potential development of skin irritation or pressure areas exists
with digital flexion, and the person does not have a full
functional grasp.
Laboratory Exercise 7.4
1. Hypothenar bar
2. Metacarpal bar (palmar bar)
3. Forearm trough
Chapter 8
Self-Quiz 8.1
1. T
2. F
3. F
4. T
5. F
6. T
7. T
8. F
9. F

Case Study 8.1

1. The hand is placed in a hand-based thumb immobilization
orthosis (MP radial and ulnar deviation restriction orthosis)
with the CMC joint in 40 degrees of palmar abduction and the
MCP joint in neutral to slight flexion and ulnar deviation. It is
important to place the thumb CMC joint in a position of
comfort and that position may not be exactly in the suggested
degrees
2. To provide rest and protection during healing.
3. Precautions may include: 1) Not restricting IP joint movement
by extending the thumb post too high. 2) Monitor for skin
irritation and for pressure sores especially at the radial base of
the first metacarpal and the first web space. 3) Make sure that
the thumb post is supportive and not too restrictive.
4. As Jack is a 10-year-old male he may not adhere to wearing the
orthosis, which is essential for proper healing of the ulnar
collateral ligament. Perhaps to make the orthosis more
acceptable for Jack to wear the therapist might fabricate it out
 of colored thermoplastic material that Jack selects, decorate the
orthosis, or make it look like a cartoon character. The therapist
needs to work with Jack’s mother to encourage adherence.
5. Jack will need to wear the orthosis continuously for 4 to 5
weeks except for removal for hygiene.
6. An option as suggested by Ford et al.25 is to fabricate a hybrid
orthosis with a circumferential thermoplastic mold around the
thumb covered by a neoprene wrap. This orthosis will provide
stability to the MCP joint and allow for functional movements
during skiing. Other options exist based on therapist clinical
reasoning.

Case Study 8.2

1. Based on Margaret’s symptoms, the therapists should fabricate
a hand-based orthosis. Because only the carpometacarpal
(CMC) joint is involved, the orthosis designed by Colditz17
which immobilizes only the CMC joint—would be
appropriate.
2. To provide stability and to control subluxation and pain.
3. Based on Colditz’s recommendations,17 Margaret should wear
the orthosis continuously for 2 to 3 weeks (with removal for
hygiene). After that time, she should wear the orthosis during
times when the thumb is irritated by activities.
4. Because of the wrist and thumb involvement, the therapist
would consider fabricating a forearm-based thumb orthosis.
5. Because the thumb metacarpophalangeal (MCP) joint is
involved, consider fabricating a hand-based orthosis that
includes the MCP joint.
6. The therapist should position the thumb MCP joint in 30
degrees flexion and in palmar abduction as tolerated.

Laboratory Exercise 8.1

 1. Thumb post
2. Metacarpal (palmar) bar
3. Forearm trough

Laboratory Exercise 8.3

1. The two problems are the following: (1) The metacarpal bar is
too high to allow full finger metacarpophalangeal (MCP)
flexion and (2) the thumb interphalangeal (IP) joint flexion is
limited because the material around the thumb extends too far
distally.
2. An irritation might develop at the thumb IP joint (where the
thumb opening is too high) and at the base of the index finger
(where the metacarpal bar is too high). The orthosis limits full
finger flexion.
Chapter 9
Case Study 9.1
1. b
2. c
3. b
4. c
5. b

Case Study 9.2

1. Diabetes mellitus is associated with Dupuytren disease.
2. Either a resting hand orthosis or a dorsal forearm-based static
extension orthosis is appropriate to use after a Dupuytren
contracture release.
3. The therapeutic position includes wrist in neutral or slight
extension and metacarpophalangeals (MCPs), proximal
interphalangeals (PIPs), and distal interphalangeals (DIPs) in
full extension. The thumb does not need to be included in the
orthosis.
4. Ken should wear his orthosis well after the wounds have
completely healed. After healing, he should wear the orthosis
several weeks or months thereafter during the nighttime to
provide stress and tension to counteract the scar contraction.
(He may discontinue his resting hand orthosis in favor of
individual finger orthoses.) The orthosis can be removed for
hygiene, exercise, and activities of daily living (ADLs).
5. To accommodate for bandage thickness, the design of the
orthosis should be wider. As bandage bulk is reduced, the
orthosis should be modified to maintain as close to an ideal
position as possible. Therefore thermoplastic material that has
memory will assist with the modification process. In addition,
 because this is a fairly long orthosis, a material with rigidity is
helpful to adequately support the weight of the forearm, wrist,
and hand.
6. Assuming no major complications in Ken’s rehabilitation, he
may require outpatient therapy. At a minimum, Ken should be
seen for a home exercise program and monitored until the
wound heals. The therapy may entail a minimum of one visit
per week.
7. Ken may require assistance for any wound care and dressing
changes initially. In addition, if he has difficulty with any one-
handed techniques, he may require some assistance with
ADLs or instrumental activities of daily living (IADLs)
(particularly writing). Temporary accommodations may be
required at work or when driving if the automobile has a
manual transmission.

Laboratory Exercise 9.2

1. Thumb interphalangeal (IP) joint is flexed rather than
extended; incorrect strap placement at distal forearm trough.
2. Radial deviation at the wrist; incorrect strap placement at distal
forearm trough.
3. Poor wrist support; incorrect placement of straps at distal
forearm trough.
Chapter 10
Self-Quiz 10.1
1. T
2. F
3. F
4. T
5. F
6. F
7. F
8. T
9. T
10. F
11. T

Case Study 10.1

For Laura

1. Posterior elbow immobilization orthosis: Elbow in 120 degrees

of flexion, forearm in neutral, and wrist in 15 degrees of
extension.
2. Supine on a plinth, with the shoulder in 90 degrees of forward
flexion, elbow in 120 degrees of flexion, forearm in neutral
rotation, and wrist in neutral extension of 15 degrees.
3. Protect the olecranon, medial and lateral epicondyles, and
radial and ulnar heads by padding the bony prominences and
molding the orthosis over the padding.
4. The orthosis is worn at all times and removed for protected
range-of-motion (ROM) exercises only in a protected
environment.
Case Study 10.2
For Marissa

1. Orthosis: A commercial brace that can be blocked at 90 degrees

of flexion and allow for active flexion from 90-degree position
as tolerated.
2. Wearing schedule: To wear the brace always, and to perform
the exercises within the brace. The brace will be adjusted in
therapy every week to increase the flexion angle by 10 to 15
degrees.

For Frank

1. A posterior elbow splint with elbow in approximately 70 to 90

degrees of flexion would be appropriate to allow for the
transpose ulnar nerve and the surgically manipulated soft
tissues to heal. Because this procedure included an ulnar nerve
submuscular transposition, slight pronation in the forearm is
recommended. The orthosis should support Frank’s wrist but
keep the fingers and thumb free to move.
2. At 10 days after surgery it is expected that Frank’s
inflammation will have subsided. For this reason the wearing
schedule will depend on Frank’s activity-rest cycle. In the first
2 weeks of orthotic use, Frank should keep the orthosis on
during daytime activity and off at rest and during exercise.
Nighttime orthotic wear may be indicated depending on
Frank’s preferred posture (e.g., excessive flexion). Orthotic use
should be prescribed with intermittent ROM exercise to
prevent stiffness. Typically, clients such as Frank will need 6
weeks to heal. The orthosis should be gradually weaned off
and used as a tool for behavior modification (i.e., to prevent
vigorous activities too soon).

For Bob
1. Bob may need two forms of orthoses for contracture
management—one for flexion, one for extension. However, the
priority at this time is to increase Bob’s elbow extension using
a static progressive turnbuckle orthosis with the goal of
increasing Bob’s outward reach. The turnbuckle orthosis may
be discharged once Bob achieves elbow extension of −30
degrees because at this position the orthosis loses its leverage.
However, with the remaining −30-degree limitation, Bob could
benefit from an anterior elbow orthosis to continue stretching
the elbow into extension.
2. Static progressive splinting depends on low-load passive
stretch principle and therefore the therapist should consider
prescribing a wearing period of gentle but prolonged stretch of
4-6 hours daily total. The periods may be broken up and
interspersed with activities. Since Bob just had his external
fixator removed and has significant contractures/stiffness of
the elbow, it is imperative that the therapist prescribes a high-
repetition, low-intensity exercise and activity program that
maximizes and challenges the available ROM. Night time-
splinting is no longer indicated.
Chapter 11
Self-Quiz 11.1
1. T
2. T
3. F
4. T
5. F
6. T
7. T
8. F
9. F
10. T

Case Study 11.1

1. Traditional adduction and internal rotation (IR) sling
2. Less than 4 weeks
3. Scapula dyskinesis and frozen shoulder syndrome
4. Lauren should be educated about proper wearing positioning,
including scapula alignment. Her shoulders should be at an
equal height, and there should not be excessive compression of
the humeral head. Lauren should remove the orthosis when
not in the community and perform a light range of motion
(ROM) and isometric-based home exercise program (HEP).
Chapter 12
Self-Quiz 12.1
1. T
2. F
3. F
4. F
5. T

Self-Quiz 12.2
1. Swan neck deformity and/or rheumatoid arthritis, distal
interphalangeal (DIP) joint osteoarthritis (OA), or trigger
finger
2. Volar plate injury
3. Trigger finger
4. Proximal interphalangeal (PIP) collateral ligament injury

Case Study 12.1

1. The orthosis should cross the distal interphalangeal (DIP) joint.
2. Marge needs to wear the orthoses during sleep.
3. Marge needs to continue using the devices as long as she is still
having pain.

Case Study 12.2

1. The distal interphalangeal (DIP) joint of the right long finger.
2. All of the time except for skin care, during which time the joint
needs to be supported in extension.
 3. Dip gutter orthosis, dorsal-volar DIP orthosis, or stack orthosis.
4. Ryan is likely to need to wear his orthosis for 6 to 8 weeks.

Case Study 12.3

1. Debbie should have a dorsal proximal interphalangeal (PIP)
orthosis because the injury involved the volar plate.
2. The orthosis should cross the PIP joint in 20 to 30 degrees of
flexion to protect the injured volar plate.
3. The index and long fingers should be buddy taped to support
the injured long finger and maintain alignment. With injury to
the radial collateral ligament, the middle phalanx would tend
to ulnarly deviate, and the buddy strap helps correct this
tendency.
4. Teach Debbie how to use self-adherent compressive wrap to
treat the edema. Consider building up the girth of her tennis
racquet handle to minimize stress on her injured joint.

Case Study 12.4

1. Yes, Alexa would benefit from proximal interphalangeal (PIP)
hyperextension block orthoses to improve her active PIP
flexion.
2. You could fabricate trial thermoplastic orthoses for a few
fingers and assess if they help.
3. Important client factors are Alexa’s job dealing with the public
and what she finds to be most cosmetically appealing.
Orthoses will be needed for multiple fingers and will be used
long term, and thus streamlined fit and durability are desired
qualities. Orthosis adjustability may also be beneficial because
PIP size may fluctuate from swelling related to her arthritis.
4. Alexa should wear her orthoses during the daytime only,
because these are functional orthoses.
Laboratory Exercise 12.1
1. It blocks the proximal interphalangeal (PIP) joint.
2. It blocks the distal interphalangeal (DIP) joint.
3. It does not prevent the PIP from hyperextending, allowing the
finger to still posture in a swan neck deformity.
Chapter 13
Self-Quiz 13.1
1. T
2. T
3. F
4. F
5. T
6. T

Case Study 13.1

1. a. Y
b. Y
c. Y
d. Y
e. Y
2. b
3. d
4. a
5. c
Chapter 14
Self-Quiz 14.1
1. T
2. T
3. F
4. T
5. F
6. T
7. T
8. F
9. F
10. T
11. T
12. F

Self-Quiz 14.2
1. B
2. F
3. A
4. G
5. D
6. E
7. C
8. H

Case Study 14.1

1. Activities that require grasp and pinch will be affected.
2. An elbow orthosis is appropriate. Due to interosseous
 weakness, the hand should be monitored for a possible hand-
based orthosis for the ulnar nerve.
3. The elbow is flexed 30 to 45 degrees, and the wrist, if included,
is in neutral to 20 degrees of extension.
4. There are a couple of options that the therapist may consider.
The first option is lining the orthosis to make it more
comfortable. Another option would be to consider the comfort
benefits of a prefabricated elbow orthosis. Care must be taken,
however, that the prefabricated orthosis correctly positions his
elbow in the appropriate amount of flexion.
5. Because symptoms are continuous, the therapist should
suggest that Mark wear the orthosis all the time.
6. Mark must become aware of activities that irritate his
condition, such as sleeping with his elbow bent.

Case Study 14.2

1. b
2. b
3. b
4. b
5. a

Laboratory Exercise 14.1

S: “My pain has decreased.”
O: Pt. reports that pain has decreased with resisted pronation
from a score of 5 out of 10 to 2 out of 10. Manual muscle testing
for the pronator quadratus, pronator teres, flexor carpi radialis,
palmaris longus and flexor digitorum superficialis, flexor
pollicis longus, and flexor digitorum profundus to index and
long fingers were all 4 (good). The long arm orthosis was
discontinued on [date] with physician order.
A: Pt. was receptive to continue doing ADLs and home exercise
 program. Pt. plans to modify work and home activities to
decrease repetitive pronation and supination. Pt. has been
instructed in a light strengthening program.
P: Occupational therapist will continue to monitor home exercise
program.
Chapter 15
Case Study 15.1
1. d. A volar forearm-based hand immobilization orthosis that
stretches and positions the wrist and the fingers in composite
extension at or slightly greater than 5 degrees is most
appropriate. Over time the angle of wrist extension with the
fingers in composite extension may be adjusted. Because Rose
also has edema, the orthosis facilitates edema reduction by
keeping the hand upright and in a nondependent position. A
dorsal-based forearm platform with a volar hand component
that positions the wrist and fingers in tolerable composite
extension may position the hand in a desirable manner, but
with Rose’s edema, donning the orthosis will be difficult. A
volar finger spreader with volar forearm component is a viable
alternative because it provides the added benefit of keeping
the web spaces aerated. However, since Rose reports pain with
passive extension greater than 5 degrees, the position of
maximum passive extension may increase the pain and
compromise orthotic adherence. With Rose’s condition still in
the acute stages of recovery, a rigid cast is not appropriate at
this time. Finally, a volar cone orthosis is not appropriate
because it may accentuate the edema and skin breakdown. In
addition, placing the fingers in flexion over a cone and the
wrist at submaximal stretch promotes contractures.
2. Before altering or discontinuing the orthosis, the therapist
monitors how caregivers and the nursing staff apply the
orthosis. A common pitfall is when the straps are applied
tightly, creating choke points, especially at the wrist. The
therapist reinforces the importance of proper carryover for the
orthotic program to be successful. The therapist considers
interventions to manage edema and evaluate other potential
reasons for the swelling.
 3. e. When a client has early signs of active control of hand
movement, the therapist considers using orthoses to facilitate
better hand control so that the client can engage in intensive,
repetitive task practice. With the edema resolved the
appropriate orthosis is a Neoprene thumb abduction and
extension orthosis that extends to the forearm radially. The
forearm component supports the wrist with emerging stability.
Once the client is more capable of stabilizing the wrist during
grip, the therapist may switch to a short opponens orthosis.
Both Neoprene-based and short opponens orthoses restrict the
thumb from assuming flexion-adduction. These orthoses
prevent contracture formation and facilitate a greater
repertoire of prehensile patterns. A finger spreader, a hard
cone, and an inflatable orthosis are inappropriate substitutes
because they only restrict hand use in a functional, task-
oriented manner. If Rose’s spastic tone continues to pose
problems with hand function, the therapist may provide a
hand immobilization orthosis to provide wrist and hand flexor
stretch during intervals of rest.
4. While Rose is using a Neoprene-based orthosis or a short
opponens orthosis, family and caregivers encourage Rose to
use her affected hand during activities, such as eating or
drinking (e.g., holding a cup, picking up dense finger foods)
and leisure (e.g., playing cards). The therapist considers active
strategies and modalities to further develop strength and
stability of grasp and maintain range of motion.

Case Study 15.2

1. d. The most immediate goal is to ensure that the hand and
wrist are not kept in a composite flexion position. Because of
the Modified Ashworth Scale grade, a comfortable composite
stretch of the finger and wrist flexors is warranted. The volar
design ensures ease of wear especially during the acute
rehabilitation phase.
2. a. This orthotic design allows Brian to practice reaching to
grasp by assisting the fingers and wrist in appropriate
extension. Repetitive resistance at maximum stretch of the
flexors will promote muscle inhibition over time.
Chapter 16
Self-Quiz 16.1
1. T
2. F
3. F
4. T
5. F
6. T
7. F
8. T
9. F
10. T
11. T
12. T
13. T

Self-Quiz 16.2
1. A material that has high drapability and moldability is not a
good choice for making antigravity orthoses. A material that
has resistance to drape and memory is suitable. A slightly
tacky orthotic material that lightly adheres to underlying
stockinette may be helpful. Preshaping techniques assist in
molding.
2. A positioning orthosis places the involved joints in
submaximum extension. This position permits adequate skin
hygiene.
3. An orthosis should not limit the use of uninvolved joints. An
arthritis orthosis immobilizes only the affected joints and
positions the thumb in a resting position. When there is
bilateral hand involvement, the client may need to alternate
 wearing right and left orthotics.
4. Pad the outside of the orthosis.
5. The straps should be soft, wide foam straps that are cut a little
long to adjust for edema. The orthotic design should be made
wide enough to accommodate the edema.

Self-Quiz 16.3
Matching

1. b
2. d
3. c
4. a
5. e

Case Study 16.1

1. c
2. a and c
3. b, c, and d
4. d

Case Study 16.2

1. a and d
2. d
3. a
4. d
5. c

Laboratory Exercise 16.1

1. The orthosis blocks the wrist and thumb interphalangeal (IP)
joint.
2. The figure-eight is not properly positioned to effectively
prevent hyperextension of the thumb IP joint. The figure-eight
orthosis should be rotated and placed on the finger to prevent
IP hyperextension.
Chapter 17
Case Study 17.1
1. Option A would probably not be adequate to address concerns
of losing range of motion (ROM) of the wrist and fingers. Once
range is lost, it can be difficult (if not impossible) to regain.
Therefore prevention is paramount. Relying on passive range
of motion (PROM) may be disruptive to other activities and
occupations during the day. The constant effects of moderately
to severely increased tone will be difficult to overcome with
activities alone. The thumb orthoses alone would not be
adequate to address concerns with the wrist and finger flexors.
2. Option B would probably best meet Mathew’s needs at this
time. Prolonged stretch to the wrist and finger flexors could
occur at night. Active functional movement during play, z-
care, communication, and school activities could be
emphasized during his waking hours. Because the left upper
extremity is tighter and less functional, it would also be
prudent to wear the left resting orthosis on this hand
periodically during the day. A thermoplastic thumb orthosis
for the right hand would control some of the increased tone in
the hand but leave the wrist and fingers free for active and
functional movement. ROM measurements would be required
to determine optimal wearing schedules. You will contact
Matthew’s parents to discuss your recommendations for using
the orthoses and the purpose of the orthoses and to get their
input. Assuming they are in agreement, you arrange a meeting
with his parents before the orthoses are taken home. At this
time you will review the purpose of the orthoses, demonstrate
how to apply the orthoses, and provide an opportunity for the
parents to practice donning and doffing the orthoses. You will
also give the parents written instructions, precautions, and
your phone number. Photographs of the orthoses on
 Matthew’s hands will be included if needed.
3. Option C would be excessive use of resting hand orthoses at
the present time. Matthew should continue to experience
active movement and sensory feedback as much as possible
during the day, especially with the right hand.
4. Option D would unnecessarily restrict active use of the hands
during the day while leaving the wrist and finger flexors
shortened during the night and on weekends. This family is
involved in Matthew’s programming, and you will address the
issue of correct application at home by meeting with the
parents as described in Option B. If you have questions
regarding follow-through at home, you should obtain more
information about the family’s strengths and limitations, the
parents’ understanding of intervention, and family routines.
You should then individualize your style of collaboration and
provide instruction for that family.

Case Study 17.2

1. Option A, a resting hand orthosis, would not be appropriate
because Luke has full passive range of motion (PROM) in the
left wrist and hand. Elongation of wrist and finger flexors is
desirable but could be accomplished through weight-bearing
activities.
2. Option B, a standard wrist cock-up (immobilization) orthosis,
would not adequately address the problem of thumb
adduction into the palm. It is likely that positioning the thumb
in opposition will have an inhibitory effect on the wrist and
hand. If the wrist flexion continues to be a problem after the
thumb is addressed, other orthotic or treatment options could
be considered.
3. Option C, issue a Neoprene thumb abduction orthosis for
daytime wear to facilitate a functional thumb position during
grasp and prehension activities. Consider a thermoplastic “C”
bar insert attached to the Neoprene orthosis if needing a firmer
 material to adequately position thumb in more challenging
cases. A thermoplastic thumb spica may be considered for
night wear in those patients who would benefit from more
continuous intervention.
4. Option D, fabricating a resting-hand orthosis for both hands
would immobilize all digits unnecessarily and would result in
Luke being unable to use his hands for exploration, play, and
to assist in self-feeding activities. Luke has full range of motion
in all digits, except for the right thumb and orthotic
intervention should aim to be as least restrictive as possible,
while facilitating continued use of his hand for play.

Laboratory Exercise 17.1

Two fabrication problems are present in this orthosis. First, the C bar
does not fit into the web space of the thumb and provides inadequate
positioning of the thumb between radial and palmar abduction.
Second, the sides of the forearm trough are too high, resulting in
bridging of the straps.

Laboratory Exercise 17.2

The straps are not keeping the wrist positioned in the orthosis. The
distal forearm strap should be placed just proximal to the ulnar
styloid, and a second strap should be added just distal to the ulnar
styloid, preventing the flexor action of the wrist from lifting the wrist
away from the orthosis’ surface. The orthosis does not fit snugly into
the thumb web space.
Chapter 18
Case Study 18.1
1. The occupational therapist could assist with donning and
doffing of the device, developing wear schedules based on the
client’s needs, and develop skills to integrate the device into
activities of daily living (ADLs).
2. An optimally provided orthosis could address the client’s
concerns with mobility and ADLs that require lower extremity
(LE) functionality.
3. Total contact, three-point pressure systems, and kinaesthetic
reminder could each play a role in this particular client. Three-
point pressure systems could address the client’s paralytic
equinus in swing phase, total contact would distribute the
pressure throughout a larger area of the limb, and the
sensation of wearing an orthosis could enhance
proprioception.
4. This client would most benefit from a thermoplastic ankle-foot
orthosis (AFO). The AFO would enable a heel strike at initial
contact, modulate forward progression of the tibia during
stance phase, and eliminate equinus positioning throughout
swing phase.

Case Study 18.2

1. Neuropathy can negatively affect the sensory, motor, and
autonomic functions. Sensory deficits could result in
diminished protective sensation, making the client unaware of
injury. Motor neuropathy can result in atrophy of the intrinsic
muscles of the foot, resulting in an imbalance of the muscles
that facilitate locomotion and other weight-earing activities.
Autonomic neuropathy can result in diminished function of
 the glands within the feet, compromising skin integrity, which
may compromise the soft tissue envelope, increasing the risk
of infection.
2. Extra-depth footwear has the ability to be adjusted to achieve
an optimal fit to the client’s foot, creating additional volume
for deformities such as clawed toes.
3. Accommodative foot orthoses create an interface for the
diabetic foot that conforms to the client’s present alignment,
ensuring pressure is distributed over the largest possible
surface area. A corrective orthosis applies specific forces to
achieve an alignment different from the client’s in situ
presentation, which could potentially result in skin breakdown
where forces are excessive.

Case Study 18.3

1. The common peroneal nerve bifurcates into the deep and
superficial peroneal nerves, which innervate the anterior and
lateral compartments of the leg.
2. Swing phase functionality would be affected in a similar
manner, but the solid ankle trimline would not allow for the
client’s tibia to progress forward to 10 degrees of relative
dorsiflexion at terminal stance, forcing the client to either take
a shorter contralateral step or hyperextend the knee on the
ipsolateral side to maintain step length symmetry.

Case Study 18.4

1. The anatomical knee joint is a polycentric joint. The application
of a single-axis joint would not accurately follow the knee’s
axis of rotation as it moves through normal range of motion,
which could result in the orthosis migrating and placing less
than optimal forces through the client’s knee.
2. The three-point pressure system is exemplified in the coronal
 plane to create an unloading of the client’s osteoarthritic lateral
compartment.

Case Study 18.5

1. Both sensation and proprioception are unaffected by paralytic
postpolio syndrome as polio affects the anterior horn of the
spinal cord, resulting in only motor deficits.
2. The client should be provided a knee joint that locks as the
posterior offset joint on the provided orthosis relies on
maintaining the weight line anterior to the knee joint, which
cannot consistently be done with a client who does not achieve
terminal extension.

Case Study 18.6

1. This position seats the prosthesis into the socket, encouraging
joint stability. Relative adduction or excessive hip flexion
could encourage the prosthesis to shift out of the socket.
2. Sitting and transferring would be more difficult and require
modifications to perform these tasks.

Case Study 18.7

1. A client with a thoracic-level lesion would not have adequate
volitional strength at the hips or knees to facilitate ambulation
with just ankle-foot orthoses.
2. Ambulation with the hip-knee-ankle-foot orthosis (HKAFO)
would require a swing-through gait versus the much more
natural reciprocating pattern that is enabled by the
reciprocating gait orthosis (RGO).
Chapter 19
Case Study 19.1
1. Baseline evaluation includes range of motion, manual muscle
test, functional use, Modified Ashworth Scale, and sensation.
2. The rigid circular wrist cast can assist with improving range of
motion into wrist extension, where the wrist flexors are more
dominant and lead to myostatic contracture. A roll or small
cone can be placed if the fingers require positioning. The
metacarpophalangeal (MCP) wrist cast can improve range of
motion into wrist extension and increase the MCP range into
extension due to spasticity of the lumbricals. However, care
must be taken that the intrinsic musculature is not
overstretched and causing microtear.
3. After the client receives a botulinum toxin type A (BtA)
injection, the therapist should wait 2 to 7 days for the BtA to
take effect. The wrist and fingers may feel extremely loose, and
caution should be taken on the initial position of the wrist for
casting. Remember, nerves and blood vessels have been in a
shortened position. Placing the wrist in an overstretched
position may cause pain. Ella’s stretch reflex was felt at 85
degrees of wrist flexion, at the beginning of range. Position the
cast at the point of stretch reflex or submaximal range to
prevent overstretching, microtearing, and pain.
4. An increase of at least 5 to 10 degrees in passive range of
motion is expected when each cast is removed. The casting
program is discontinued when range of motion has not
increased or there is no improvement in volitional movement.
5. An orthosis can be fabricated to maintain the range of motion.
6. The primary goal for Ella is that the caregiver will be able to
place her arms through a sleeve of a shirt or coat with ease and
for her to wear a splint to maintain her range of motion.
Case Study 19.2
1. a and/or d
2. c
3. a, b, e
4. a, c, d

Competency Checkout Review 19.3

1. Casts are applied to improve range of motion, to improve
movement that may interfere with task performance, to assist
with contracture and spasticity management for impairment of
muscle or absence of opposing force, hygiene care for washing
and bathing, and for wearing a definitive splint.
2. Contraindications for casting include severe skin redness, open
wounds, edema, heterotopic ossification, and severe rigidity.
3. Special monitoring of the cast may be required for a client with
burns, and the need to change the cast within 2 to 3 days to
allow monitoring of skin needs to be considered. Pediatric
clients and clients at risk for edema require additional
diligence to ensure that they do not get the cast wet, place
items in the cast, or have restricted circulation.
4. Types of casts
a. Rigid circular elbow cast
b. Long arm cast
c. Wrist cast with thumb enclosed
d. Metacarpophalangeal (MCP) wrist cast
e. Rigid circular elbow cast (monitor for swelling
distally)
5. Cast removal
a. Cast saw
b. Unravel
c. Cutting strip, bandage scissors
d. Cast saw
6. Casting saw procedure
1. f
2. b
3. c
4. a
5. d
6. e
Chapter 20
Self-Quiz 20.1
1. b
2. c
3. c
4. b
5. a
6. b
7. c
8. Step 1: C
Step 2: A
Step 3: B
9. a
10. a

Case Study 20.1

1. Following an evaluation that included developmental
assessment, and given that Michael is progressing along a
developmental continuum, the OT would likely have
recommended a passive prosthesis to assist with weight-
bearing during sit, quadruped and transitional movements,
and for bimanual activities such as clapping and fingering
hands, holding a cup or bottle, and self-feeding finger foods.
2. Findings from the evaluation, parent goals, available
technology
3. Relevant play and self-care activities; parent education; play
group, peer support

Case Study 20.2

 1. The OT will want to prepare Amy for the differences in the
features of this technology, how it will be controlled and what
tasks for which it might be most beneficial. It will be important
for the OT to communicate with the prosthetist to understand
the difference in weight and to use a pre-prosthetic
progressive weight tolerance program to facilitate. In addition,
the OT will access information from the OT evaluation to
determine the activities most meaningful to Amy and
incorporate them into the plan of care.

Case Study 20.3

1. Given best available information available from current
evidence, the OT recommends that the surgeon avoid an
amputation through a joint (such as the wrist), but consider an
amputation proximal to it. Individuals with trans-radial level
of loss appear to manage well with prosthetic technology, and
have more options. Should the amputation occur as a wrist
disarticulation, the options become limited.

Case Study 20.4

1. The OT will likely complete the OT evaluation and consider all
areas of reported pain as well as the a query into how Matt
completes most tasks and what compensatory methods he
uses. The OT will want to focus on education to prevent
further disparity such as joint protection, other adaptive
strategies, conditioning exercises, assistive devices, and peer
support to prevent isolation. The OT may want to role play
social circumstances that are awkward or uncomfortable to
help Matt develop his own responses that are comfortable and
that he can be confident using.
APPENDIX B
Web Resources and Vendors
Societies, Organizations, Education
American Academy of Orthopaedic Surgeons
http://www.aaos.org/
American Association for Hand Surgery
http://www.handsurgery.org/
American Hand Therapy Foundation
http://www.ahtf.org/
The American Occupational Therapy Association, Inc.
http://www.aota.org/
The American Occupational Therapy Foundation
http://www.aotf.org/
American Orthotic & Prosthetic Association
http://www.aopanet.org/
American Physical Therapy Association
http://www.apta.org/
American Society of Hand Therapists
http://www.asht.org/
American Society for Surgery of the Hand
http://www.assh.org/
Canadian Association of Occupational Therapists
http://www.caot.ca/
E-hand.com The Electronic Textbook of Hand Surgery
http://www.eatonhand.com/
Exploring Hand Therapy
http://www.exploringhandtherapy.com/
Hand Therapy Certification Commission
http://www.htcc.org/
International Federation of Societies for Hand Therapy
http://www.ifsht.org/
Journal of Hand Therapy
http://journals.elsevierhealth.com/periodicals/hanthe
World Federation of Occupational Therapists
http://www.wfot.org/
Orthotic Materials and Accessories
Suppliers
The following list is of course not exhaustive. Neither is the quality
and/or service of products implied, and company contact information
is subject to change.

AliMed Dynasplint
1-800-225-2610 1-800-638-6771
http://www.alimed.com/online- http://www.dynasplint.ca/en/
catalog.aspx
Allegro Medical Joint Active Systems
1-800-861-3211 1-800-879-0117
https://www.allegromedical.com https://jointactivesystems.com/

Benik Corporation Joint Jack Company

1-800-442-8910 http://benik.com/ 1-860-657-1200
http://jointjackcompany.com/
Biodynamic Technologies North Coast Medical, Inc.
1-800-879-2276 1-800-821-9319
https://www.biodynamictech.com http://www.ncmedical.com/

Chesapeake Medical Products Performance Health

1-888-560-2674 1-800-323-5547
http://www.chesapeakemedical.com http://www.performancehealth.com

Core Products International, Inc. Restorative Care of America, Inc. (RCAI)

1-877-249-1251 1-800-627-1595 http://www.rcai.com/
http://www.coreproducts.com/
DeRoyal Smith & Nephew, Inc.
1-800-251-9864 http://www.deroyal.com/ 1-800-558-8633 http://smith-
nephew.com/us/professional/
3-Point Products Tetra Medical Supply Corporation
1-410-604-6393 1-800-621-4041 http://www.tetramed.com/
http://www.3pointproducts.com/
Soft Cast Vendors
3M Scotchcast Soft Cast (Fiberglass)
3M Health Care
3M Center Building 275-4E-0
Saint Paul, MN 55144-1000
1-888-364-3577
Delta-Cast Soft (Polyester Cast Tape)
Delta-Cast Conformable—Functional Cast Therapy (Polyester
Cast Tape)
BSN Medical, Inc.
5825 Carnegie Blvd.
Charlotte, NC 28209-4633
1-800-552-1157
Index
Note: Page numbers followed by “f” indicate figures, “t” indicate
tables, and “b” indicate boxes.

A
Abduction and/or external rotation sling, 240f , 242
Abductor pollicis longus (APL), 57
Able-bodied adults, freely-selected walking speed, 418
Able-bodied walking, characteristics, 418
Above elbow (AE) amputation, 462
Accommodative (soft) FOs, 420
Accreditation Council for Occupational Therapy Education (ACOTE),
483
ACOTE, See Accreditation Council for Occupational Therapy
Education
Acromioclavicular dislocations, 240–241 , 241f
Acromion, 233
Active range of motion (AROM), 366
Activities of daily living (ADLs)
carrying out, 3
completion of, 98 , 462–463
device, 364f
 function, maximization, 5
grip, 131
improvement, 166
instrumental, 4 , 83
completion, 98
difficulties, 358
tasks, bilateral, 82–83
Activity-specific prosthesis, 465
Acute postsurgical phase, 472–473
Acute rheumatoid arthritis, resting hand orthoses (usage), 195
Adaptations, for resting hand orthosis, 395
Adduction and internal rotation sling, 239f , 242
Adherence, 86
See also Orthosis
client, 98–100
dimensions of, 98
factors, 99 , 99b
self-, 31
Adults, hip orthoses in, 425
Age, orthotic approach and, 97
Airplane orthoses, 241–242 , 241f
Allen test, 81 , 81f
Allergic contact dermatitis, orthosis and, 46–47
AMBRI (Atraumatic, Multidirectional instability, Bilateral,
Rehabilitation, Inferior capsule shift), 234
American Hand Therapy Foundation (AHTF), 485
American Occupational Therapy Association (AOTA), 483
American Society of Hand Therapists (ASHT), 2–3
Amputation
See also Upper extremity amputation
counseling, 476
family dynamics, 475
psychological and social issues of, 475–476
surgery, dressing phase and, 472
Amyoplasia, 384
Ankle-foot orthosis (AFO), 415 , 421–422
clinical considerations, for occupational therapist, 421–422
description, 421
designation, 421
designs, 422f
function, 421
Antecubital fossa, 52–53
Anterior elbow immobilization orthosis, 220f
cubital window, inclusion, 220f
Anterior elbow orthosis, 220 , 314f
extension angle, 218 , 218f
Anterior interosseous syndrome, 303t–304t , 317–318
orthotic intervention for, 319 , 320f
Anterior transposition, 218
Anticlaw orthosis, 288f , 327
 form and grading sheet, 328–330 , 328f–330f
Antideformity position, 191 , 191f
Anti-swan neck orthosis, 399–400 , 400f
fabrication of, 400 , 400b
AOTA, See American Occupational Therapy Association
Ape hand, 316 , 319f
Aplasia, of thumb, 379t
Aponeurosis, 56
Appendicular skeleton, 233
Applied force, 278
Area of force application, 277
Arms, 52–53
troughs
fit, rechecking, 227f
overlapping, 225f
seams, smoothing, 226f
Arthritis
carpometacarpal (CMC), occurrence, 164–165
orthosis, 160t–161t , 164f
Arthrogryposis, 377 , 384–385 , 384f
multiplex congenita, 384–385
Articular orthoses, identification of, 6 , 6f
Articulated AFOs, 421
Articulating orthotic components, 416
Assessments, 74–85
 content, 75
tools, 75
Atypical motor development, 385–386
Atypical upper extremity motor development, 377
Auditory system, sensory functions, 361
Axial skeleton, 233
Axilla contractures, 241 , 241f
Axonotmesis, 299–300 , 300f
B
Bail lock, 425f
Bamboo Brace (elbow extension orthosis), 400
Bankart repairs, 239–240 , 240f
Below elbow (BE) amputation, 462
Below knee amputation (BKA), 364
Benik Orthoses, 400
Benik Pediatric Neoprene Glove, 336–337
Biceps rupture, 217
Bilateral activities
of daily living, 82–83
examples, 475b
Bilateral double-upright HKAFOs, 427f
Bilateral hip abduction orthoses, pelvic band (inclusion), 426f
Bilateral HKAFOs, ambulation, 426
Bilateral thermoplastic HKAFOs, 427f
Biofeedback machines, 473
Biomechanics
impact, 335–337
principles, 278–280 , 280b , 413–420
Birth, brachial plexus palsy, 383–384 , 383f
Bivalve cast or orthosis, protocol in, 439
Black wound, 77
Bledsoe brace, 216f
Body diagram, 76 , 77f
Body fluids, open wounds, 78
Body mass, carriage, 418
Body weight, transfer, 418
Body-powered prosthesis, 465–469
cable, 467–468
components of, 466f
functional work area, 468f
glove, 469
harness, 466–467
liners, 467
socket, 467
terminal device, 468
Bone, assessment of, 78–79
Bony prominences, padding, 225f , 340f
contours, 343f
Boutonnière deformity, 253
anatomy of, 253f
orthotics for, 253 , 254f
Box cutter, usage, 338
Brachial plexus palsy, 377
at birth, 383–384 , 383f
casting for, 433
long arm cast for, 447–448
surgical options for, 384
Breg braces, 239 , 240f
Buddy straps, 256 , 257f
Bungee cords, usage of, 221 , 222f
Burns, hand, 195–198 , 197f
acute phase of, 198
emergent phase of, 197–198 , 197f
rehabilitation phase of, 198
resting hand orthosis, usage of, 196t
skin graft phase of, 198
C
Cable, 467–468
Camptodactyly, 377 , 381–382 , 381f
Canadian Occupational Performance Measure (COPM), 19–20 , 98
Cardiovascular functions, 364
Care partner, instructions, 368–369
Carpal bones, 54 , 55f
Carpal tunnel release surgery, 122t
Carpal tunnel syndrome (CTS), 119 , 303t–304t , 316–318
orthotic intervention, examination, 124
orthotic intervention for, 319–320
wrist orthotic intervention, 121–124
Carpometacarpal (CMC) arthritis, occurrence, 164–165
Carpometacarpal (CMC) immobilization orthosis, pattern, 166f
Carpometacarpal (CMC) joint, 56 , 156
movement, 171f
support, thermoplastic orthosis (usage), 166f , 175f
Carpometacarpal (CMC) osteoarthritis
orthoses, 160t–161t , 164–167 , 165f
orthotic option, 165
Carpometacarpal (CMC) rheumatoid arthritis, orthoses, 167–168
Cast cutter, for cast removal, 455–456 , 456f
Casting, 432–460
case studies, 459
 checkout procedure in, 460
contraindications to, 433 , 433b
diagnostic indications for, 432–433 , 433b
evidence for, 433–436 , 434t–435t
laboratory exercise, 459
materials, 439–441 , 440t
in neurological and neuromuscular conditions, 432–433
options, 436 , 436f
in orthopedic conditions, 432
review in, 460
upper extremity assessment for, 436–438
functional use, 437–438 , 438t
grip strength, 437
manual muscle test, 437
Modified Ashworth Scale (MAS), 437 , 437t
postural control, 437
range of motion, 436–437
sensibility, 437
skin condition, 437
Casts
assessment between, 438
care and precautions, 439t
client participation and other factors in, 438
functional cast therapy (FCT), 453
Delta-Cast Conformable, 453–455 , 453f–455f , 453t
 materials, 453–455
thumb spica with, 453
instruction for application of, 438–439
long arm cast, 447–449
rationale for use of, 447–448
semirigid soft cast material for, 448–449 , 448f–449f , 448t
metacarpophalangeal wrist cast, 450–451
to increase flexion, of metacarpophalangeal and proximal
interphalangeal joints, 452–453
materials for, 451 , 451t
rationale for use of, 450–451
semirigid soft cast for, 451 , 451f
padding, 440t
protocol for, 439
purpose of, sample letter for, 439t
rationale for use of, 438–439
removal of, 455–456 , 455f–456f
rigid circular elbow cast, 441–443
application instructions, 441–443 , 442b , 443f–444f
materials for, 441t
rationale for use of, 441
rigid circular wrist cast, 443–447
plaster material for, 443–446 , 444f–446f , 445t
rationale for use of, 443
semirigid soft cast material for, 446–447 , 447f
 types of, 438–439
wrist cast with thumb, 449
materials for, 449 , 450t
polyester soft cast for, 449 , 450f
rationale for use of, 449
C bar, 190 , 190f
conformity, 203f
Central compartment, muscles of, 59
Central slip, 251–252
Centralization, 378 , 378f
Cerebral palsy, 376f , 377 , 385–388 , 385f
Botox injections and, 388
orthoses for
children with increased tone, 388
types of, 386–387 , 386f–387f
orthotic intervention for, 386 , 386f
spastic, 385–386
surgery and, 388
Cerebrovascular accidents (CVAs), 358 , 421–422
Certified hand therapist (CHT), 3 , 483–486
Certified occupational therapy assistants, 3
Certified orthotists, 3
Cervical nerve problems, 79–81
Cervical spine, osteoarthritis, 363
Charcot-Marie-Tooth polyneuropathy, low-profile proximal
 interphalangeal (PIP) extension outrigger for, 282f
Children
with arthrogryposis, 384f
with cerebral palsy, orthoses for
fabrication of, 387
with increased tone, 388
types of, 386–387
hip muscles, spasticity, 425
preparation of, for orthotic fabrication, 389–390
resting hand orthosis for, 393–396
features of, 394
upper extremity prosthetic intervention for, 476
Chronic recurring flexor tenosynovitis, Siris Silver Ring Trigger Finger
(usage), 357f
Chronic rheumatoid arthritis, resting hand orthoses (usage), 195
CHT, See Certified hand therapist
Circumferential measurements, 81
Circumferential orthosis, zipper orthosis option, 120f
Circumferential wrist immobilization
orthosis, 118f , 119
pattern, 135f
Clasped thumb, 377 , 382–383 , 382f
Clavicle fractures, 240–241
Clavicular facet, 233
Claw hand, 313
 deformity, by ulnar nerve injury, 313f
Client adherence, 98–100
Client safety issues, 107–108
Client-centered intervention, 15
Client-centered outcome measure, 20t
Clinical examination, 72–85
fundamental principles, 358
Clinical reasoning, 93
approaches, 95t–96t
depiction of, 94
considerations, 101–102
models, 94–95
conditional, 94 , 95t–96t
interactive, 94 , 95t–96t
narrative, 94 , 95t–96t
pragmatic, 94 , 95t–96t
procedural, 94–95 , 95t–96t
for orthotic fabrication, 93–114 , 108b
case studies, 111–112
examples, 112–113
skills, expectation, 96–97
usage of, 95–100
Clinical utility, 75
Clinodactyly, 377 , 382
Closed-cell foam (non-absorbent) padding, 367–368
Cognitive status, orthotic approach and, 100
Cohistories, 73
Cold intolerance, reduction, 357f
Collateral ligaments, 251–252
injuries, buddy straps for, 257f
Colles fracture
orthoses, usage, 131–133
scaphoid fractures, comparison, 169
Comfort, orthotic interventions and, 43
Comfort Cool ulnar protector, 218 , 218f
Comfy Hand Wrist Finger Orthosis, 359f
Comfy Splints, 400
Commercial orthoses, 400
Commercial prefabricated orthoses, effect, 141
Community integration phase, 474–475
Complex proximal interphalangeal fracture, traction orthosis for, 289 ,
289f–290f
Complex regional pain syndrome (CRPS) type I (reflex sympathetic
dystrophy), 200–201
comprehensive therapy regimen for, 200–201
resting hand orthoses, usage of, 201
wrist orthotic intervention, 133
Componentry, 463–464
Composite extension, recommendation, 337
Composite finger flexion, static-progressive approach for, 289–291 ,
291f
Composite thermoplastic material, 368f
Compression syndromes, 317–318
Concomitant injury, impact, 214
Conditional reasoning, 94 , 95t–96t
Congenital finger contractures, 395
Congenital hand anomalies, 377–383
Context, 15–18 , 16b
Contextual dimensions, components of, 5
Contour, 68 , 68f
Contractures
formation, 332
management, 366
prevention, 472
traditional intervention techniques for, 433
Contralateral limb, 464
Controlled motion
application of, 289 , 289f–290f
provision of, 276
Coordination, 82–83
COPM, See Canadian Occupational Performance Measure
Copper wire, in outrigger, 281 , 282f
Coracohumeral ligament, 234
Corrective (rigid) FOs, 420
Cosmetic orthotic components, 416
Counterforce brace, 219 , 219f
Crawford Small Parts Dexterity Test, 82
Creep, 278
Cubital tunnel, long arm orthosis for, 315f
Cubital tunnel syndrome, 217–218 , 303t–304t
Cuff design orthosis, 221–222 , 222f
Cultural context, 16
Cumulative trauma disorder (CTD), 302
Current Procedural Terminology (CPT) codes, 105
Custom-fabricated orthosis, provision, 415–416
Custom-fit orthosis, 415–416
Customized orthoses, 189
Custom-made wrist orthosis, prefabricated wrist orthosis (contrast),
142b
Custom-ordered proximal interphalangeal hyperextension block
orthoses, 262f
Cylindrical grasp, 61–62 , 62f–63f
Cylindrical orthotic designs, types, 335
D
Dart thrower’s orthoses, 119 , 120f
de Quervain tenosynovitis, 156
acute phase, 160–161
orthotic intervention, 160–162 , 164f
presence (assessment), Finkelstein test (usage), 162f
result, 160
thermoplastic fabric orthosis, 365f
thumb orthotic intervention, efficacy, 161–162
Deformities, correction of, 275
Degrees of freedom, 54–55
Delta-Cast Conformable
for casting, 440t
functional cast therapy (FCT) using, 453–455 , 453f–455f , 453t
Delta-Cast Soft, for casting, 440t
Dexterity, 82–83
commercial prefabricated orthoses, effect, 141
Diabetes mellitus (DM), 364
risk, 364
Digestive functions, 364
Digestive systems, 364
Digital palmar flexion creases, 61
Disabilities of the Arm, Shoulder, and Hand (DASH), 20 , 76
questionnaires, 76
Distal arches, natural curves, 172
Distal humerus fractures, 214
Distal interphalangeal flexion orthoses, examples, 258f
Distal interphalangeal (DIP) joint, 56 , 376
enlargement, 363 , 363f
extensor lag, 252
flexion contracture, 252
Distal interphalangeal (DIP) osteoarthritis, 255
on occupations, 266
orthoses for, 255
Distal interphalangeal (DIP) stabilization orthosis
fabrication of, 266 , 267f
prefabricated, 266
proper fit of, technical tips for, 266
safety tips for, 266
Distal palmar crease, 60–61
Distal palmar crease (DPC), measurement of, 221–222 , 223f
Distal radioulnar joint, 54
Distal wrist crease, 61
Dorsal, term, 53
Dorsal-based resting hand orthosis, 191f , 395
pattern for, 203f
Dorsal forearm volar hand immobilization orthosis
construction, 338–342
edges, smoothing, 342f
 fabrication, 339–342
forearm, straps (application), 343f
form and grading sheet, 352–355 , 352f–355f
material, 338
orthotic provision, 342–343
pattern making, 338–339
radial/ulnar folds, finishing/reinforcement, 342f
splint, reapplying, 343f
stability, radial/ulnar sides (folding), 341f
task-oriented intervention, 342–343
thumb component, spot-heating/bonding, 344f
Dorsal forearm-based orthosis, minimalist design (usage), 337–338
Dorsal gutter orthosis blocking, 256f
Dorsal gutter wrist immobilization orthoses, 320
Dorsal hand-based thumb immobilization orthosis
fabrication, 165 , 171–174
orthotic intervention, 167f , 172
Dorsal orthosis
fabrication, 133
volar orthosis, combination, 169f
Dorsal static protective orthosis, usage of, 199f
Dorsal thumb immobilization orthosis, 158f
pattern, 169f
Dorsal wrist cock-up orthosis, instructions for, 397f
Dorsal wrist immobilization
 orthosis (orthoses), 117f , 119 , 396–397
components, identification, 121f
procedure for fabrication of, 396b
pattern, 135f
Dorsally based forearm trough, 189
Dorsal-volar mallet orthosis
fabrication of, 257–258
pattern of, 259f
“Drag-to” gait, 426
Draping material, 225f
Dressing phase, 472
D-ring orthosis, circumferential design, 362f
D-ring straps, Rolyan D-Ring Wrist Brace, 142f
Dropout casts, 436 , 436f
Dropout orthosis, 7 , 9f
Dupuytren contracture, 198–199
surgical release of, 199
Dupuytren disease, 198–200
resting hand orthosis, usage of, 196t
Dupuytren fasciectomy, skin incision patterns, 199f
Dupuytren release, 199
Dynamic anti-claw-hand orthosis, fabrication for, 287–289 , 288f
Dynamic (mobilization) orthosis, 7 , 9f , 277
fabrication
materials and equipment for, 284
 technical tips for, 283–284
precautions for, 284
for repaired tendons, 277f
Dynamic orthotic prescription, 277
Dynamic proximal interphalangeal extension orthosis, fabrication
instructions for, 285–287 , 286f–287f
Dynamic tenodesis suspension orthosis, 308
Dystonic thumb, wrist cast with thumb for, 449
E
Edema, 85 , 86f
control, 141
management, 366
monitoring, 102
Elastic thread, 281
Elastomer, 395
Elbow turnbuckle orthosis, 278f
for extension, 284f
Elbows
capsule, strengthen, medial and lateral collateral, 54
dislocation of, 214–217
draping material, 225f
flexion/extension, ranges of, 214
fractures of, 214–217
concomitant injury, impact of, 214
immobilization orthoses, 213–232 , 227b
case studies, 229
clinical indications of, 214–219
diagnoses of, 214–219
form and grading sheet, 230–232 , 230f–232f
laboratory exercises, 229
precautions for, 226–227
immobilization splint, conditions, 215t
 instability, 217
prevention of, 217
joints, 54
anatomic/biomechanical considerations of, 213–214
muscles, 54
actions and nerve supply for, 55t
orthoses, 384f
features of, 220–222
posterior elbow immobilization orthosis, 214–216 , 216f
serial static elbow extension orthosis, 219f
sleeve with a gel pad for, 315f
stiffness, 218–219
tennis, 219
ulnar nerve compression at, orthotic intervention for, 314–315 ,
314f–315f
upper extremity compression neuropathies in, 303t–304t
valgus angulation (carrying angle) of, 213–214
Electrodes
function of, 470
training, 473
End feel, 282
Endocrine functions, 364
Endocrine system, 364
End-stage renal disease (ESRD), 365
Entry-level occupational therapists, 482
Entry-level practice, in upper extremity rehabilitation, 482–483 , 483b
Environments, 15–18
orthotic interventions and, 43–44
Erb palsy, 383
Essex-Lopresti fractures, 216–217
Exolite Wrist Brace, 142f
Expected environment, orthotic approach and, 98
Extension orthoses, 254f
Extensor carpi radialis brevis (ECRB), 58
Extensor carpi radialis longus (ECRL), 58
Extensor carpi ulnaris (ECU), 58
Extensor digiti minimi (EDM), 58
Extensor digitorum communis (EDC) tendons, 58
Extensor indicis proprius (EIP) tendons, 58
Extensor lag, DIP, 252
Extensor pollicis brevis (EPB), 57
Extensor pollicis longus (EPL), 58
Externally powered prosthesis, 469–471
battery, usage, 471
components of, 470f
dual-site control system, 470
functional work area, 469f
harness, 469–470
joints, 471
multiarticulating terminal device, 471
Externally powered prosthetic socket, 470
F
Fabrication, of cast, 439
Family dynamics (amputations), 475
Fellowship programs, 483
Felt strip, for casting, 440t
Fiberglass, for casting, 440t
Fiberglass casting procedures, 346–347
Fibrocartilaginous volar plates, 57
Fifth-degree injury, 301
Figure-eight orthosis
shoulder, 240 , 240f–241f , 242–246
for ulnar nerve injury, 316 , 317f
Fine motor skill development, 377 , 377t
Finger separator, 380–381
Fingers
anatomy of, 253f–254f
buckling, prevention, 341–342
flexed position, 335
joints, 56–57 , 57f
loops, 68 , 69f , 281
metacarpophalangeal (MCP) joint extension, loss of muscle
function, 275
molding process, 340
orthotics for, 251–273 , 268b
 case studies, 269–270
diagnostic indications for, 252–256
distal interphalangeal osteoarthritis, on occupations, 266
distal interphalangeal stabilization, fabrication of, 266 , 267f
dorsal-volar mallet, fabrication of, 257–258 , 259f
finger-based trigger finger, fabrication of, 263–266 , 267f
form and grading sheet, 271–273 , 271f–273f
functional and anatomical considerations of, 251–252
laboratory exercises, 270 , 270f
occupation-based, 256–257
precautions for, 256
prefabricated distal interphalangeal stabilization, 266
prefabricated mallet, 259 , 259f
prefabricated proximal interphalangeal extension, 263
prefabricated trigger finger, 266
proximal interphalangeal flexion contractures, on occupations,
263
proximal interphalangeal gutter, fabrication of, 259–260 , 260f
proximal interphalangeal hyperextension block, fabrication of,
260–261 , 261f
swan neck deformities, on occupations, 262
three-point proximal interphalangeal extension low-profile,
fabrication of, 262–263
trigger finger, on occupations, 266
prefabricated finger spreader/ball orthosis, 335f
pressure areas, 132f
 proximal interphalangeal sprains, 255–256
buddy straps for, 256 , 257f
dorsal gutter in, 256 , 256f
orthoses for, 256 , 257f–258f
Fingertip prehension, 61 , 63f
Finkelstein test, usage, 162f
First-degree injury, 300
Flexion contractures
distal interphalangeal (DIP), 252
impact of, 220
palmar fascia, 364
proximal interphalangeal (PIP), 255
on occupations, 263
serial-static casting (orthosis) for, 285 , 285f
Flexor carpi radialis (FCR), 131
Flexor carpi ulnaris (FCU), 131
Flexor digitorum superficialis, 57
Floor-reaction AFOs, 421
Follow-up visits, documentation for, 106–107
Foot orthoses (FOs), 420–421
categories, 420
clinical considerations (occupational therapist), 420–421
description, 420 , 420f
designs, 421f
vacuum forming, 420
Force
application of, 279–280
area of, 277
result in, 280f
magnitude, 278 , 280
resistance, 278
Forearm, 52–53
forearm-based thumb orthoses, 156 , 164
immobilization orthoses, 213–232 , 227b
case studies, 229
clinical indications of, 214–219
diagnoses of, 214–219
laboratory exercises, 229
sugar tong type, 217f
molding, 341f
pressure areas, 132f
restriction, 222
rotation strap, 398f
straps
application, 343f , 345f
reapplication, 345f
tracing, 338f
upper extremity compression neuropathies in, 303t–304t
Forearm troughs, 119 , 189 , 190f
fit, rechecking, 227f
 overlapping, 225f
for resting hand orthosis, 394
seams, smoothing, 226f
twisting, 140f
types of, 189 , 190f–191f
Fourth-degree injury, 300
Fractures
brace, rationale for using, 78–79
casting for, 432
clavicle, 240–241
Colles
orthoses, usage, 131–133
scaphoid fractures, comparison, 169
distal humerus, 214
elbow, 214–217
Essex-Lopresti, 216–217
forearm, 216–217 , 217f
Monteggia, 216–217
osteoporotic, 234
proximal humerus, 234 , 239f
proximal radius, 214–216
proximal ulnar, 216
scaphoid, 169
wrist orthotic intervention, 131–133
Free posterior offset, 425f
Froment sign, 314
Functional cast therapy (FCT), 453
Delta-Cast Conformable, 453–455 , 453f–455f , 453t
materials, 453–455
thumb spica with, 453
Functional classification system, 438 , 438t
Functional position (resting hand orthosis), 191 , 191f
Functional work area
body-powered prosthesis, 468f
externally powered prosthesis, 469f
Fusiform swelling, 256
G
Gait
biomechanics, 417–420
energetic issues, 419–420
leading leg, 418
normal, 417–419 , 417f
observational gait analysis, 417
pathological, 419–420
primary deviations, 419
secondary deviations, 419–420
Gait cycle, 417f
stance phase, 417f
swing phase, 417f
Gamekeeper’s thumb, 160t–161t , 168
Genitourinary functions, 365
Genu recurvatum (knee hyperextension), 420f
KAFO application condition, 424
Genu valgum (correction), three-point force system (usage), 414f
Glenoid fossa, 234
Golfer’s thumb (radial collateral ligament injury), 160t–161t , 168–169
Goniometer, usage, 137f–138f
Grasp, 61–62
cylindrical, 61–62 , 62f–63f
hook, 62 , 64f
 spherical, 62 , 64f
Grasping, thumb orthoses, 386f
Grip
commercial prefabricated orthoses, 141
force, 466
strength
body-powered terminal device, 468–469
upper extremity assessment, 437
Gross motor skill development, 377t
Ground reaction force (GRF) vector
control, 418
vertical GRF vector, orientation, 424
Guyon canal, 312
H
Hand burns, 195–198 , 197f
acute phase of, 198
emergent phase of, 197–198 , 197f
rehabilitation phase of, 198
resting hand orthosis, usage of, 196t
skin graft phase of, 198
Hand crush injury, 201
Hand Rehabilitation Foundation (HRF), 485
Hand therapy certification, 483–486 , 484b
Hand Therapy Certification Commission (HTCC), 483–484
Hand therapy credential, benefits of, 484–485
Hand-based orthotic intervention, for ulnar nerve injury, 315–316 ,
315f–316f
Hand-based proximal interphalangeal (PIP) extension orthosis,
orthotic pattern for, 286f
Hand-based thumb immobilization orthoses
fabrication, 171–174
pattern, 169f , 171f
usage, 157
Hand-based thumb orthoses, usage, 156
Hand-forearm patterns, transfer, 338–339
Hands
anatomical landmarks of, 60–61
arches of, 60 , 60f
congenital anomalies of, 377–383
crease of, 60–61 , 61f
cutaneous and connective coverings of, 56
cylindrical orthotic designs, types, 335
development of
abnormal, 377
normal, 377
evaluation check-off sheet, 91 , 91f
fascial structure, 56
immobilization orthoses, 187–212
case studies, 206
form and grading sheet, 209–212 , 209f–212f
laboratory exercises, 207–208 , 207f–208f
movements, 61
muscles of, 58t
extrinsic, 57–58 , 58b , 59f
intrinsic, 58–59 , 59f–60f , 59b
orthoses, 165
evidence-based practice, 192t–194t
examples, 188f , 188t
fabrication of, 2
fitting process, 81
pattern, completion, 339f
positioning, pattern tracing, 338f
preformed hand orthoses, 187–189
 prehensile patterns, 61–62
pressure areas, 132f
range of motion (ROM), 358
stabilization, 341
terminal devices, advantages and disadvantages of, 469t
tracing, 339f
volar forearm hand immobilization orthosis, 338f
zones of, 53 , 53f
Handwriting Assessment Battery, 83
Harness
body-powered prosthesis, 466–467
externally powered prosthesis, 469–470
Healing, stage of, 277f
Health, 19
Health Insurance Portability and Accountability Act (HIPAA), 106
Health literacy, orthotic approach and, 100
Hearing impaired, talking guidelines, 361b
Heat gun, 37 , 37f
Heelbo padded soft elbow sleeve protector, 362f
Hematological functions, 364
High ulnar nerve injury, surgical decompression of, 218
High-profile outrigger, 281 , 282f
dynamic traction, on replanted thumb, 282f
High-temperature thermoplastics, usage, 416–417
Hip muscles, spasticity, 425
Hip orthoses (HOs), 425–426
adults, 425
clinical considerations, for occupational therapist, 426
description, 425
designs, 426f
usage, 425
HIPAA, See Health Insurance Portability and Accountability Act
Hip-knee-ankle-foot orthoses (HKAFOs), 426–428
considerations, 426–428
clinical, for occupational therapist, 428
designs, 427f
History, 72–73
medical history, 73
Holster design orthosis, 221–222 , 222f
Hook grasp, 62 , 64f
Hook rubbers, 469
Hook terminal devices, advantages and disadvantages of, 469t
HTCC, See Hand Therapy Certification Commission
Humeral cap orthosis, with cross-body strap, 241 , 242f
Hybrid prosthesis, 464
Hyperextension block orthosis, safety tips for, 261
Hypertonicity
severity of, 437
thumb, 157 , 157f
Hypoplastic thumb, 377 , 379 , 379f–380f , 379t , 380b
Hypothenar bar, 119
formation, 139f
impact, 140f
I
Ilfeld orthosis, usage, 426f
Immobilization orthoses, 6 , 8f , 307–308
Impact forces, cushioning, 419
Inelastic nylon string, in finger loops, 283f
Infants
congenital finger contractures in, 395
resting hand, 381f
Infection control, orthoses (cleaning techniques), 201b
Informal assessment, 72
Inhibitory cast, 436 , 436f
usage, 438–439
Instability syndrome, 234–239 , 239f
Instrumental activities of daily living (IADLs), 4 , 83
completion, 98
difficulties, 358
Integumentary system, 365
Intensive care unit (ICU), resting hand orthosis (usage), 201
Interactive reasoning, 94 , 95t–96t
Interface orthotic components, 416
Intermediate (semirigid) FOs, 420
Interosseous ligaments, closed-packed positions and, 54–55
Interphalangeal (IP) joint, 56 , 156
involvement, 131
 thumb
lateral instability, 164f
Siris Swan Neck, 363f
stabilization, tripoint figure-eight design (impact), 363f
Intervention process, 94
clinical reasoning, usage of, 95–100
Interview, 73
J
Jeanne sign, 314
Jebsen-Taylor Hand Test, 83f
Joint
assessment of, 79
limitation, 103
motion (modification), orthosis (control options), 415t
orthotist identification, 415
stability, 79
structure, 56–57
Joint Active Systems (JAS) elbow orthosis, 220 , 221f
Juvenile idiopathic arthritis, 377 , 385
K
Kinaesthetic reminder, 414
Knee-ankle-foot orthoses (KAFOs), 423–425
clinical considerations, for occupational therapist, 424–425
description, 423–424
designs, 424f
proximal component of, 423
Knee flexion, mechanism, 418
Knee hyperextension (genu recurvatum), 420f
ongoing knee hyperextension, 420
Knee joint, 414–415
locking mechanisms, 425f
stance control knee joints, mechanisms, 424
Knee orthoses (KOs), 422–423
clinical considerations, for occupational therapist, 423
description, 422
designs, 423f
effectiveness, 422
orthotic knee joints, comparison, 423
L
Lateral bands, 251–252
Lateral collateral ligaments, 54
Lateral epicondyle, 214
Lateral folds, heating, 341
Lateral pinch, 256
Lateral prehension, 61 , 62f–63f
Ligament of Landsmeer, 253
Ligament sprain injuries, grades of, 256t
Ligaments
assessment of, 79
complex, stability to the shoulder, 53
Limb shrinkage and shaping, 473
Liners, 467
Lister tubercle, 164
Little finger, Dupuytren contracture of, 198f
Locus of control, psychosocial construct of, 98
Long arm cast, 447–449
rationale for use of, 447–448
semirigid soft cast material for, 448–449 , 448f–449f , 448t
Long arm orthosis, for cubital tunnel, 315f
Longitudinal arch, natural curves, 172
Low load, prolonged stress, 275
Lower extremity
 casting, evidence of, 433–436
movement, joints and structures contributing to, 415f
Lower extremity orthotics, 411–431
biomechanical goals, 412
case studies, 430–431
intervention, assessment, 414b
management, clinical assessment, 414–416
shoes as, integral part of, 420
treatment, clinical objectives, 413b
Lower limb orthoses, abbreviations, 413t
Low-profile hand-based extension orthosis, 286f
Low-profile mobilization orthosis, for radial nerve palsy, 309b , 310f–
311f
fabrication of, 310 , 312f
Low-profile orthotic designs, with prepurchased outrigger parts, 308f
Low-profile outrigger, 281 , 282f
Low-profile proximal interphalangeal (PIP) extension outrigger, for
Charcot-Marie-Tooth polyneuropathy, 282f
Low-profile radial nerve palsy orthosis, with radial and ulnar
deviation, 310f
fabrication of, 309
pattern for, 310f
Low-temperature thermoplastic (LTT)
materials, 29 , 49
engineered, 30
usage of, 252
Lycra, usage, 336–337
Lymphatics, examination of, 77
M
Mallet finger, 252–253
deformity of, 252f
impact on occupation, 259
injuries of, 251–252
orthoses for, 252–253
prefabricated, 259
safety tips for, 258
technical tips for, 258
Manual Ability Measure, 83
Manual Ability Measure-20 (MAM-20), 21
Margins, marking, 339f
Mass movement pattern, volitional control, 342
Materials
science, 416–417
selection, 367–368
Mayo elbow universal brace, 220 , 221f
McGill Pain Questionnaire (MPQ), 76
McKie Splints, 400
Mechanical advantage, 65 , 65f , 278–279
demonstration of, 279f
Medial epicondyle, 214
Medial folds, heating, 341
Medial ligaments, 54
Median nerve, 301
lesions of, 316–320 , 318t
motor innervation of, 318f
sensory distribution of, 307f
Median nerve injuries
functional implications of, 316
locations and types of, 316–319 , 319f
orthotic interventions for, 319–320
with thumb involvement, 320
ulnar and, 320 , 321f
thumb web spacer for, 320f
Medical history, 72
Medicare Physician Fee Schedule (MPFS), 105
Medications, side effects, 365
Memory, 30
See also Thermoplastic materials
Mental functions, 359–360
Metabolic functions, 364
Metacarpal bar, 119
impact, 140f
rolling, 139f
wrapping, 139f
Metacarpophalangeal (MCP) extension hand-based orthosis, 326–327
Metacarpophalangeal (MCP) hyperextension
blockage, orthosis (usage), 164f
 prevention, 163
Metacarpophalangeal (MCP) joint, 56 , 73–74 , 156
flexion
allowance, 116
restriction, thermoplastic orthosis (impact), 357f
static-progressive turnbuckle, 283f
involvement, 131
palmar side, extrinsic muscle tendons, 57
stabilization, orthosis (usage), 164f
support, thermoplastic orthosis (usage), 166f , 175f
Metacarpophalangeal (MCP) mobilization extension orthosis
dorsal base of, pattern for, 312f
for radial nerve injury, 308
for radial nerve palsies, 309b , 310f–312f
fabrication, 310
Metacarpophalangeal (MCP) wrist cast, 450–451
to increase flexion, of metacarpophalangeal and proximal
interphalangeal joints, 452–453
materials for, 451 , 451t
rationale for use of, 450–451
semirigid soft cast for, 451 , 451f
Methods time measurement (MTM), 82
Microtearing, of overstretched muscle, 438
Midcarpal joint, 54 , 56f
articulation of, 54
Middle finger traction orthosis, 289f
Minimalist design, usage, 337–338
Minnesota Rate of Manipulation Test (MRMT), 82
Moberg Pick-up Test, 83f
Mobility, loss, 366
Mobilization low-profile orthosis, for radial nerve palsy, 311b , 312f
Mobilization orthoses, 6 , 274–297 , 308–309 , 308f–309f
anatomical and biomechanical considerations for, 278
application of force in, 279–280 , 280f–281f
biomechanical principles of, 278–280 , 280b
case study, 294
clinical considerations for, 284–291
common features of, 280–282
form and grading sheet, 295–297
goals of, 274–277
mechanical advantage of, 278–279 , 279f
precautions for, 284
torque in, 278–279 , 279f
types of, 277–278
for ulnar nerve injuries, 316 , 317f
Mobilization orthotic provision, 275–276
Modified Ashworth Scale (MAS), 437 , 437t
Monofilament line, 281
Monteggia fractures, 216–217
Motor vehicle accident, casting in, 459
Movement-related functions, 362–363
MRMT, See Minnesota Rate of Manipulation Test
Multiarticulating terminal device, 471
Multidirectional three-point pressure, 65f
Muscles
assessment of, 79
biomechanical properties, 335–336
function, loss of, substitution for, 275–276 , 276f
tone of, fluctuating, 385
Myoelectric prosthesis, 469
N
Narrative reasoning, 94 , 95t–96t
Neoprene, 336–337
Neoprene straps, 46f
Neoprene thumb orthosis, 387
decorated, 392f
Neoprene thumb wrap, 168
Neoprene Trigger Finger Solution (TFS), 357f
Nerve injuries
categorization of, 299
classification of, 299–301 , 300f
median, 316
orthotic intervention for, 298–330 , 321b–322b
case studies, 326
form and grading sheet, 328–330
laboratory exercises, 326–327
purposes of, 301–302
orthotic provision with, general guidelines for, 302
prognosis of, 302–304
radial, 304–310 , 305f
substitutions in, 302
ulnar, 311–316
Nerves
assessment of, 79–81 , 80f , 80t
 compression, 122t
decompression, 301
entrapment, 464
grafting, 301
lesions, locations of, 302
sensory evaluations, 79
surgical nerve repair in, 301
operative procedures for, 301
transfers, 301
Neurapraxia, 299–300 , 300f
Neurological system, 363–364
Neurologically impaired hand
management, problem-solving approach (usage), 337–347
orthotic designs, 332–337
Neurolysis, 301
Neuromusculoskeletal functions, 362–363
Neurotmesis, 299–300 , 300f
Nine Hole Peg Test, 82 , 83f
Nonarticular orthoses
identification of, 6 , 6f
two-point pressure force, 6
Nonarticulated AFOs, 421
Nonstretchable string, 281
Normal gait, 417–419 , 417f
O
Objective sensory assessment data, 79
Oblique midtarsal (Chopart) joint, 414–415
Oblique retinacular ligament (ORL), 253
Observation, 73–74 , 74f
points, 74
Observational gait analysis, 417
Occupation
orthotic approach and, 97–98
Pierce’s notions, of contextual and subjective dimensions of, 5
three lens’ of, 14–19
thumbs (impact), 174
Occupational deprivation, 21–22
Occupational disruption, 21–22
Occupational engagement, 21–22 , 21b
Occupational justice, 19
Occupational performance
See also Orthosis
improvement, 365–366
Occupational Performance Model, use of, 4–5
Occupational profile, 19
Occupational therapists, 3 , 483
role of, 412–413
Occupational therapy
 models, 4–5 , 4t–5t , 5b
specialty areas in, 483–486
theories, 4–5 , 4t–5t , 5b
Occupational Therapy Practice Framework (OTPF), 4 , 4t–5t
Occupational-based activity, 474–475
Occupation-based approach, 15 , 16b
Occupation-based orthotics, 256–257
examples, 257 , 257b
intervention checklist, 27 , 27f
Older adults
care partner instructions/follow-through, 368–369
considerations for interactions, 367b
cost and payment issues, 369–370
orthoses, purposes, 365–366
orthotic intervention, 356–374 , 369b–370b
case studies, 373
laboratory exercise, 374 , 374f
process, 366–369
Olecranon process, 214
Ongoing knee hyperextension, 420
Open reduction internal fixation (ORIF), 214–216 , 241
Open-and-close control, 464
Open-cell foam padding, 367–368
Orficast thermoplastic tape, 253 , 254f
Orthosis (orthoses)
aesthetics, 99
age of the person and, 42
airplane, 241–242 , 241f
allergic contact dermatitis and, 46–47
application, evidence of, 412
ASHT classification, 160–161
ASHT definition, 2–3
case study, 12 , 12f
circumferential wrist immobilization orthosis, 118f , 119
cleaning techniques for, 201b
client protections, 105–106 , 106b
commercial, 47
control options, 415t
cost, issues, 104–107
customized, 189
definition of, 2–3
direct/indirect costs, determination of, 104 , 104b
direction and, 6
discontinuation of, 104
distal end, flaring, 137f–138f
documentation, 47 , 106–107
dorsal wrist immobilization orthosis, 117f , 119
dorsum of, buttons on, 392f
edges, smoothing, 342f
evaluation/adjustment of, 103
evidence-based practice, 8–10 , 10f , 10t , 10b
fit, technical tips, 137–140
forming, 137f–138f
frame-of-reference, 4–5
hand, fabrication, 2
historical synopsis of, 3
immobilization, 6 , 8f
incidental disclosures, 106
infection control procedures, 101
instructions, hints, 361b
interdisciplinary approach, 413
International Organization for Standardization (ISO) definition, 412
intervention process, 94
latex sensitivity, 46
location and, 6
making, 32–40
materials for, selection of, 390
mobilization, 6
molding, 36–37 , 36b
palmar/wrist part, formation, 140
pan of, 189–190
patterns for, 32
adjustments, 34f
fabrication, 135
fitting, 32–34
payment, issues, 104–107
for pediatric population, 375–410
planning, clinical reasoning considerations for, 101–102
with pointer, 388f
policy regulations, 105–106
postfabrication monitoring, 102
edema, monitoring, 102
physical/functional status, monitoring, 102
pressure, monitoring, 102
skin maceration, monitoring for, 102
precut orthotic kit, 189
primitive orthoses, reports of, 3
processes, tools and techniques, 29–51
form, 50
laboratory exercise, 49
sources of vendors, 51
professionals and, 3–4 , 3f
proximal humerus cap, 241
with cross-body strap, 234 , 239f , 241 , 242f
fabrication of, 243b , 244f–246f
purpose of, 6
reassessment for, 47
satisfaction, material selection (impact), 99
selecting, 42–44
supply charges, 105
 thumb, position (variation), 157
torque transmission, 6 , 7f
type of, 6–7
ulnar wrist immobilization orthosis, 118f , 119
usage, follow-up telephone calls/email communication (questions),
99 , 99b
volar wrist immobilization orthosis, 117f , 118–119
wearing schedule, 45–46
factors, 103
sample, 103 , 103b
zipper orthosis option, 120f
Orthotic approach
activities of daily living, 98
age, impact, 97
client adherence/motivation, 98–100
cognitive status, 100
expected environment, 98
factors, 97–100
health literacy, 100
occupation, 97–98
Orthotic care, 86–87
adherence, 369b
Orthotic components, 416
categories, 416
fabrication, 157
Orthotic design, 2
assessment findings for, 23
biomechanics, basis, 335–337
clinical reasoning considerations for, 101–102
considerations, 358t
determining, 23 , 23f
diagnosis, 100–101
medical complications of, 42
occupational desires and, 19–21
positioning, choices in, 101 , 101t
principles, 413–420
concept, 413 , 413b
to promote occupational engagement and participation, 23 , 23f
terminology of, 7–8
treatment settings, 358
Orthotic fabrication, 141
client/nursing/caregiver education, 101–102
clinical reasoning for, 93–114 , 108b
case studies on, 111–112
examples, 112–113
general principles for, 388–400
steps for, 389–393
thermoplastic material, 34–36 , 35f
time
allotment for, 101–102
 dependence of, 101
Orthotic intervention, 69b–70b
age-related changes, 358–365
summary, 359t–360t
anatomical review for, 52–53
application approach, physician orders, 100
approach, considerations, 100–101
biomechanical principles for, 62–67
client- and occupation-centered practice with, 14–15 , 15b
client safety issues, 107–108
client-centered and occupation-based evaluation, 22
client’s function, 101
clinical examination for, 72–92 , 87b
design considerations, 100–101
errors, 107–108
occurrence of, 107
result of, 107
as facilitator of therapeutic outcome, 18–19
forms, 91–92
medical conditions, 358–365
summary, 359t–360t
occupation-centered, 13–28 , 14f , 24b
case studies, 26
form, 27
older adults, 356–374
 referral, 22
terminology for, 52–53 , 53f
as therapeutic approach, 18
therapist judgment, 101
Orthotic precautions, 85–86
check-off sheet, 92 , 92f
Orthotic provision, 342–343
approaches to, 219
client, supine position, 224f
diagnostic implications for, 97
hints for, 92 , 92f
Orthotic referral, 22
essentials of, 95
incomplete/complete orthotic referrals, examples, 96 , 97b
therapist/physician communication about, 96–97
Orthotic regimen, 85–86
Orthotic wear, adherence, factors (examples), 99 , 99b
Orthotic workroom or cart, 47
Orthotics
categorization of, 6–7
foundations of, 1–12
occupation-centered, 18–19
Osteoarthritis (OA)
carpometacarpal (CMC)
orthoses, 160t–161t , 164–167 , 165f
 orthotic option, 165
cervical spine, 363
diagnosis, 362
distal interphalangeal (DIP), 255
on occupations, 266
orthoses for, 255
thumbs, 363
Osteoporosis
diagnosis, 362
fracture, 234
Outrigger, 280–281 , 287f
classification of, 281
Oval-8, example, 357f
Overuse syndrome, 464
P
Padding, 38–40
See also Thermoplastic materials
categorization guidelines, 39t
closed/open cells, presence, 40
for pediatric orthotic fabrication, 391
for resting hand orthosis, 394
selection, 367–368
types, 367–368
Pain, 76–77
assessment questions, 76b
children’s report, 77t
control, wrist immobilization orthosis, 131
desensitization and, 474
intensity, ViAS for, 76
pediatric pain, assessment of, 77
reduction, 365
sensory functions, 362
Pain-free range of motion (ROM) exercises, 124–131
Palm
Dupuytren contracture of, 198f
metacarpal bar, wrapping, 139f
Palmar, term, 53
Palmar aponeurosis, 56
 superficial palmar aponeurosis, 56 , 56f
Palmar creases, 60–61
Palmar fascia, 56
flexion contracture, 364
superficial layer of, 56
Palmar prehension, 61 , 63f
Palmar wrist creases, 61
Palpation, 74
Paralysis, long arm cast for, 448
Parapodium, 426
Passive finger flexion, tenodesis orthosis in, 276f
Passive functional aesthetic prosthesis, 464–465
Passive motion, goniometric measurements, 82f
Passive prosthesis, 464–465
Passive range of motion (PROM)
improvement, 67
increase, 45
wrist mobilization orthosis serial static approach, usage, 120–121
Pathological gait, 419–420
Patient-Rated Wrist Hand Evaluation (PRWHE), 20–21
Pattern recognition, of upper limb, 470
Pavlick harness, usage, 426f
Pediatric orthoses, 375–410
anti-swan neck orthosis, 399–400
case studies, 408
 commercial orthoses, 400
development of, 377
dorsal wrist immobilization orthosis, 396–397
evaluation of, 393
evidence for, 400 , 401t–405t
goals of, 376 , 389b
laboratory exercises, 409 , 409f
precautions for, 393
purpose of, 376
resting hand orthosis, 393–396
rotation strap in, 397–398
soft thumb orthosis, 397
Pediatric orthotic fabrication
application of, instruction for, 392–393 , 393f
approaches to, 389
closure, Velcro strap (usage), 392f
design for, 390
environment for, preparation of, 390
hastening the process of, 391
heating the thermoplastic material in, 391
materials for, selection of, 390
padding for, 391
pattern making in, 391
safety tips and precautions for, 389
steps for, 389–393
 strapping in, 391–392 , 392f
wearing schedules for, 393
Pediatric pain, assessment of, 77
Pediatric trigger thumb, 377 , 379–380 , 380f
Pediatric upper extremity conditions, 377–388
Peripheral nerve
anatomy of, 299 , 299f
injury, 79
lesions, orthotic interventions for, 319t
Personal context, 16
Phalangeal arc, holes (punching), 340f
Phalen sign, 79
Phantom pain, 473
phantom sensation, contrast, 473
Phantom sensation, 473
occurrence, 473
Physical agent modality (PAM), 36
Physical environment, 17–18 , 17f
Physical therapists, 3
Pil-O-Splint, 218 , 218f
Pinch meter, 82f
Plastazote, 368f
Plaster bandage, 345–346
Plaster casting procedures, 346
Plaster casts, 440t
 for proximal interphalangeal flexion contractures, 285f
Plaster material, for rigid circular wrist cast, 443–446 , 444f–446f , 445t
Plasticity, 68
Posterior elbow immobilization orthosis, 214–216
fabrication of, 222
procedure for, 223b–224b
Posterior elbow orthosis, 220
examples, 220f
flexion angle, 216f
Posterior interosseous nerve compression, 304–305
Posterior interosseous nerve syndrome, 303t–304t
orthotic intervention for, 307
Posterior offset, drop locks (inclusion), 425f
Posterior offset knee joints, impact, 424
Postoperative hip abduction orthosis, 426f
Postoperative KO control, 423f
Postsurgical syndactyly release, 380–381
Pragmatic reasoning, 94 , 95t–96t
Precut orthotic kit, 189
Prefabricated AlumaFoam orthosis, 259
Prefabricated cone orthosis, 335f
Prefabricated distal interphalangeal stabilization orthosis, 266
Prefabricated finger spreader/ball orthosis, 334f
Prefabricated mallet orthoses, 259 , 259f
Prefabricated Neoprene thumb orthosis, 336f
Prefabricated Neoprene thumb wrap, purchase, 168
Prefabricated orthosis, 40–47 , 141
adjustment for, 44–45 , 45f–46f
advantages, 41 , 41b
care of, 46
disadvantages, 41–42 , 42f
industrial setting, 44
long-term care setting, 44
precautions, 46–47
provision, 415–416
school setting, 44
Prefabricated proximal interphalangeal extension orthoses, 260f , 263
Prefabricated proximal interphalangeal hyperextension block
orthoses, 262f
Prefabricated proximal interphalangeal orthoses, 260
Prefabricated trigger finger orthosis, 266
Prefabricated wrist orthosis, custom-made wrist orthosis (contrast),
142b
Preformed hand orthoses, 187–189
Prehensile pattern, 61–62 , 62f–64f
Preprosthetic phase, 473
Pressure, 66
areas, 85
desensitization to, 473–474
monitoring, 102
Procedural reasoning, 94–95 , 95t–96t
Progressive elbow flexion orthosis, bungee cords (usage), 221 , 222f
Pronation strapping, 399f
Pronator syndrome, 303t–304t
orthotic intervention for, 319
Pronator tunnel syndrome, 318–319
Prosthesis (prostheses)
activity-specific, 465
age appropriate, suggestions for, 476t
body-powered, 465–469
delivery of, 473
early fitting, 476
wearing, absence, 464
Prosthetic options, 464–472
advantages and disadvantages of, 465t
Prosthetic rehabilitation
acute postsurgical phase, 472b
bilateral involvement of, 474
community integration phase, 474–475
control training of, 474
fabrication phase, 473–474
family involvement of, 476
impact on, 476
orientation of, 474
phases of, 472–475 , 472b
preoperative phase, 472
 prescription phase, 473–474
process of, 472
training phase, 473
unilateral independence, 474
vocational rehabilitation phase, 474–475
Prosthetist, 463–464
Protected health information (PHI), 105
Proximal arches, natural curves, 172
Proximal humerus cap orthoses, 241
with cross-body strap, 234 , 239f , 241 , 242f
fabrication of, 243b , 244f–246f
Proximal humerus fractures, 234 , 239f
Proximal interphalangeal (PIP) collateral ligament injuries, buddy
straps for, 257f
Proximal interphalangeal (PIP) extension
dorsal gutter orthosis in, 256f
orthosis with lateral support, 257f
prefabricated, orthosis, 260f
Proximal interphalangeal (PIP) flexion contractures, 255
on occupations, 263
serial-static casting (orthosis) for, 285 , 285f
Proximal interphalangeal (PIP) flexion orthoses, examples of, 258f
Proximal interphalangeal (PIP) fracture, with K-wire placement, 290f
Proximal interphalangeal (PIP) gutter orthosis
fabrication of, 259–260 , 260f
 proper fit of, technical tips for, 260
Proximal interphalangeal (PIP) hyperextension block (swan neck)
orthoses, 255f
custom-ordered, 262f
fabrication of, 260–261 , 261f
prefabricated, 262f
proper fit of, technical tips for, 261
Proximal interphalangeal (PIP) injuries, on occupations, 260
Proximal interphalangeal (PIP) joint, 56
Proximal interphalangeal (PIP) orthosis, safety tips for, 260
Proximal palmar crease, 60–61
Proximal radioulnar joint (PRUJ), 213
space, 217
Proximal radius fractures, 214–216
Proximal ulnar fractures, 216
Proximal wrist creases, 61
Purposeful activity, 474
Push MetaGrip orthosis, 175f
R
Radial, term, 53
Radial clubhand, 377–379 , 378f
Radial collateral ligament (RCL) injury (golfer’s thumb), 160t–161t ,
168–169
Radial deficiency, 378
Radial gutter orthosis, 173
Radial gutter thumb immobilization orthosis, 159f
orthotic intervention pattern, 172
pattern, 170 , 170f
wearing, 161
Radial head and neck, fractures (occurrence), 214–216
Radial longitudinal deficiency, 377–379
Radial nerve
motor innervation, 305f
sensory distribution, 307f
Radial nerve injuries, 304–310
mobilization MCP extension orthosis for, 308
orthotic intervention for, 306–310
wrist drop deformity from, 305f
wrist orthotic intervention, 124
Radial nerve lesions, 306t
functional involvement from, 305–306
types of, 304
Radial nerve palsies, 303t–304t , 304
mobilization low-profile orthosis for, 311b , 312f
mobilization MCP extension orthosis for, 309b , 310f–312f
fabrication of, 310
orthotic intervention for, 307 , 308f–310f
static wrist extension for, 312f
Radial sensory entrapment, 303t–304t
Radial styloid, pressure points (adjustments), 140–141
Radial tunnel syndrome, 303t–304t
orthotic intervention for, 307 , 307f
Radialization, 378
Radiocarpal joint, 54 , 56f
Radio-frequency identification (RFID), 470
Range of motion (ROM), 81 , 82f , 365–366
active range of motion (AROM), 366
assessment of, 213–214
documentation of, 436f
hand, 358
loss, prevention, 365
monitoring of, 104
pain-free ROM exercises, 124–131
Reassessments, 72
Reciprocating gait orthoses (RGOs), 427 , 427f
Red wound, 77
Reflex-inhibiting pattern (RIP), impact, 335
Rehabilitation
acute postsurgical phase, 472b
bilateral involvement of, 474
community integration phase, 474–475
control training of, 474
fabrication phase, 473–474
family involvement of, 476
impact on, 476
orientation of, 474
phases of, 472–475 , 472b
preoperative phase, 472
prescription phase, 473–474
process of, 472
training phase, 473
unilateral independence, 474
vocational rehabilitation phase, 474–475
Reinforcement, See Orthosis , Thermoplastic materials
Reliability, 75 , 75t
Repetitive stress, 66
Residual limb
desensitization of, 473–474
prosthesis, suspension, 466
Responsiveness, 75
Resting hand orthosis, 187 , 393–396
acute rheumatoid arthritis, relationship of, 195
adaptation for, 395
antideformity position, 191 , 191f
application of, instructions for, 396
case studies, 206
chronic rheumatoid arthritis, relationship of, 195
components of, 189–190 , 190f–191f
conditions, 196t
diagnostic indications of, 191–201
evaluation of, 396
fabrication of, 201 , 203f
procedure for, 201b–203b , 394–396 , 396b
features of, 394
forearm trough for, 394
form and grading sheet, 209–212 , 209f–212f
forming of, 394
functional position of, 191 , 191f
laboratory exercises, 207–208 , 207f–208f
padding for, 394
pan for, 394
pattern for, 200f , 394
positions, 190–191
precautions for, 201–204 , 395
purpose of, 189
rheumatoid arthritis, relationship of, 195
straps for, 394–395
 thermoplastic material selection for, 394
volar-based, 190f
wearing schedule for, 195 , 395–396
Resting pan orthoses, 187
Rheumatoid arthritis (RA), 131
acute, resting hand orthoses (usage), 195
carpometacarpal (CMC), orthoses, 167–168
chronic, resting hand orthoses (usage), 195
orthoses, 122t , 165f
orthotic intervention, 162
resting hand orthoses, usage of, 195 , 196t
wrist orthosis, fabrication, 131
wrist orthotic intervention, 131
Rigid circular elbow cast, 441–443
application instructions, 441–443 , 442b , 443f–444f
materials for, 441t
rationale for use of, 441
Rigid circular wrist cast, 443–447
plaster material for, 443–446 , 444f–446f , 445t
rationale for use of, 443
semirigid soft cast material for, 446–447 , 447f
Rigid FOs, impact, 420
Role competence, 18–19
Rosenbusch Test of Dexterity, 82
Rotation strap, 397–398
 instructions for, 399
Rotator cuff repairs, 239 , 240f
Roylan D-Ring Wrist Brace, 142f
Rubber bands, 281
S
Saebo orthosis, 275f
SaeboFlex, 342–343
dynamic orthosis, 345f
usage, 346f
SaeboStretch orthosis, 337f
Sammons Preston Rolyan Laced Wrist Support, 142f
Saturday night palsy, 303t–304t , 304
Scaphoid fractures, 160t–161t
occurrence, 169
orthotic interventions, 169
Scapula, muscles, 55t
Scapulohumeral rhythm, 53
Scars, 77
Schultz Pain Assessment, 76
Second-degree injury, 300
Self-adherence, 31
Self-report questionnaires, 76
Semirigid soft cast
casting materials, 440t
for long arm cast, 448–449 , 448f–449f , 448t
for metacarpophalangeal wrist cast, 451 , 451f
and aquaplast, 452f–453f , 452t
removing, 456 , 456f
 for rigid circular wrist cast, 446–447 , 447f
Semmes-Weinstein Monofilament Test, 79
Sensorimotor function, loss (substitution), 366
Sensory functions, 360–362
Sequential Occupational Dexterity Assessment, 82–83
Serial casting, 253 , 254f , 436 , 436f
usage, 343–347
Serial orthotic intervention, wrist orthosis (usage), 133
Serial-static casting (orthosis), 7 , 8f
for proximal interphalangeal flexion contractures, 285 , 285f
Serial static elbow extension orthosis, 219f
Serial-static mobilization orthoses, 379
Serial-static orthotic prescription, 277 , 277f
Serial wrist orthotic intervention, 134f
SF-36, 83
Shoulder
anatomical and biomechanical consideration of, 233–234 , 234f
joint, 53
ligaments and tendons, for stability of, 53
muscles, 55t
orthoses for, 233–250 , 246b
case study, 248
common diagnoses of, 234–241
evidence-based practice, 235t–238t
figure-eight, 240 , 240f–241f , 242–246
 form and grading sheet, 249–250 , 249f–250f
laboratory exercises, 248
sling with support strap, 234 , 239f
subluxation, 234–239
Showa Atlas lightweight nitrile-coated garden glove, 357f
Silver ring orthoses, evidence-based practice, 253t
Simian hand, 316 , 319f
Siris Silver Ring Trigger Finger, usage, 357f
Siris Swan Neck, 363f
Sixth-degree injury, 301
Skeletal system, 362–363
Skier’s thumb, 160t–161t , 168
Skin, 77
care, 369
folds, perspiration (accumulation), 366
functions, 365
integrity, protection, 366
maceration, monitoring for, 102
mechanics of, 68–69
protection, stockinette (application), 340f
soft tissue, 68–69
Small finger traction orthosis, 289f
Social environment, 17 , 17f
Socket, 467
fit, intimate, 467
Soft cast supplies, 440t
Soft Neoprene knee sleeve, 423f
Soft orthoses, 365
Soft thumb orthosis, 397
fabrication of, procedure for, 398b
with loop, 399f
Soft tissue
contracture, casting for, 433
inflammation, orthosis, 160t–161t
length, maintenance, 336
Sorry Works! Coalition, disclosure/apology educational programs, 107
Spastic cerebral palsy (CP), casting in, 459
Spasticity, 385
casting for, 433
complexity, 332
definition, 331–332
development, 337
dynamic nature, 336–337
evidence-based practice, 333t
fiberglass casting procedures, 346–347
management, serial casting (usage), 343–347
materials/tools/equipment, 346
plaster casting procedures, 346
provision to manage, 331–355
case studies, 350–351
 form and grading sheet, 352–355
laboratory exercises, 351
rehabilitative intervention, 332
Spherical grasp, 62 , 64f
Splint
ASHT definition, 2–3
definition of, 2–3
pattern, 50 , 50f
Sprains
finger proximal interphalangeal, 255–256
buddy straps for, 256 , 257f
dorsal gutter in, 256 , 256f
orthoses for, 256 , 257f–258f
ligament, grades of, 256t
wrist orthotic intervention, 133
wrists, orthoses, 122t
Stance control knee joints, mechanisms, 424
Static immobilization orthosis, 7 , 8f
Static lumbrical blocking orthosis, 288 , 288f
Static progressive “come along” orthosis, 221–222 , 223f
Static progressive elbow extension, 220–222
Static progressive elbow flexion, 221–222
orthosis, 221f
Static progressive elbow orthosis, turnbuckle (usage), 221f
Static progressive orthoses, 7–8 , 9f
Static-progressive approach, for composite finger flexion, 289–291 ,
291f
Static-progressive finger flexion orthosis, form and grading sheet,
295–297 , 295f–297f
Static-progressive mobilization orthoses, 379
Static-progressive orthosis, 278 , 281–282
Static wrist extension, dorsal base of, pattern for, 312f
Steroid injection, orthotic intervention, 161–162
Stockinette
application, 340f
for casting, 440t
Strapping
material, 367
in pediatric orthotic fabrication, 391–392 , 392f
pronation, 399f
supination, 399f
usage, See Thermoplastic materials
Straps
application of, 226f
for resting hand orthosis, 394–395
rotation, 397–398
Strength, assessment, 81 , 82f
Stress, 66
degree and duration of, 66
direction of, 66–67 , 66f–67f
repetitive, 66
Stretch reflex, hyperactivity, 331–332
Structural orthotic components, 416
Subcutaneous method, 218
Submaximal range, 438
Submuscular method, 218
Subtalar joint, 414–415
Superficial palmar aponeurosis, 56 , 56f
Superior labrum anterior to posterior (SLAP) repair, labrum tear, 239–
240 , 240f
Supination strapping, 399f
Supinator strap, 386f
Surgical nerve repair, 301
Swan neck deformity, 164f , 254
anatomy of, 254f
identification, 163
occupations and, 262
orthoses for, 254 , 255f
Swing-to gait, 426
Swivel Walker, 426
Syndactyly, 377 , 380–381 , 381f
release of, postsurgical, 380–381
T
Tactile label markers, 361f
Tactile sensation, 362
Targeted muscle reinnervation (TMR), 471
Task-oriented approaches, 342–343
Task-oriented intervention, 342–343
Technical analysis form (TAF), 415
Tendinopathy
substitution patterns/muscle imbalance, 124
wrist orthotic intervention, 124–131
Tendinosis
orthoses, 122t
wrist orthotic intervention, 124–131
Tendons
assessment of, 79
shoulder stability and, 53
Tennis elbow, 219
Tenodesis orthosis, 276f
for radial nerve injury, 308 , 309f
Tenosynovitis
de Quervain, 156
acute phase, 160–161
orthotic intervention, 160–162 , 164f
presence (assessment), Finkelstein test (usage), 162f
 result, 160
thermoplastic fabric orthosis, 365f
thumb orthotic intervention, efficacy, 161–162
orthoses, 122t
wrist orthotic intervention, 124–131
Tensile strength, 79
Tension, line of, 280f
Terminal device (TD)
body-powered terminal device, grip strength, 468
force, transmission to, 466f
impact of, 470–471
rotation of, 462–463
voluntary-opening and voluntary-closing, 468–469
Terminal extensor tendon, 251–252
Terrible triad injury, 217
The Joe Cool Company, 400
Thenar area, formation, 139f
Thenar crease, 61
Thenar eminence, 59
Thenar web space, rolling (problem), 141f
TheraKool Breathable Neoprene Thumb Spica, 336–337
Therapists, experienced
pathways of service for, 487b
professional development for, 486–487
Thermoplastic materials, 29–30
adjustments, 37
bonding, 31
client, positioning, 36
color, 32
components, 416–417
conformability, 31
considerations, 30–31
content and properties of, 30–32
contour and, 30–31
cooling, 140
process, 37
cutting, 35–36 , 36f
draping, 30–31 , 340f
durability, 32
edge finishing, 40
elasticity, 31
excess, cutting, 137f–138f
finish, 32
flexibility, 31
hand-forearm pattern, transfer, 338–339
handling characteristics for, 30–31
heating, 35 , 35f , 391
high-temperature thermoplastics, usage, 416–417
memory, 30
padding, 38–40 , 39f , 39t
 pattern, fitting, 32–34 , 34f
perforations, 32
performance characteristics, 31–32
plastic content, characteristics, 30
pressure areas, avoiding, 38–40
property, 33t–34t
reinforcement, 40 , 40f
rigidity, 32
selection of, for resting hand orthosis, 394
self-finishing edges, 31
strapping, 37–38 , 38f
thickness, 32
thumb patterns, transfer, 338–339
thumb web space, overlap, 173f
trimming, 340f
Thermoplastic orthosis (orthoses)
impact, 357f
support, 166f , 175f
Thigh, soft tissue (grasping), 425
Third-degree injury, 300
Thoracic outlet syndrome (TOS), 311–312
Three jaw chuck pinch, 61
3-D printing, of upper limb prosthesis, 471–472
3M Scotchcast Soft Cast, for casting, 440t
Three-point force systems, 413
 usage, 414f
Three-point pressure, 64 , 64f–65f
Three-point proximal interphalangeal extension low-profile orthosis
fabrication of, 262–263
materials for, 262
procedure for, 263 , 264f–265f
proper fit of, technical tips for, 263
safety tips for, 263
Thumb carpometacarpal Push Metagrip orthosis, 357f
Thumb orthosis (orthoses), 255 , 379 , 380f
coated material, usage, 368
conditions, 174
design/comfort, 174–175
fabrication, tips/precautions, 173–174
fit, technical tips, 172–173
materials, 174
Thumb-in-palm deformity, wrist cast with thumb for, 449
Thumbs
adhesive Velcro, application, 344f
aplasia of, 379t
carpometacarpal (CMC) immobilization orthosis, 358
pattern, 166f
component
molding, 344f
spot-heating/bonding, 344f
deformities, 163–164
dorsal hand-based thumb immobilization orthosis, fabrication, 165
dorsal thumb immobilization orthosis, 158f
extensor weakness, 345f
fit, ensuring, 170f
hypertonicity, 157 , 157f
hypoplastic, 377 , 379 , 379f–380f , 379t , 380b
immobilization, diagnostic indications, 157–169
immobilization orthosis, 156–186 , 176b
case studies, 185–186
components, 159f
fabrication, 169–171
features, 157
form and grading sheet, 181–184 , 181f–184f
IP mobility, impact, 173
laboratory exercises, 179–180 , 179f–180f
requirements, conditions, 160t–161t
impact, 174
interphalangeal (IP) joint
lateral instability, 164f
Siris Swan Neck, 363f
stabilization, tripoint figure-eight design (impact), 363f
involvement of, median nerve injuries with, orthotic intervention
for, 320
joints, 56–57
 positions, monitoring, 172
metacarpophalangeal (MCP) joint, pressure (provision), 171f
metacarpophalangeal (MCP) radial/ulnar deviation restriction
orthosis, 168
metacarpotrapezial or CMC joint, 56–57
mobility, allowance, 116
orthotic component, spot-heating/bonding, 344f
orthotic intervention
evidence-based practice, 163t
functional/anatomic considerations, 157
osteoarthritis, 363
patterns, transfer, 338–339
piece, thermoplastic (trimming), 340f
post
fabrication, 173
interphalangeal (IP) flexion, 173f
molding, 173
radial gutter thumb immobilization orthosis, 159f
short opponens orthosis, 345f
thumb-hole orthosis, volar wrist immobilization pattern, 134f
tip, touching, 171f
tracing, 339f
traumatic injuries, 160t–161t
trough, 190 , 190f
volar thumb immobilization orthosis, 158f
 web space, thermoplastic material (overlap), 173f
web spacer orthosis, for median nerve injuries, 320f
Tight muscle, in casting, 439
Torque, 65–66 , 278–279 , 279f
definition of, 279
moment arm in, 279f
transmission orthoses, 6 , 7f
Total active motion (TAM), 81
Total contact, 414
equation, 414
Total passive motion (TPM), 81
Touch, sensory functions, 361–362
Trace pattern/cut out, 224f
Traction orthosis, for complex proximal interphalangeal fracture, 289 ,
289f–290f
Traction outrigger, conforming to digit, 290f
Traditional intervention techniques, for contractures, 433
Traditional shoulder sling, 234 , 239f
Transhumeral amputation, 462
Transradial amputation, 462
Transverse humeral ligament, 234
Transverse retinacular ligament, 251–252
Trauma, resting hand orthosis, usage of, 196t
Treatment settings, 358
Tremors, neurological conditions (impact), 363
Triceps repair, 217
Trigger finger, 254–255 , 380
on occupations, 266
Oval-8, example, 357f
Trigger finger orthosis, 255 , 255f
fabrication steps for, 267f
finger-based, fabrication of, 263–266
prefabricated, 266
proper fit of, technical tips for, 266
safety tips for, 266
Trigger lock, 425f
Tripod jaw chuck pinch, 61
Tripoint figure-eight design, impact, 363f
TUBS (Traumatic etiology, Unidirectional instability, Bankart lesion,
whereby Surgery is required), 234
Turnbuckle, usage of, 221f
Two-point discrimination
American Society for Surgery of the Hand, 79
somatosensory function, 361
Two-point pressure force, 6
U
Ulnar, term, 53
Ulnar collateral ligament (UCL) injury, 157
athletes, hybrid orthosis, 168
gamekeeper’s thumb, 168
orthoses, 168–169
protective orthosis, 169f
skier’s thumb, 168
treatment protocols, 168
Ulnar compression syndromes, 311–312
Ulnar gutter wrist immobilization orthoses, 320
Ulnar nerve
compressions of, 312
orthotic intervention for, at elbow, 314–315 , 314f–315f
conditions, grading system for, 313
entrapment, at wrist, 303t–304t
lesions of, 312 , 313t
motor innervation of, 314f
pressure (decrease), Heelbo padded soft elbow sleeve protector
(usage), 362f
sensory distribution of, 307f
Ulnar nerve injuries, 311–316 , 314f
claw hand deformity caused by, 313f
mobilization orthoses for, 316 , 317f
 orthotic interventions for, 314–316
fabrication of, 316b
figure-eight, 317f
median and, 320 , 321f
wrist- and hand-based, 315–316 , 315f–316f
Ulnar tunnel syndrome, 303t–304t
Ulnar wrist immobilization
orthosis, 118f , 119
pattern, 135f
Ulnarization, 378
Unilateral double-upright HKAFO, 427f
Unilateral independence, 474
Upper extremity
assessment for, 72
compression neuropathies in, 303t–304t
orthoses, OT fabrication, 413
spastic, cerebral palsy and, 385
Upper extremity amputation
causes for, 462
client, 463
general knowledge of, 462–463
levels of, 463f
occupational therapist, 464
prosthetist, 463–464
reasons for, 462
 secondary conditions of, 475
team members and, 463–464
Upper extremity casting
assessment for, 436–438
functional use, 437–438 , 438t
grip strength, 437
manual muscle test, 437
Modified Ashworth Scale (MAS), 437 , 437t
postural control, 437
range of motion, 436–437
sensibility, 437
skin condition, 437
influence of, 433–436
Upper extremity compression neuropathies, 302 , 303t–304t
Upper extremity conditions, pediatric, 377–388
Upper extremity prosthetics, 461–481 , 477b
activity-specific prosthesis, 465
body-powered prosthesis, 465–469
case studies, 481
externally powered prosthesis, 469–471
intervention (children), 476
no prosthesis, 464
options, advantages and disadvantages of, 465t
passive functional aesthetic prosthesis, 464–465
rehabilitation, marketing strategies/recommendations, 477–478
Upper extremity rehabilitation
entry-level practice in, 482–483 , 483b
professional development, 482–488
for experienced therapists, 486–487
Upper motor neuron lesions (UMNLs), 332
flexor contractures, propensity, 337
manifestations, 332
Upper quarter, inspection, 73–74
V
Valgus angulation (carrying angle), 213–214
Validity, 75 , 75t
Valpar Component Work Samples (VCWS), 82
Vascular status, 81 , 81f
Veins, examination of, 77
Velcro
adhesive, application, 344f
tabs, 281–282
heating, 137f–138f
for static-progressive tension, 283f
Verbal analog scale (VeAS), 76
Viscoelasticity, 68
Vision, sensory functions, 360–361
Visual analog scale, 76 , 76f
Vocational rehabilitation phase, 474–475
Volar, term, 53
Volar forearm hand immobilization orthosis, 338f
Volar forearm-based orthosis, 172
orthotic intervention pattern, 172
pattern, 172f
Volar hand-based extension orthosis, 200f
Volar orthosis
dorsal orthosis, combination, 169f
 fabrication, 133
Volar plate (VP), 251–252
Volar support, traction with, 290f
Volar thumb immobilization orthosis, 158f
pattern, 169f
Volar wrist immobilization
orthosis (orthoses), 117f , 118–119 , 320
components, identification, 121f
dependence, 118–119
detailed pattern, 135f
metacarpal bar, positioning, 138
pattern, 134–135
thumb-hole orthosis, 134f
thumb-hole orthosis, 134f
Volar-based forearm trough, 189
Volar-based resting hand orthosis, 190f
W
Wallerian degeneration, 299–300
Wartenberg neuropathy, 303t–304t
orthotic intervention for, 307
Wartenberg sign, 314
Wartenberg syndrome, 305
Water height, adequate, 35
Wear post fasciectomy, dorsal static protective orthosis for, 199f
Wearing
See also Orthosis
schedule, 45–46 , 369 , 369b
Web spacer, 380–381
Weight
desensitization of, 473–474
transfer, 418
Well-being, 19
Wellness, 19
Working memory impairment, 359
Wounds
black, 77
color, 77
contracture prevention, 472
draining/infection, 101
examination of, 77–78
 fibroblastic (reparative) phase, 78
healing, 472
facilitation of, 276–277
inflammatory (exudative) phase, 78
maturation (remodelling) phase, 78
myoplastic closure of, 472
open, 78
red, 77
Wrist cast
metacarpophalangeal, 450–451
to increase flexion, of metacarpophalangeal and proximal
interphalangeal joints, 452–453
materials for, 451 , 451t
rationale for use of, 450–451
semirigid soft cast for, 451 , 451f
rigid circular, 443–447
plaster material for, 443–446 , 444f–446f , 445t
rationale for use of, 443
semirigid soft cast material for, 446–447 , 447f
with thumb, 449
materials for, 449 , 450t
polyester soft cast for, 449 , 450f
rationale for use of, 449
Wrist drop deformity, from radial nerve injury, 305f
Wrist immobilization orthosis (orthoses)
 circumferential wrist immobilization orthosis, 118f , 119
conditions, 122t
diagnostic indications, 120–121
dorsal wrist immobilization orthosis, 117f , 119
fabrication, 116 , 134–141
features, 119–133
lumbrical positioning, 123f
molding, position, 137f–138f
provision, consideration, 123
serial static approach, usage, 120–121
sprains, 133
troubleshooting, 140–141
ulnar wrist immobilization orthosis, 118f , 119
volar wrist immobilization orthosis, 117f , 118–119
Wrist immobilization pattern, placement, 137f–138f
Wrist orthotic intervention, 121–124
complex regional pain syndrome type I (reflex sympathetic
dystrophy), 133
evidence-based practice, 125t–130t
patient safety considerations, 136t
radial nerve injuries, 124
rheumatoid arthritis, 131
serial wrist orthotic intervention, 134f
ulnar nerve injury, 315–316
wrist, 133
Wrist orthotic provision, safety considerations, 135
Wrists
alignment, maintenance, 116
degrees of freedom, 54–55
extension, 339
joints, 54–55
contracture, 133
metacarpophalangeal (MCP) joint extension, loss of muscle
function, 275
molding, 341f
muscles of, 58t
extrinsic, 58b
intrinsic, 58–59
orthoses, 115–155 , 143b
case studies, 147–148
evidence-based practice, 192t–194t
examples, 188f , 188t
form and grading sheet, 152–155 , 152f–155f
laboratory exercises, 149–151 , 149f–151f
strapping system, 142f
positioning, 121
pressure areas, 132f
sprain, orthoses, 122t
stability, 54–55
close-packed positions, 54–55
upper extremity compression neuropathies in, 303t–304t
Y
Yoke orthosis, for middle metacarpophalangeal (MCP) joint, with
radial tunnel syndrome, 307 , 307f
Z
Zigzag deformity, orthosis (usage), 132f
Zipper orthosis option, 120f
Zones of the hand, 53 , 53f
tendon injury, 54t
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