Definition

OT practitioners traditionally used the term splint to describe temporary devices fabricated to support a part of the body, whereas the term orthotic was used to refer to a more permanent device. To eliminate confusion in the use of terminology among orthotists, OT practitioners, and insurance companies, OT practitioners are now encouraged to use the term orthosis to refer to temporary and permanent devices that immobilize, restrain, or support a part of the body.² Therefore, this chapter will use the terms splints and orthoses interchangeably.

The purpose of an orthosis/splint is to protect, correct, or assist a joint, limb, or muscle to increase functional performance.⁵ For example, an orthosis might protect an injured wrist from increased pain when a child or adolescent is playing or prevent deformity occurring during sleep. An orthosis might help support a child’s wrist to make writing more efficient.

Orthoses may be classified as static or dynamic. Static orthoses prevent movement, promote functional position, and prevent deformity. Dynamic orthoses allow children to move the joints and assist with movement. Table 27-1 provides additional definitions of the types of orthoses in accordance with the Centers for Medicare and Medicaid (CMS).

Kinesio taping refers to a specialized taping procedure that is used to provide support to muscle and joint structures in the upper extremities, lower extremities, trunk, neck, and face. For example, taping may be used to cue a child to keep the shoulders depressed and the scapulae in the correct position so that he or she may use the arms more fully.

General considerations

Orthoses may stabilize, support, or protect body parts enabling children to use their hands (or legs in the case of lower extremity orthoses) during activities of daily living (ADLs), education, play, and social participation. OT practitioners consider many factors before designing and fabricating an orthosis to help a child engage in daily occupations. The OT practitioner considers the child’s age, diagnosis, motivations, interests, habits, and routines, along with the context in which the orthosis will be worn. Context refers to the setting in which the child belongs, such as school, home, and his or her cultural, physical, temporal (i.e., time in child’s life), and social environments.¹ The OT practitioner also considers the child’s physical abilities (including range of motion [ROM], muscle tone, strength, endurance, and structural appearance). The OT practitioner uses clinical reasoning to determine the best solution for the child. For example, the OT practitioner may decide that a simple design is best to ensure proper wear and compliance or that a prefabricated orthosis will meet a particular child’s temporary needs, whereas another child may need a custom-made orthosis for long-term wear.

Examples of the use of orthoses include the following:

• Orthoses sometimes provide children with external support necessary to improve ROM or to help the child compensate for lack of ROM. For example, a universal cuff allows a child who has a hand deformity to hold a spoon.

• Children who experience joint pain, such as children who have juvenile rheumatoid arthritis (JRA), may benefit from orthoses that will help them rest their joints. In this case, the purpose of the orthosis is to help children maintain ROM but rest the joint adequately during inflammatory periods of this disease (Figure 27-1).

• Children with muscle tone abnormalities may benefit from external support of the joints, which will provide them with stability that they typically lack. For example, an elbow orthosis may stabilize the elbow joint allowing the child or adolescent to focus on using his or her hands for holding objects more easily. A thumb splint may provide enough tactile input, sustained over time to open a fisted hand enough so that the child is able to pick up objects in the palm.

OT practitioners consider typical child and adolescent development (e.g., gross and fine motor skill development, age, and occupational roles) when fabricating an orthosis. (See Table 27-2 for a description of upper extremity development.) For example, 8-month-old infants crawl on their hands and knees. Therefore, the OT practitioner making an orthosis for this infant wants to be sure that the splint allows the child to crawl.

Orthoses are customized to fit the individual and meet his or her occupational needs.^2,3,9 By positioning a limb in a functional position, the child or adolescent may engage in meaningful occupations such as play and ADLs. OT practitioners use their knowledge of anatomy, kinesiology, the child’s medical condition(s) along with information about the child’s age, developmental level, contexts, and, most importantly, the purpose of the orthosis. The OT practitioner uses all of these factors for clinical reasoning in order to design and fabricate the device. Generally, orthoses are recommended to improve function, promote proper position, and ensure hygiene.

Goals of orthosis fabrication

OT practitioners fabricate orthoses based on principles of anatomy and kinesiology. Box 27-1 provides an overview of these principles.

Use of orthoses to improve function

CASE Study

Kira is a 4-year-old girl with cerebral palsy (CP). She has decreased wrist stability, which makes it difficult for her to hold utensils. She is able to sit at a table but has poor coordination and is continuously dropping her spoon. A wrist extension splint was fabricated for Kira to help her hold the spoon (Figure 27-2).

A supported wrist orthosis was designed for Kira to wear while eating. This orthosis provides Kira with the wrist support she needs to increase hand control and be successful in this important ADL. The OT practitioner uses the principle that external stability may increase mobility. In this case, the orthosis allows Kira to use her hand and fingers to grasp the spoon. Therefore, creating stability around the wrist or elbow with the use of the orthosis may promote hand function.

A functional orthosis can substitute for weak or absent muscles, which may be caused by peripheral nerve dysfunction, neuromuscular disorders (e.g., CP), or spinal cord injuries.^2,4 Other examples of functional orthoses include those designed to help the child hold a pencil, toy, or eating utensil.

Several types of orthoses are used to improve hand function.

• Serial static orthoses immobilize joints in a stationary position.⁶ The serial static orthosis applies continued force to maximize the length of the tissue and is worn for long periods allowing the tissue to adapt. Once the tissue has accommodated to the stretch, a new orthosis may be made, or the old orthosis is remolded, to hold the tissue at a new maximum length.⁶

• Dynamic orthoses apply force to one or more joints. These orthoses include a rubber band, pulley, spring, screw, hook, elastic, or other outriggers to provide the continuous force.⁴ These types of orthoses are not worn as long as the serial orthoses. The force is continuous while the orthosis remains on, but the orthosis is removed periodically.⁴

• Static progressive orthoses are used to apply adjustable static force. The orthosis is applied as the joint is positioned at its maximum. The force is then adjusted when the tissue response allows repositioning to a new length.⁴

Three stages of healing follow tissue injury: (1) inflammatory (where the wound prepares to heal), (2) fibroplastic (the tissue structure is rebuilt), and (3) remodeling (configuration develops).⁷ Edema can occur during any of these stages due to lack of functional use, which leads to stiffness and adherence and therefore continued inactivity.⁴ Edema, or excess fluid build up, may develop due to increased capillary permeability, which results in leakage of fluid and protein into the tissue spaces.¹³

Elevation, active motion, gentle external massage, and compression may all help minimize edema. orthoses provide a form of compression and may decrease edema, reduce pain, and encourage tissue repair.¹³ Applying orthoses during the early phase of healing allows the necessary rest and compression, as well as positioning, which protects the healing structures while maintaining a balanced, functional position.¹³ Some health disorders cause edema and inflammation as well. Orthoses are an effective way to mobilize the stiff hand, but orthoses are most effective when combined with an exercise program.⁴

Use of orthoses to promote proper position

CASE Study

Timmy is an 8-year-old boy who is developing contractures (limitations in movement caused by soft tissue shortening, which may result in a “stiff” or fused joint that is unable to move) in his hands secondary to juvenile rheumatoid arthritis (JRA). His wrists are beginning to deviate in an ulnar direction; redness and swelling are present around the joints.

If a joint remains in an abnormal position, the risk of fusion and deformity increases, which may lead to limited use of the hands. Early use of an orthosis protects the affected joint and helps maintain the length of the soft tissue. The orthosis applies a continuous stretch to the muscles and promotes the performance of daily occupations.

Static orthoses serve the following purposes:

• They decrease or prevent contractures by maximizing range of motion (ROM), thus preventing muscle and tendon shortening.

• They provide stability to an unstable joint by giving external support to the joint.

• They improve joint alignment and prevent the progression of deformity. An orthosis may place the child’s or adolescent’s hand in the proper anatomical position.

• They provide rest to assist the healing process. (An orthosis will, for example, hold the hand in proper anatomic alignment, allowing the soft tissues to heal and edema and inflammation to diminish.⁴)

The occupational therapist evaluated Timmy’s hand function. The occupational therapist and OTA together designed a wrist extension orthosis with ulnar deviation block for Timmy (Figure 27-3). The wrist extension orthosis held Timmy’s hand in slight wrist extension while providing a passive stretch to the wrist flexors. He wore his wrist extension orthosis with 2-hour increments to eliminate joint stiffness. See Figure 27-4 for Timmy’s schedule for wearing the orthosis.

Some children require orthoses to protect them from injuring themselves. The OT practitioner must consider the safety of providing such orthoses and the consequences to the child and to others.

Use of orthoses to improve hygiene and prevent skin breakdown

CASE Study

Matt is a 10-year-old boy with pervasive developmental disorder (PDD). He continually picks at his scabs, increasing the risk of infection. The scabs fail to heal and bleed continuously, and they are beginning to scar. An orthosis is needed to protect Matt’s fragile skin. The occupational therapist working with Matt decided on providing Matt with a protective covering for his skin. The OTA, under the supervision of the occupational therapist, fabricated a covering made of stockinette and terry cloth to provide comfort and also cover the existing scabs. However, after several weeks, it became apparent that Matt was able to pick at the scabs after biting through the covering. After collaboration with the occupational therapist, the OTA applied orthotic material over the stockinette so that Matt would be unable to pick at his scabs (Figure 27-5).

Using orthotic devices to prevent a child or adolescent from self-abuse and interfering behaviors or after a surgical procedure may be an adjunctive intervention provided by the OT practitioner.2–4 For example, an orthosis can protect a postoperative area before complete healing has occurred.

CASE Study

Alex is a 10-year-old boy who has spastic–quadriplegic cerebral palsy. He keeps his left hand fisted with an in-dwelling thumb. His parents and teachers are concerned about his hands being sweaty and smelly because of the continuous fisting. The skin on Alex’s hands is flaking, and food is being lodged in his hands. His fingernails have grown long and are digging into his palm. Furthermore, when Alex’s hand is opened, his palm appears red and is bleeding. An orthosis is therefore needed to protect the palm from long and jagged fingernails.

The OTA and the occupational therapist collaborated to design a palm protector orthosis for Alex to improve hygiene and prevent his fingernails from cutting into his palm. He wore the orthosis during his waking hours, taking it off only for bathing and grooming. At night, Alex’s hands were sufficiently relaxed and open, so he did not require a night orthosis.

An orthosis can be designed to help prevent or improve hygiene problems.5–7 For example, a spastic hand that remains fisted is at high risk for skin breakdown. The inability to extend the fingers makes nail clipping difficult, and long or sharp fingernails can cut the skin, which may lead to infection. Orthoses are frequently fabricated to protect the palm and decrease the risk of skin breakdown (Figure 27-6). For example, an elbow extension orthosis may prevent a child from scratching his face.

Considerations for providing orthoses to children and adolescents

Prior to designing and fabricating an orthosis for a child or adolescent, the OT practitioner considers the occupations in which he or she engages and the purpose of the orthosis for that child. Understanding the desires of the client helps the OT practitioner design an orthosis that is appealing and meaningful to the client, thereby increasing the chances that the orthosis will be worn. Compliance in wearing the orthosis is clearly related to how well the OT practitioner matches the interests and goals of the client. Consequently, the OT practitioner also considers the developmental and functional level as well as the ability to don and doff the orthosis. During consideration of the physical status, the OT practitioner examines skin integrity, edema, ROM, muscle tone, and current functional status. The OT practitioner must clearly evaluate how the client moves and functions to design an orthosis that does not interfere with the client’s own techniques for moving. Since wearing an orthosis is key to the success of the intervention, OT practitioners use a variety of questions to guide decisions on orthoses, such as the following:⁷

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