Upper limb orthosis

1. Upper limb orthosis - HETVI BHATT

2. Contents: Introduction Objectives of upper limb orthosis Nomenclature Classification Biomechanics of orthosis General principles Special principles Assessment of upper limb orthosis Description of upper limb orthosis Recent advances

3. Introduction Mechanical device- anatomical and functional position Orthos – to correct or maintain straight Any externally device used to modify structural and functional characteristics of the neuromuscular skeletal system Physiotherapist + orthotist

4. Categorized : Upper limb orthosis Trunk orthosis Lower limb orthosis

5. Objectives of upper limb orthosis : Protection : - stabilization Dynamic control 2) Correction 3) Assistance

6. To immobilize a body part to promote tissue healing Prevent contractures Increase ROM Correct deformities Strengthen muscles Reduce tone Reduce pain Restrict motion to prevent harmful postures

7. Nomenclature : On basis of joint they cover the function they provide condition they treat by appearance name of the person who designed them

8. Mainly three systems: 1) International Organization for Standards(ISO) which gives anatomic region wise names 2) 1992, American Society of Hand Therapists published ASHT splint classification system (SCS) which gives function and body part wise. In that, numbering system – ‘type’ 3) McKee and Morgan

9. Common name ASHT splint classification system IOS McKee and Morgan Humeral fracture brace Non articular splints- humerus Not applicable Circumferential non- articular humerus stabilizing Tennis elbow splints or brace 45 degree elbow flexion immobilization type 1[1] Shoulder- elbow – wrist – hand orthosis Circumferential non- articular proximal forearm strap Duran splint, post operative flexor tendon splint Wrist and finger flexion immobilization; type 0[4] WHO Dorsal forearm based static MCP-IP protective flexion and MCP extension blocking orthosis Thumb spica splint Thumb MCP extension immobilization type 2[3] WHFO Volar forearm- based static wrist thumb orthosis

10. Classification : On basis of anatomical regions: Shoulder and arm orthosis Elbow orthosis Wrist orthosis Hand orthosis

11. Based on function: Supportive Functional Corrective Protective Prevent substitution of function Prevent weight bearing Relief of pain

12. Based on design: non- articular Static Serial static Static motion-blocking Static progressive Dynamic Dynamic motion-blocking Dynamic traction splints Tenodesis Continuous passive motion orthoses Adaptive or functional usage

13. Non- articular splint – gel shell splint

14. Static – wrist splint for carpal tunnel syndrome, with the wrist position 0-5 degree of extension, distal palmar crease free to allow MCP motion

15. Static motion – blocking – swan neck splint

16. Static progressive – forearm based splint with both static line pull and MERIT component for increasing MCP flexion

17. Dynamic – capener splint for increasing joint extension in the proximal IP joint of the finger

18. Dynamic motion-blocking – Kleinert post operative splint for flexor tendon repairs

19. Dynamic traction splints- schenck splint for intraarticular fracture

20. Tenodesis – Rehabilitation Institute of Chicago tenodesis splint to achieve functional pinch

21. Biomechanics of orthosis External force + moments on body Internal forces Mainly 4 biomechanical principles: Control of moment across a joint Control of normal forces across a joint Control of axial forces across a joint Control of action of ground reaction force

22. General principles: Uses of force Limitation of movements- pain Correcting the mobile deformities Fixed deformity Adjustability Pressure reduction Heat

23. 8) Weight 9) Maintenance and cleaning 10) Application 11) Sensation 12) Gravity 13) Comfort 14) Cosmesis

24. Special principles: Principle of Jordan May assist with residual motor power or substitute for absent motor power Prehension force must be adequate Only one action Operation of electrically powered orthosis Tactile sensation

25. Assessment : Subjective assessment: Comprehension Complaints – pain, performance, appearance Previous orthotic experiences Gadget tolerance The goals Economic consideration

26. Objective assessment: Type of paralysis and prognosis Limb alignment Joint range Muscle power Coordination and spasticity Sensory status Skin Manual dexterity Vision Other disabilities

27. Description of orthoses : 1) Calvicular orthoses : Regional name : shoulder orthosis Common names : figure of four harness, clavicular brace/ harness

28. Functions Indications Restrict motion to promote tissue healing Clavicular fractures Improve posture Forward shoulder posture TOS Reduced scapular myofascial pain Cumulative trauma disorder Increase/maintain PROM Pectoral contractures

29. Placement : - Material goes over clavicles, under arms and crosses over high thoracic spinous processes .   Biomechanical efficacy: - Restrict movement of the clavicle and to some extent inhibit scapular protraction while allowing free movement at the GH joint . Materials : - Webbing straps - Padding and velcro - Prefabricated orthoses often used.

30. 2) Arm sling Regional name: shoulder orthosis Common names: figure of eight slings universal sling Nothern ring sling Cuff sling Hemi sling Orthopaedic sling Flail arm sling Homemade Bandanna- Type sling Glenohumeral support Hook hemiharness Rolyan hemi Arm sling(vertical arm sling)

31. Functions indications Immobilize to promote tissue healing AC joint injury Scapular, humeral fractures PO shoulder repair/arthroplasty PO tendon,artery, or nerve repairs Rotator cuff injury Bicipital tendinitis Prevent overstretching of GH musculature/ligaments Brachial plexus lesion Decreased shoulder pain related to arm distraction and shoulder-hand syndrome Upper motor neuron lesion: hemiparesis with subluxation Keep hand and forearm elevated to reduce oedema

32. Placement : Most slings support the forearm with the elbow flexed, shoulder internally rotated and arm adducted. - The Rolyan hemi arm sling supports the humerus and allows the elbow and forearm to be free by using a humeral cuff with figure of eight suspension. - The hook hemiharness has two humeral cuffs connected by a posterior yoke and abduct each arm slightly while allowing the elbow and forearm to be free.

33. Biomechanical efficacy : - Slings may be static or dynamic. - Dynamic slings use elastic straps and are designed to allow some motion of the forearm while supporting the arm. - The wrist should be supported by the sling to prevent wrist drop if there is distal weakness. - Hand should be higher than the elbow to decrease the oedema. - Care must be taken to mobilize the shoulder SOS possible to prevent adhesive capsulitis .

34. Materials : - Cloth - Webbing - Elastic - Metal ring/ fastners - Velcro - Prefabricated slings are often used.

35. Contraindications: - Slings have fallen over out of favour with a neurodevelopment treatment approach to UMN lesion because they are thought to encourage flexion synergy, increase flexor tone, and promote contractures. - The Rolyan hemi arm slings or the hook hemiharness may not approximate the GH joint in a large patient.

36. 3) Arm abduction orthosis : - Regional name: shoulder elbow wrist hand orthosis - Common name: airplane splint

37. Functions Indications Immobilize to promote tissue healing Axilary burns Post operative shoulder fusion Post operative scar release Shoulder dislocation Increase PROM by soft tissue elongation via low load prolonged stretch( serial static splinting) Burns contractures

38. Placement : - Medial arm and lateral trunk with weight of arm borne primarily on the iliac crest or lateral trunk. - May be one piece or separate waist piece with arm attachment . Biomechanical efficacy: - The shoulder should be positioned in abduction with the degree determined by pathology. - Care should be taken not to overstretch skin, nerves or vascular structure .   Material : - Casting - Thermoplastic -Metal -Pillow - Padding - Strapping - Velcro

39. Functional arm orthosis Arm suspension sling – deltoid aid Balanced forearm orthosis - gun slinger Arm supports- wheelchair arm trough

40. Nonarticular fracture orthosis - humeral fracture brace

41. 4) Elbow- forearm wrist othosis : Regional name : elbow wrist hand orthosis Common name : sugar-tong splint

42. Functions Indications Immobilize elbow/forearm/wrist to promote tissue healing CTD Forearm fractures Post operative elbow arthroplasty Post operative ulnar nerve transposition Placement : - Circumferential with elbow in 90 of flexion and forearm/wrist in neutral.   Biomechanical efficacy: - Orthosis should totally restrict elbow, wrist and forearm AROM yet should allow full active use of all digits.   Materials : - Thermoplastics - Strapping - Velcro

43. 5) Elbow or wrist mobilization orthoses : Regional name: elbow orthoses or wrist orthoses Common name: - Dynamic elbow - Wrist flexion/extension splint - Dynasplint - Ultraflex splint - Static progressive splint - Phoenix wrist hinge - Turn buckle splint

44. Functions Indications Increased PROM by soft tissue elongation via low-load prolonged stretch Contracture Post operative scar release Burns Fracture (late phase) Replace or assist weak wrist extensors to enhance ADL Radial nerve lesion Spinal cord injury Brachial plexus lesion polio Placement : Dorsal (posterior), volar (anterior) or circumferential

45. Biomechanical efficacy: Two distinct methods can be used to stretch soft tissue, thereby encouraging tissue elongation and increased PROM .   1) Serial splinting: - With low temperature thermoplastics (progressive static splinting) or serial casting. Advantages: good conformity, little shifting Disadvantage : potential skin breakdown   2) Traction : (via elastics, coils, or springs) is applied across the joint(often a hinged joint) Advantage : amount of load can be adjusted Disadvantage: forces can cause shifting of orthosis such splints are more difficult to fabricate unless prefabrications are used. Non compliant patients can remove the orthosis .

46. Materials: - Casting - Thermoplastics - Elastics - Neoprene - Metal - Strapping - Velcro - Springs Contraindications: - Dynamic traction put on muscles with high tone may increase tone.

47. Posterior elbow splint Epicondylar straps Articulated elbow orthosis Dynamic supination / pronation splint

48. 6) Forearm-wrist orthosis : Regional name : wrist-hand orthosis common name : Thumb whole wrist cock up splint Wrist extension splint Static wrist splint Bunnell dorsal wrist splint Bunnell spring cock up splint Serpentine splint Neoprene or leather prefabricated wrist extension splint Gutter splint

49. Dynamic cock up splint Half cock up splint Spring cock up splint

50. Functions Indications Immobilize to promote tissue healing CTD CTS Flexor/extensor tendinitis Lateral/medial epicondylitis Wrist sprain/contusion Arthritis Forearm/wrist fractures Post operative extensor tendon repair Post operative wrist fusion Post operative skin grafting Substitute for weak wrist extension SCI BPL Prevent overstretching of wrist extensors Stabilize the wrist for maximal grasp and pinch prehension /strength ALS Radial nerve lesion Polio GBS Arthrogryposis UMN lesion: CVA, TBI, CP,MS

51. Immobilize wrist / forearm to maintain PROM Restrict motion to prevent harmful wrist postures during activities Burns Post operative scar release CTD arthritis Elongate soft tissue via low-load prolonged stretch( serial static splinting) Burns wrist contractures

52. Placement: This orthoses are volar , dorsal, circumferential, or gutter based, extending from the proximal MP to 2/3 rd of the distal forearm. If volar based, palmar material should end 1/4 th inch proximal to the distal palmar crease to allow unrestricted MP flexion Biomechanical efficacy: The wrist can be positioned in flexion or extension but for optimal hand function, it should be in 15-30 degrees of dorsiflexion . For CTS, wrist should be neutral.

53. Materials: Rigid: metal, thermoplastics, casting, straping , velcro Flexible: neoprene leather, plastics, fabric, strapping, velcro

54. 7) Forearm-wrist- thumb orthosis : Regional name : wrist-hand-forearm orthosis Common names : Long opponens splint Thumb spica

55. Functions Indications Immobilize thumb/wrist to promote tissue healing CMC/MP synovitis / arthritis CTD de Q ueryain’s disease Tenosynovitis Thenar tendinitis Thumb sprain CMC/MP collatral ligament injury( gamekeeper’s thumb) Scaphoid / thumb fracture Post operative thumb - ORIF - Surgical CMC/MP fusion - arthroplasty or reconstruction - tendon transfer - tendon/ligament repair - nerve repair - postoperative trapeziumectomy Substitute for weak thumb muscles, stabilize thumb in opposition for three jaw chuck pinch Median/ ulnar nerve lesion UMN lesion: CVA, TBI, CP

56. Maintain thumb prom burns Restrict motion to prevent harmful thumb positions during activities CTD Arthritis Athletes or performing artists Elongate soft tissues via low-load, prolonged stretch (serial static splinting) Burns Thumb contractures Placement : - The orthotic material usually cover 2/3 rd of the distal radial forearm and surrounds the thumb to the IP ( but can extend to tip)

57. Biomechanical efficacy: In most cases, the thumb should be positioned in palmar abduction so that three jaw chuck prehension is easily achieved , unless pathology dictates otherwise. Material should not restrict motion of digits 2-5.

58. Materials : rigid: thermoplastics, metal, strapping, velcro , casting, padding Flexible: neoprene, elastics, fabric, leather, strapping, velcro

59. Bunnell knuckle bender Spider splint Radial gutter splints

60. Dynamic finger flexion splint RIC tenodesis othosis Resting pan splint

61. Bobath splint Kleinert flexor tendon repair splint Short opponens splint Ulnar deviation correction splint

62. Partial hand opposition splint Finger orthosis Reverse knuckle bender C-Bar splint web splint

63. Shock absorbing gloves

64. 8) Ring orthosis : Regional name : finger orthosis Common name: Silver ring splint Swan neck splint Figure eight splint PIP hyperextension block splint Murphy ring splint Boutonnaire splint Pulley ring PIP extension stop

65. Swan neck splint Boutonniere splint

66. Functions Indications Block PIP/DIP hyperextension but allow normal IP flexion /extension Arthritis Swan neck deformity PIP/DIP volar palte injury Prevent overstretching of PIP/DIP volar plate Prevent further deformity Immobilize PIP in extension (DIP free) arthritis Prevent deformity Boutonniere deformity Prevent bowstring of flexor tendons A2 pulley injury(annular pulley for flexor tendon located on volar surface of proximal phalanx) Protect reconstruction/ allow dynamic motion, without immobilizing finger Post operative pulley repair

67. Biomechanical efficacy: - Rings are custom fitted and worn at all time. swan neck splint: - Prevent IP hyperextension via three points of pressure but allows full IP flexion. Lateral or distal supports may be added for stability. boutonniere splint: - Immobilize the IP in extension via three points of pressure. Needs to remove several times in a day.

68. A2 pulley ring: Fits firmly around the proximal phalanx from the PIP volar crease to the MP volar crease. Materials : Metal thermoplastics

69. Recent advances: 1) Ibrahim M et al. did study on Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study To compare a static progressive stretch device plus traditional therapy with traditional therapy alone for the treatment of adhesive capsulitis of the shoulder

70. CONCLUSION: Use of a static progressive stretch device in combination with traditional therapy appears to have beneficial long-term effects onshoulder  range of motion, pain and functional outcomes in patients with adhesive capsulitis of the shoulder. At 12-month follow-up, the experimental group had continued to improve, while the control group had relapsed. Physiotherapy.  2013 Oct 3. pii : S0031-9406(13)00085-0.

71. 2) Merolla G et al.did study on Efficacy, usability and tolerability of a dynamic elbow  orthosis  after collateral ligament reconstruction: a prospective randomized study. To assess the efficacy, usability and tolerability of a dynamic  orthosis  compared with a standard plaster splint after the reconstruction of elbow medial or lateral collateral ligaments (MCL, LCL).

72. CONCLUSIONS: The dynamic  orthosis  and the plaster splint both provided effective and safe elbow immobilization after MCL or LCL reconstruction. The  orthosis  provided greater pain reduction, faster recovery of muscle trophism and grip strength, and was better tolerated. Musculoskelet Surg.  2013 Oct 25.

73. 3) Garg R et al.did study on A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis . To compare the clinical outcomes of a wrist splint with that of a counterforce forearm strap for the management of acute lateral epicondylitis .

74. CONCLUSION: The wrist extension splint allows a greater degree of pain relief than does the forearm strap brace for patients with lateral epicondylitis . J Shoulder Elbow Surg.  2010 Jun;19(4):508-12.

75. 4) Woo Y et al.did study on Kinematics variations after spring-assisted  orthosis  training in persons with stroke. To evaluate the efficacy of training using kinematic parameters after a SaeboFlex   orthosis  training on chronic stroke patients. CONCLUSION: The results of this study indicate that a SaeboFlex training is effective in recovering the movement of the hemiparetic upper extremity of patients after stroke. Prosthet Orthot Int.  2013 Aug;37(4):311-6.

76. 5) Forogh B et al.did study on The effects of a new designed forearm  orthosis  in treatment of lateral epicondylitis . on the design and testing of a new designed forearm  orthosis  and explores its efficacious in comparison to the standard counterforce  orthosis  in patients with lateral epicondylitis .

77. CONCLUSIONS: The new-designed  orthosis  can significantly relieve pain, improve function, increase pain threshold and grip strength after application. This  orthosis  seemed to be more effective than counterforce  orthosis  in relieving pain and increasing the pain threshold probably due to the limitation of forearm supination . Disabil Rehabil Assist Technol.  2012 Jul;7(4):336-9.

78. 6) Chang M et al. did study on Comparison of Task Performance, Hand Power, and Dexterity with and without a Cock-up Splint. Men's grip power with the cock-up splint was found to be significantly decreased compared to without the splint. Women's grip and palmar pinch strength with the splint decreased significantly compared to without the splint. In the grooved pegboard test, the dexterity of both men and women with the cock-up splint decreased significantly compared to without the splint

79. Conclusion: To assist patients to make wise decisions regarding the use of splints, occupational therapists must have empirical knowledge of the topic as well as an understanding of the theoretical, technical, and related research evidence. J Phys Ther Sci.  2013 Nov;25(11):1429-31

80. 7) Whelan DB et al did study on External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized Controlled Trial. To compare the (1) frequency of recurrent instability and (2) disease-specific quality-of-life scores after treatment of first-time shoulder dislocation using either immobilization in external rotation or immobilization in internal rotation in a group of young patients.

81. CONCLUSIONS: Despite previous published findings, our results show immobilization in external rotation did not confer a significant benefit versus sling immobilization in the prevention of recurrent instability after primary anterior shoulder dislocation. Clin Orthop Relat Res.  2014 Jan 3.

82. References: S Sunder ; Text book of rehabilitation; second edition ; pg no:103-130 Orthotics: a complete clinical approach SLACK P. Bowker ; biomechanical basis of othotic management; pg no: 27-37 John B. Redford ,  John V. Basmajian ,  Paul Trautman orthotics: clinical practice and rehabilitation technology; pg no: 103- 130

83. Randall L.Braddom ; physical medicine and rehabilitation: third edition; pg no: 325-341 Joel A. Delisa ; rehabilitation medicine principles and practice; third edition; pg no: 635-651 Jan stephen tecklin ; pediatric physical therapy; second edition ) Whelan DB et al. External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized Controlled Trial Clin Orthop Relat Res.  2014 Jan 3

84. Ibrahim M et al. ; Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study ; Physiotherapy.  2013 Oct 3. pii : S0031-9406(13)00085-0. ) Merolla G et al.; Efficacy, usability and tolerability of a dynamic elbow  orthosis  after collateral ligament reconstruction: a prospective randomized study; Musculoskelet Surg.  2013 Oct 25.

85. Garg R et al.; A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis ; J Shoulder Elbow Surg.  2010 Jun;19(4):508-12. Woo Y et al.; Kinematics variations after spring-assisted  orthosis  training in persons with stroke; Prosthet Orthot Int.  2013 Aug;37(4):311-6. Forogh B et al. The effects of a new designed forearm  orthosis  in treatment of lateral epicondylitis ; Disabil Rehabil Assist Technol.  2012 Jul;7(4):336-9.

86. Chang M et al. ; Comparison of Task Performance, Hand Power, and Dexterity with and without a Cock-up Splint ; J Phys Ther Sci.  2013 Nov;25(11):1429-31 www.ottobock.com

87. Thank you