Deborah A. Schwartz, OTD, OTR/L, CHT

Product and Educational Specialist

Orfit Industries America

Learning Objectives:

• Gain understanding of the indications, precautions and contraindications.

• Gain understanding of the evidence supporting static progressive splinting.

• Appreciate the mechanical principles.

• Appreciate the anatomical knowledge base.

• Learn some tips and tricks for splinting.

Definition:

“Splints that incorporate inelastic components to apply

torque to a joint to statically hold it in its end range

position in order to increase passive range of motion”

“creates static mobilizing force on segment, resulting in

passive motion of joint or successive joints”

Schultz- Johnson, K. (2002). Static progressive splinting.

Journal of Hand Therapy, 15, 163-178.

Static Progressive Splinting

Dynamic Splinting

Serial Splinting

Static Progressive Splinting Dynamic Splinting

• Base

• Outrigger

• Static components for force application

Velcro, static line, screws

gears, turnbuckles

• Used to increase passive joint range

• Base

• Outrigger

• Dynamic components for force application

Rubber bands, elastic,

coils, springs

• Mobilize joints

As tissue length changes,

patient is able to readjust tension

to new maximum tolerable length.

Indications:

Loss of joint motion

Contraindications:

Stage of Healing

Diagnosis

Protocol

•Bony Structures

•Nerve Pathways

•Arches

•Blood Supply

•Stages of Healing

Duncan, R. (1989). Basic Principles of Splinting

the Hand. Physical Therapy. 69(12);1104-1116.

The biologic rationale for using

splints to increase range of motion…..

peri-articular connective tissues

remodel over time in response

to the type and amount of physical

stress they receive…..

Brand, P. (1985).

Clinical Mechanics of the Hand. St Louis, MO:C.V. Mosby.

• Wider longer splints

distribute pressure better

• Flared edges cause less

pressure than straight

edges

• Avoid pressure on bony

prominences

• Allow full motion at non

involved joints

Colditz, J. C. (1983). Low profile dynamic

splinting of the injured hand. American Journal

of Occupational Therapy, 37(3) 182-188.

• Prevent distal migration

• Maintain proper angle

of pull

• Secure attachments

• Stabilize proximal

joints

Colditz, J. C. (1983). Low profile dynamic

splinting of the injured hand. American Journal of

Occupational Therapy, 37(3) 182-188.

• Low Load Prolonged Stress= LLPS

• 90° angle of pull.

• If angle is less than or greater than 90°, the force can damage the joint or the articular cartilage.

Colditz, J. C. (1983). Low profile dynamic splinting

of the injured hand. American Journal of

Occupational Therapy, 37(3) 182-188.

How to measure a 90º angle of pull?

90º

The amount of increase in passive range of motion

(PROM) at a stiff joint is proportional to the amount of

time the joint is held at its end range or

“TERT “ (Total End Range Time)

TERT = frequency x duration

Flowers. K., LaStayo, P. (1994). The effects of total end range

stress on increasing PROM. Journal of Hand Therapy, 7,

150- 157.

Questions

• What is the goal?

• What type of mobilization splinting?

• What structures are affected?

• What is the pathology?

• What are the precautions? • How can I measure progress?

Dynamic, Static Progressive,

or Serial Static Splinting-

How to decide?

• 20 degree increase in ROM- no splint

• 15 degree increase in ROM- static splint

• 10 degree increase in ROM- dynamic splint

• 5 degree increase in ROM- static progressive

splint

Flowers, K., (2002). A Proposed Decision Hierarchy for

Splinting the Stiff Joint, with and Emphasis on Force

Application Parameters.

Journal of Hand Therapy, 17(3), 158-162.

Quantifies the amount of torque forces required to gain

a certain amount of passive range of motion at a joint-

helps us decide which type of mobilization splint is needed.

Force Force

Degrees Degrees

Dynamic Serial Static Static Progressive

Force Elastic/ given force/ doesn’t hold tissue at max. length

Constant tension- end range position maintained

Constant tension- end range maintained-

Force Control Springs/ rubber bands deform over time- no one has control

Clinician has control

Clinician and / or patient have control

Proper tension: How much is correct amount?

Depends on:

• individual

• diagnosis

• severity of problem

• chronicity of problem

• degree of contracture

Duncan, R. (1989). Basic Principles of Splinting the

Hand. Physical Therapy. 69(12);1104- 1116.

Add splint to

interventions

If splint causes

increased pain,

Discontinue

splint use

If splint wear is

tolerated well

Reevaluate

ROM

No Change in

ROM

Reevaluate

TERT

If TERT is

maximum

Increase

intensity of

force

An Algorithm for Making Clinical Decisions For Patients with

Limited Range of Motion

McClure, P, Blackburn, L, Dusoid, C. (1994) The use of splints in the

treatment of joint stiffness: biologic rationale and an algorithm for making

clinical decisions. Physical Therapy, 74(12), 1101-7.

• Wearing schedule - frequency and duration

• Caregivers instructions / photos

• Care of splint

• Precautions

• How to know when splint

adjustments are necessary

• Improve range of motion

• without pain

• Patient able to

• adjust force

• gradually

• Takes advantage of small

• incremental changes in

• tissue length

• Splint design allows for

• small changes without

• remolding splint each time

• gains are accomplished.

Don’t Forget to Measure

Progress!

Database Searches on:

Pub Med

Ovid, Google Scholar

OT Seeker

PEDro, EBSCO

Key Words: “splinting, dynamic splinting, static

progressive splinting, splinting the upper extremity,

splinting and hand therapy”

Glasgow et al looked at 43 patients and the use of splints to

correct joint contractures.

Group A- TERT of 6 hours per day

Group B- TERT of 6-12 hours per day

Patients included PIP and MCP contractures, and used both

dynamic and static progressive splints.

Overall conclusion favored longer TERT time for contracture

resolution.

Glasgow, C., Wilton, J., Tooth, L. (2003). Optimal Daily Total

End Range Time for Contracture Resolution in Hand Splinting.

Journal of Hand Therapy, 16, 207-218.

Nuismer et al looked at the use of Low Load Prolonged Stress

with neurologically involved and orthopedically involved

caseloads.

• Splint use 10 weeks (average)

• Improved function, ADL’s

• Improved range, comfort, ability to RTW, leisure

Nuismer, B. A., Ekes, A.M., Holm, M, B., (1997). The use of low

load prolonged stretch devices in rehabilitation programs in the

Pacific Northwest.

American Journal of Occupational Therapy, 51 (7), 538-543.

Doornberg et al conducted a study:

29 consecutive patients with elbow stiffness

• Increase of 51° elbow flexion

• Use of splints for average of 4 months

• ½ hour each direction, 3 x / day

Results in ROM pre-splinting versus post splinting show

statistically significant increases.

Doornberg, J.N., Ring, D., Jupiter, J.B. (2006). Static

progressive splinting for post traumatic elbow stiffness.

Journal of Orthopedic Trauma. 20 (6), 400-404.

Gelinas, Farber, Patterson and King looked at 22 patients:

• Average splint use- 15 hours / day

• Increased of 24 ° after an average use of 4.5 months.

• 11 patients regained functional arc (30-130°)

Gelinas, J.J, Faber, K.J., Patterson, S..D., King, G.J. W. (2000).

The effectiveness of turnbuckle splinting for elbow contractures.

Journal of Bone and Joint Surgery, 82-B(1), 74-78.

McGrath et al conducted a

clinical trial of 38 patients:

• Increased arc of motion

• Increased supination

• Increased patient satisfaction

McGrath, M. S., Bonutti, P. M., Marker, D. R., Johanssen, H. R.,

& Mont, M. A. (2009). Static progressive splinting for

restoration of rotational motion of the forearm.

Journal of Hand Therapy, 22(1), 3-9.

Lucado et al looked at static progressive splinting after distal

radius fractures.

• Increased supination (mean of 14.5°)

• Increased wrist extension (mean of 18.6°)

• Improved grip

• Improved DASH

Lucado, A.M., Zhongyu, L. Russell, G.B., Papadonikolakis, A.,

Ruch, D.S.(2008). Changes in impairment and function after

static progressive splinting for stiffness after distal radius

fracture. Journal of Hand Therapy, 21(4)319-325.

McGrath et al also looked at 47 patients with limitations of

wrist motion.

Patients wore a SPS wrist splint for an average of 3

hours per day for ten weeks.

Average gains were an increase of 35 degrees of total arc of

motion.

Patient satisfaction scores were on average 8.2 out of 10.

McGrath, M.S., Ulrich, S.D., Bonutti, P.M., Smith, J.M., Seyler,

T.M., Mont, M.A. (2008). Evaluation of static progressive

stretch for the treatment of wrist stiffness.

Journal of Hand Surgery, 33A, 1498-1504.

Michlovitz et al conducted a systematic

review of treatments to improve range

of motion.

9 studies on splinting- 8 case series & 1 RCT

• Static progressive splinting

• Dynamic splinting

• Serial casting

Michlovitz, S., Harris, B.A., Watkins, M.P. (2004). Therapy

interventions for improving joint range of motions:

a systematic review. Journal of Hand

Therapy, 17(2), 401-406.

Farmer and James conducted a systematic

review of all treatments for contractures,

• Passive stretching

• Serial casting

• Splinting (Dynamic and Static Progressive)

• E-stimulation

• Surgery

• Botox

Farmer, SE., James, M. (2001). Contractures in orthopaedic and

neurological conditions; a review of causes and treatment.

Disability and Rehabilitation. 23(13); 549-558.

• Static Progressive Orthosis for a stiff finger

The hand based SPS orthosis:

• Maintains MCP joint

in extension

• Pulls PIP and DIP into

flexion

• Needs pulley to direct

angle of pull

Orfit Colors NS 1/12” is a lightweight, conforming elastic based

product, perfect for circumferential and hand based orthoses.

• Brand PW. (1995). Mechanical factors in joint stiffness and

tissue growth. Journal of Hand Therapy, 91-96.

• Colditz J. (1983). Low profile dynamic splinting of the

injured hand. American Journal of Occupational Therapy, 37

(3) 182-188.

• Duncan R. (1989). Basic principles of splinting. Physical

Therapy. 69 (12); 1104-1116.

• Flowers K. (2002). A proposed decision hierarchy for

splinting the stiff joint, with an emphasis on force application

parameters. Journal of Hand Therapy, 158-162.

• Flowers K, LaStayo P. (1994). Effect of total end range

time on improving passive range of motion. Journal of Hand

Therapy, 150–7.

•Glasgow C, Wilton J, Tooth L. (2003). Optimal daily total

end range time for contracture: resolution in hand splinting.

Journal of Hand Therapy. 16,207-218.

•Guyatt G, Rennie D, Meade M, Cook, D. ( 2002). Users

guides to the

medical literature: essentials of evidence based clinical

practice. 2nd Edition. JAMA. McGraw Hill; New York.

•Lucado, A.M., Zhongyu, L. Russell, et al. (2008). Changes in

impairment and function after static progressive splinting for

stiffness after distal radius fracture. Journal of Hand Therapy.

21,319–25.

• McClure, P.W., Blackburn, L.G., Dusoid, C. (1994). The use

of splints in the treatment of joint stiffness: biologic rationale

and an algorithm for making splints. Physical Therapy.

74,1101-1107.

• Nuismer, B.A., Ekes, A.M., Holm, M.B. (1997). The use of

low load prolonged stretch in rehabilitation programs in the

Pacific Northwest. American Journal of Occupational

Therapy, 538-543.

• Schanzer D. Static progressive end range proximal inter-

phalangeal / distal inter-phalangeal flexion splint. Journal of

Hand Therapy. 2000, 13 (4): 310.

• Schwartz, D. A., Janssen, R. G. (2007). Static progressive

splint for composite flexion. Journal of Hand Therapy. 2005,

447-450.

Schwartz DA. (2012). Thermoplastic Hinges: Eliminating the

Need for Rivets in Mobilization Orthoses. Journal of Hand

Therapy. 335-340.

Schwartz DA. (2011). Static progressive orthoses for the upper

extremity: a comprehensive literature review. Hand, March

2012. 7 (1); 10-17.

Schwartz, DA. (2010). Reflections on practice: static

progressive splints. ADVANCE for Occupational Therapy

Practitioners, June 7; 29.

• Schulz- Johnson, K. (2002). Static progressive splinting.

Journal of Hand Therapy. 15,163–178.

• Sueoko et al. Static Progressive Splinting in under 25 Minutes

and $25. Journal of Hand Therapy, February, 2011.

Thank you for your

attention!

Debby.schwartz@orfit.com