Splinting, Casting, and

Occupational Therapy

Remy Chu, Jr. MHA, OTR/L

Occupational Therapy Clinical Manager

Tyler A. Dykes Center for Robotic Rehabilitation Program Manager

Rancho Los Amigos National Rehabilitation Center, County of Los Angeles Department of Health Services

Los Angeles, CA

Disclosures

Nothing to disclose

Objectives

Explore the role of physical and occupational

therapy in the management of upper extremity

(UE) and lower extremity (LE) spasticity in

individuals with neurological impairments.

Review therapy approaches used to manage

spasticity and improve function post-botulinum

neurotoxin (BoNT) injections.

Provide a brief overview of relevant research on

post-BoNT therapy interventions.

Role of Therapy

“(Therapists) provide intervention to maximize the

benefits of

BoNT”14

Post BoNT therapy objectives:

– Minimize contractures

• Stretch spastic (injected) muscle groups

• Strengthen antagonist muscle groups

– Acquire new motor skills/increase motor control

– Spasticity reduction + increased motor control = >

increased FUNCTION and occupational performance 5

Role of Therapy 5

When: During the “window of opportunity”

– Period of clinically beneficial reduction spasticity

– Lasting 12-16 weeks

How much: Higher frequency, shorter duration

Who: Rehab potential is influenced by the following:

– Dynamic vs. fixed contracture

– Degree of voluntary movement / underlying muscular

strength

– Sensory impairment

– Motivation and ability to participate in therapeutic activities

– Caregiver support

Stretching 4, 15

Stretching to increase passive range of motion (PROM) and ultimately to elongate muscles

Manual stretch: moving through available range of motion with momentary hold at end range

– At least 20-30 seconds

– Longer hold better than a quick stretch

– Repetition

Prolonged stretch: splinting, casting, positioning

– Maintain stretch over several hours/days/weeks

– Neurophysiologic rationale: increases muscle length and number of sarcomeres, inhibits tone by decreasing muscle sensitivity to stretch during movement

– Biomechanical rationale: increases or preserves length of connective tissue and mobilizes joint

Stretching: Summary of the Evidence

Kinnear et al. (2014)

– BoNT combined with stretch-based interventions more effective

at reducing spasticity than BoNT alone 10

Splinting1

Static splints: immobilize to prevent muscle shortening or

contracture

– Serial static splinting: remolding a static splint to gradually

increase PROM

Static progressive splints: provide constant position and have built in

mechanism which is reset to progressively move joint toward end

range

Dynamic splints: moving parts (e.g. elastic or spring) apply constant

force and keep joint at end range

Splinting: Summary of the Evidence

Lai et al. (2009)

– Greater improvements in AROM and spasticity reduction with

use of dynamic elbow splint at night following BoNT 11

Kanellopoulos et al. (2009) 8

– Combination of static night splint and OT resulted in greater

improvements in function after BoNT compared to OT alone

– Improvements maintained at 6 months

Serial Casting 15,17

Cast applied over joint(s) crossed by spastic (i.e. injected) muscles

Intensity of stretch adjusted by changing joint angle

Reapplied at established intervals based upon increase in PROM

Continues until full range achieved or plateau reached

Some type of positioning device worn during periods of rest once

casting complete

Serial Casting: Summary of the Evidence

Bottos et al. (2003)

– Greater spasticity reduction and functional gains achieved when

casting used after BoNT 2

Lannin et al. ( 2007)

– Serial casting associated with improvement in quality of UE

movement and range of motion 13

Yasar et al. (2010)

– Casting associated with statistically significant improvements in

PROM and FIM gait scores 20

Kay et al. (2004)

– Casting alone appears more effective in reducing FIXED equinus

contracture 9

Therapeutic Exercise and Functional

Approaches 15

Strengthening to increase AROM and correct muscle imbalance

– Strengthening program individualized based on abilities and

level of function

– In order to increase strength a muscle must:

• Contract at maximal capacity

• Be given multiple repetitions

Principles of motor learning theory support use of repetition/mass

practice and task oriented approach

– Activities selected given consideration of patient/family goals

– Graded tasks provide a “just right challenge”

Constraint-Induced Movement Therapy (CIMT) 12

– Scientifically supported method of UE rehabilitation for

individuals with hemiplegia

– Involves constraint of non-affected UE in combination with

intensive therapy

– Foundations for treatment include neuroplasticity and motor

learning theory

– Shaping activities are used in a systematic manner to achieve

the following:

• Facilitate more spontaneous use of affected UE

• Improve motor skill quality

• Increase overall function and quality of life

Therapeutic Exercise and Functional

Approaches (continued)

Therapeutic Exercise and Functional

Approaches: Summary of the Evidence

Kinnear et al. (2014)

– BoNT combined with CIMT interventions more effective at

reducing spasticity than BoNT alone 10

Other Therapeutic Modalities

Therapeutic Taping

– Improve alignment (position)

– Muscle re-education (activating or inhibiting a muscle)

– Various techniques and brands

Neuromuscular Electrical Stimulation (NMES)

– Purpose to increase strength of antagonist and increase range of motion or length of agonist 15, 17

– Pulsating, alternating electrical current applied to muscle via electrodes to create contraction

Heat Therapy

– Creates short term tissue elasticity 15, 17

• Caution use in neurological population due to sensory and/or cognitive deficits

Other Therapeutic Modalities:

Summary of the Evidence

Santamato et al. (2015)

– BoNT in combination with adhesive taping showed a decrease in

muscle spasticity and functional impairment 16

Wright et al. (2012)

– BoNT in combination with NMES associated with increased

range of motion, improved strength, and decreased spasticity 19

Wilkenfeld et al. (2013)

– BoNT in combination with electrical stimulation of muscle group

improves the results of the BoNT injections 18

In Conclusion…

What we know 3, 6, 10

– BoNT appears to be more effective when combined with therapeutic intervention than when used alone

• There is high level evidence to support the use of BoNT in combination with physical and/or occupational therapy for best outcomes

• Therapy approaches are not harmful

– There is not a clear consensus as to which therapeutic approaches (or combination of approaches) are most beneficial for which circumstances

• Professional judgment and individual considerations remain a key component of treatment planning

– More rigorous studies are needed to determine best practice related to post BoNT therapeutic interventions and the long term effects/maintenance of gains

References

1. Bondoc, S., & Harmeyer, F. (2013, May 6). Splinting the Neurological Hand: Using Existing Splints in Innovative Ways. OT Practice. 18(8), 9-14.

2. Bottos, M., Benedetti, M.G., Salucci, P., Gasparroni,V., Giannini, S. (2003). Botulinum toxin with and

without casting in ambulant children with spastic diplegia: a clinical and functional assessment. Developmental Medicine & Child Neurology, 45(11), 758-762.

3. Demetrios, M., Khan, F., Turner-Stokes, L., Brand, C., & McSweeney, S. Mutidisciplinary rehabilitation following botulinum toxin and other focal intramuscular treatment for post stroke spasticity. Cochrane Database of Systematic Reviews 2013, Issue 6.

4. Gajdosik, R.L. (2001). Passive extensibility of skeletal muscle: review of the literature with clinical

implications. Clinical Biomechanics, 16, 87-101.

5. Hoare, B., Imms, C. (2004). Upper-Limb Injections of Botulinum Toxin-A in Children With Cerebral Palsy: A Critical Review of the Literature and Clinical Implications for Occupational Therapists. The American Journal of Occupational Therapy, 58(4), 389-397.

6. Hoare, B.J., Wallen, M.A., Imms, C., Villanueva, E., Rawicki, H.B., & Carey, L. Botulinum toxin A as an

adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE). Cochrane Database of Systematic Reviews 2010, Issue 1.

7. Hoare, B., Imms, C., Villanueva, E., Rawicki, H.B., Matyas, T., & Carey, L. (2013). Intensive therapy following upper limb botulinum toxin A injection in your children with unilateral cerebral palsy: a randomized trial. Developmental Medicine & Child Neurology, 55, 238-247.

8. Kanellopoulos, A.D., Mavrogenis, A.F., Mitsiokapa, E.A., Panagopoulos, D., Skouteli, H., Vrettos, S.G., Tzanos, G., & Papagelopoulos, P.J. (2009). Long lasting benefits following the combination of static night upper extremity splinting with botulinum toxin A injections in cerebral palsy children. European Journal of Physical and Rehabilitation Medicine, 45(4), 501-506.

9. Kay, R.M., Rethlefsen, S.A., Fern-Bueneo, A., Wren, T.A., &Skaggs, D.L. (2004). Botulinum toxin as an adjunct to serial casting treatment in children with cerebral palsy. The Journal of Bone and Joint Surgery, 86-A(11), 2377-2384.

10. Kinnear, B., Lannin, N., Cusick, A., Harvey, L., & Rawicki, B. (2014). Rehabilitation Therapies After Botulinum Toxin-A Injection to Manage Limb Spasticity: A Systematic Review. Physical Therapy, 94, 1569-1581.

References (continued)11. Lai, J.M, Francisco, G.E., & Willis, F.B. (2009). Dynamic Splinting After Treatment with Botulinum

Toxin Type-A: a Randomized Controlled Pilot Study. Advances in Therapy, 26(2), 241-248.

12. Landesman Ramey, S., Coker-Bolt, P., & DeLuca, S. (2013). Handbook of Pediatric Constraint-Induced

Movement Therapy (CIMT). Bethesda, MD: AOTA Press.

13. Lannin, N.A., Novak, I., & Cusick, A. (2007). A systematic review of upper extremity casting for

children and adults with central nervous system motor disorders. Clinical Rehabilitation, 21, 963-976.

14. Nolan, K.W., Cole, L.L., & Liptak, G.S. (2006) Use of Botulinum Toxin Type A in Children With

Cerebral Palsy. Physical Therapy 86(4), 573-584.

15. Pedretti, L.W., & Early, M. (Eds.). (2001). Occupational Therapy: Practice Skills for Physical Dysfunction (5th ed.). St Louis, MO: Mosby, Inc.

16. Santamato, A., Micello, M.F., Panza, F., Fortunato, F., Picelli, A., Smania, N., Logroscino, G., Fiore, P., & Ranieri. M. (2015). Adhesive taping vs. daily manual muscle stretching and splinting after botulinum toxin type A injection for wrist and fingers spastic overactivity in stroke patients: a randomized controlled trial. Clinical Rehabilitation, 29(1), 50-58.

17. Trombly, C.A., & Radomsky, M.V. (Eds.). (2002). Occupational Therapy for Physical Dysfunction (5th ed.). Philadelphia, PA: Lippincott, Williams, & Wilkins.

18. Wilkenfeld, A.J. (2013). Review of electrical stimulation, botulinum toxin, and their combination for spastic drop foot. Journal of Rehabilitation Research and Development 50(3), 315-326.

19. Wright, P., Durham, S., Ewins, D., & Swain, D. (2012). Neuromuscular electrical stimulation for children with cerebral palsy: a review. Archives of Disease in Childhood, 97, 364-371.

20. Yasar, E., Tok, F., Safaz, I., Balaban, B., Yilmaz, B, & Alaca, R. (2010). The efficacy of serial casting

after botulinum toxin type A injection in improving equinovarus deformity in patients with chronic stroke. Brain Injury, 24(5), 736-739.

Thank You

Break