Splinting CP

8/2/2019 Splinting CP

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Casting, splinting, and physical and occupational

therapy of hand deformity and dysfunction

in cerebral palsy

Judith Wilton, MS, GradDipHthSc, BAppSC, OTHand Rehabilitation Specialists, 10 Altona Street, West Perth, WA 6005, Australia

Significant occupational and physical therapy

time and resources are directed to the manage-

ment of the upper limb in cerebral palsy (CP). The

evidence to support therapy interventions for the

upper limb is not strong [1]. This in part reflects

the difficulties of research [2] rather than a lack of

critical review of practice. Experience and

logic underpin many therapeutic applications.

This presentation details the available options,

the rationale for their use, and the results of

treatment.

Prerequisites for hand function

Efficient performance of the upper limb

depends on proximal control and dynamic stabil-

ity of the trunk and shoulder girdle. From a stable

base, distal mobility of the limb enables partici-

pation in age-appropriate occupational tasks.

Improvement in scapulohumeral and trunk con-

trol is a major focus of neurodevelopmental

therapy (NDT), one of the most commonly used

approaches for treatment of children with CP.

NDT techniques attempt to alter muscle toneduring movement to facilitate normal movement

patterns and postural reactions under the premise

that improved postural control improves func-

tional skills [3]. Investigations into this premise in

relation to the upper limb determined the effects

of NDT on quality of upper limb movements [4]

and reaching [5,6]. Although improvements were

evident, they were not greater than reach training

using principles of motor learning or occupational

therapy directed toward functional skills.

For children with more severe motor dysfunc-

tion in whom head and trunk control are affected

by spasticity and persistent postural reflexes,

postural control for effective upper limb function

is achieved only through adaptive seating. As

children get older, the requirements for schooling

demand longer periods of time seated. Therapists

thus should consider how restrictions imposed by

the chair and table in upper limb movement may

potentiate deformity and what strategies are

needed to address it.

Altered sensibility commonly is identified as

a contributing factor to impaired hand function inchildren with CP. Much of the literature has

focused on the measurement of sensory deficits,

with two-point discrimination and stereognosis

identified as the most common tests [79]. Recent

studies of children with hemiplegia have estab-

lished a strong relationship between tactile sensi-

bility and dexterity [10] and fingertip force

regulation during object manipulation [9,11].

The relationship between sensibility and hemi-

plegic hand performance in functional bimanual

activities, however, was not as strong [10]. The

potential to improve hand sensation by systematic

sensory education programs, shown to be effective

following stroke [1214], has yet to be determined

in children with CP.

Principles of intervention options

Therapeutic modalities specific to hand func-

tion essentially fall into two categoriesthose

that have an impact on hypertonicity and

associated contracture and those that facilitate

functional use of the hand related to active motionand dexterity. In the absence of extensive evidenceE-mail address: [email protected]

0749-0712/03/$ - see front matter 2003 Elsevier Inc. All rights reserved.

doi:10.1016/S0749-0712(03)00044-1

Hand Clin 19 (2003) 573584
mailto:[email protected]:[email protected]


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under-pinning the therapeutic modalities as ap-

plied to typical patterns of deformity of the hand

and wrist.

Hypertonicity and contracture

When addressing the increased muscle tone in

children with CP, it is useful to distinguish

between the neural or reflexive componentsthe

tonic muscle contractionsfrom the non-neural

or mechanical components, the viscoelastic prop-

erties of muscle and connective tissue associated

with contraction and stretch [15,16]. Spasticity,

a somewhat imprecise term in clinical practice,

refers to the neural component of hypertonicity,

that is, the velocity-dependent increase in stretchreflex activity [17]. The altered mechanical prop-

erties of the muscle and associated tissues occur in

response to the abnormal conditions imposed on

the muscle by the spasticity. In turn, muscle

shortening may participate in the generation and

maintenance of spasticity [16,18].

Strategies that address muscle contracture

affect the neural and mechanical components of

the hypertonicity present. Studies by Nash,

Neilson, and ODwyer [19,20] suggest that neural

and non-neural components of hypertonicity

should be considered as reducing spasticity aloneand not altering muscle contracture. Following

electromyographic biofeedback training over 10

weeks, subjects were able to reduce spasticity by

50%, but no associated change in muscle con-

tracture was measured, nor improvement in

voluntary movement evident. To address contrac-

ture and hypertonicity effectively, it is recommen-

ded therapists use modalities that prevent or

reverse contracture in target muscles for sufficient

duration each day to promote muscle growth [19].

During growth and in response to changes inposture, the functional length of the muscle is

adjusted by altering the number of sarcomeres in

series for optimum force generation and power

output [21]. When movement does not put the

joint through a full range of motion and daily

passive range of movement or posturing does not

adequately maintain range, adaptation of the

muscle results in contracture. This adaptation,

a combination of shortening of muscle fibers and

remodeling of muscle connective tissue [19,22,23],

is accompanied by changes in the skin and

periarticular tissues [2426].When safe forces are applied to tissues

statically or cyclically, they demonstrate a tran-

sient lengthening depending on the viscoelastic

properties of the tissues. This elongation reverses

once the force is relaxed. This elastic response is

associated with unfolding of tissue and temporary

realignment of collagen fibers within the connec-

tive tissues. The resolution of contracture throughthe application of low-load prolonged stress to the

contracted tissues at the end of their available

range ultimately depends on the ability of the cells

to sense and transduce the mechanical force into

biologic action and to grow [20,23,27].

The response of shortened muscles to stretch,

using plaster cast immobilization, has been

explored in numerous animal studies. Adult

muscle responds to stretching by adding new

sarcomeres in series, thereby returning the sarco-

meres to their optimum tension-generating lengthwith no change in tendon length. In growing

muscles, however, the initial increase in number of

sarcomeres up to day five is followed by a decrease

in sarcomere number, thereby decreasing muscle

fiber length. Muscle tendon length is maintained

by lengthening of the tendon [23,28,29]. These

findings suggest that extended casting protocols

for young children should consider potential to

increase tendon length rather than to influence

muscle fiber length. It is stressed also that cast

lengthening of muscle contracture should be

gradual, because decrease in sarcomere numberis greater than decrease in length of muscle

connective tissue [23]. Potential exists for

muscle fiber breakdown from too fast or forceful

stretching.

Although stretch is essential to muscle growth

and in maintenance of functional length once

growth has stopped [30], the effectiveness of

passive range of motion exercises depends on

their frequency. Long-term stretch, applied con-

tinuously for periods greater than 6 hours, has

been shown to be most effective [31,32]. Castingand splinting are best in applying low-load

prolonged stretch to contracted tissues. Experi-

ence suggests that, in muscles with hypertonicity,

shortening of muscle and connective tissues recur

unless stretch is maintained [20,33].

Splinting and casting

Published studies in the last 50 years that have

addressed the issue of hand splinting in the

presence of spasticity have tended to reflect the

theoretic basis of therapy at the time [3440].Although direct comparison between studies is not

possible, the vast majority identified improvement

574 J. Wilton / Hand Clin 19 (2003) 573584


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in range of motion associated with splint wearing

[4143].

Static splints and casts maintain the joint in

one position with the goal of stabilizing it for

efficient transfer of muscular forces to distal

joints. Serial static splints and casts are designedto lengthen tissues and correct deformity through

application of gentle forces sustained for extended

periods of time [44]. Splints are remolded and

casts replaced at intervals that allowed for tissue

response to the lengthened position. Casting has

biomechanic and neurophysiologic effects. Bio-

mechanic effects relate to changes in the length of

muscle and connective tissues reversing the

histologic changes that occur in tissues main-

tained in a shortened position. The exact neuro-

physiologic effects of casting on spasticity areundefined. It is proposed that inhibition results

from decreased sensory input from cutaneous

and muscle receptors during the period of immo-

bilization. The effects of neutral warmth and

circumferential contact also are believed to

contribute to modification of spasticity.

Much of the research on upper limb casting in

the presence of spasticity is undertaken in a single

case study design. Two groups of studies are

seenthose using mobilizing principles with

a series of circumferential casts worn for 24 hours

per day for periods up to 4 weeks [4550] andthose in which a single cast is bivalved and worn

for periods of 35 hours per day for many months

[33,44,51,52]. In the first group, serial casts

applied to elbow and wrist flexion contractures

for 24 hours per day over several weeks resulted in

significant gains in range of motion. Intermittent

static casting of the wrist also demonstrated

improvements in range of motion, quality of

movements, and functional use of the hand.

Biomechanically, bivalved casts achieve wrist

immobilization as effectively as a thermoplasticsplint. The studies that used static bivalved casts

to immobilize the wrist joint for function for

extended periods provided no explanation re-

garding choice of material. Choice may relate to

the skills of the therapist in splinting or casting,

ease of fabrication, cost, comfort, and aesthetics.

Splints to facilitate functional use of the hand

include the wrist splints with reflex inhibiting

components [53,41], a neoprene splint to position

the thumb in abduction and the forearm in

supination [54], and splints to position the thumb

in abduction [55,56]. Studies that investigatedsplints worn by children with CP reveal trends

toward more normal movement patterns and

greater grasp skills [57,58]. No significant rela-

tionship was found between splint type and

changes in hand function. Functional gains were

associated with splint wear. In practice, splints are

designed to meet specific objectives identified by

the patient or their caregiver. In many instancessplints compensate for functional deficits in hand

grasping or pointing to secure toys, eating

utensils, and writing and computing devices.

When a variety of postures of the upper

limb are required in the performance of func-

tional tasks, rigid correction of deformity is not

always compatible with function. It is probably

one of the key issues for noncompliance with

rigid splinting and the preference for use of

custom made or commercial neoprene and Lycra

splints. These splints use a wraparound designwith inserts to position the thumb and reinforce-

ment achieved by way of splinting material or

metal inserts.

Dynamic Lycra splints use the inherent prop-

erties of the fabric and design features of the

garment to create a low force to resist the spastic

muscle action while also facilitating the antagonist

action. The mechanical properties of dynamic

Lycra arm and hand splints have been established

in studies involving normal and hemiplegic sub-

jects [18,59]. More extensive Lycra body splinting

in children with CP [60] also showed improveddynamic upper limb function, with reduction in

involuntary movement and improved patterns of

movement associated with a reduction in muscle

tone. Thirteen of fourteen subjects experienced an

immediate reduction in involuntary movement,

with six maintaining some improvement after

removal of the body splint. Although preliminary

research suggests Lycra splints have potential to

influence involuntary movement and apply low

stretching force to the limb in people with CP

without compromising comfort or functional useof the limb, further controlled clinical trials are

needed.

Functional strength

Current understanding is that spasticity is not

the primary cause of voluntary movement impair-

ment [20]. The perception of greater strength in

the hypertonic muscle, with weakness in its

antagonist, is in part caused by the techniques

used to determine strength. As skeletal muscle is

highly adaptable, its structural characteristics aredetermined by its conditions of use. Shortened

muscles may seem strong at normal length

575J. Wilton / Hand Clin 19 (2003) 573584


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because they are tested in their optimal position.

Associated changes in passive tension through

shortening of the connective tissue elements also

may contribute to perceived strength. Weakness

in lengthened muscles is the result of remaining in

an elongated position beyond the neutral physi-ologic rest position but not beyond the normal

range. Muscles seem weaker because they are not

tested at their optimal length. Constant contrac-

tion of the muscle when allowed to shorten also

may exaggerate the rate and quantity of sarco-

mere loss, thus weakening the muscle [21]. The

hypertonic muscle may be constrained during

voluntary movement by the passive mechanical

properties of the muscle itself.

Lengthening the shortened connective tissue

elements in the muscle, together with modifica-tion of the functional length with adaptation of

sarcomere number, has potential to modify

strength of the muscle. Improvement in

strength of wrist extensor musculature described

following serial progressive casting [50] is in part

the consequence of muscle length adaptation.

Following the period of immobilization, therapy

is required to assist weaker muscles to work

against gravity and to perform functional grasp.

Splints that offer support to the joint but allow

active motion are preferable to rigid immobiliza-

tion.It is observed that repetitive use of the hand in

functional tasks has the potential to further

increase strength and endurance. Further investi-

gation is required, however, to validate grip and

pinch strength exercise protocols.

Manipulation and dexterity

Improvement in manipulation and dexterity

are aims for children with CP with milder motor

difficulties [61,62]. Hand intrinsic muscular con-trol is essential to achieve fine motor coordina-

tion. Therapy aims to facilitate isolated thumb

and finger stability and mobility, accurate pat-

terns of pinch and grip of objects of varying sizes,

shapes, and textures, translation and rotation of

objects within the hand, bilateral manipulation,

and strength and endurance to meet functional

demands.

The efficacy of occupational therapy programs

to address development of fine motor skills in

preschool children has been established in several

studies by Case Smith [61,63,64]. Although thenumber of children in these studies with a di-

agnosis of CP was small, the therapists use of

play and peer interaction influenced fine motor

skills, improving function. Therapists therefore

are encouraged to use activities of daily living

(ADL), play, and recreational and vocational

activities as an integral part of therapy [33,63].

Analysis and treatment of hand dysfunction

The wrist and hand present a complex in-

teraction of intrinsic and extrinsic musculature in

which hypertonicity dictates the predominant

pattern of deformity. Performance of an isolated

movement may elicit a different pattern from that

evident when attempting to use the hand in

a functional task. Analysis of patterns of function

of the wrist and digits during movement and

during function provide the basis for treatmentdecisions. In addition to the usual tests of passive

and active range of motion, information from

parents or caregivers about the posture of the limb

during sleep often can assist in determining

whether contracture is present.

In 1981, Zancolli and Zancolli [65] described

a surgical classification of spastic hand deformities

in the wrist and fingers, whereas House, Gwath-

mey, and Fidler [66] identified four patterns of

deformity in the thumb. Building on these

classifications, the following model was developed

to facilitate analysis of the anatomic and bio-mechanic components of deformity and dysfunc-

tion. Patterns of deformity may evolve over time.

Pattern 1: minimal wrist flexion in function,

thumb adduction

Children with this deformity have mild spas-

ticity in flexor carpi ulnaris (FCU), which means

that reach to grasp, occurs with slight wrist flexion

and ulnar deviation. The wrist extensor muscles

can extend against the resistance of hypertonicityin FCU and there is no evidence of hypertonia in

the finger musculature. In a large number of

patients, no deficit is seen in the thumb, but when

present the deformity pattern is adduction at the

carpometacarpal (CMC) joint from a combination

of contraction and contracture in the adductor

pollicis (AP) and first dorsal interosseous (DI)

muscles. Some CMC joint extension and abduc-

tion are restricted but with no limitations in

motion of the metacarpophalangeal (MCP) and

interphalangeal (IP) joints.

Full passive range of motion (ROM) is avail-able at all joints of the wrist and fingers with the

possibility of reduced ROM of the thumbindex



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finger web space. Imbalance of muscles acting

across the joints can contribute to instability.

Hyperextension seen at the proximal interphalan-

geal (PIP) joints results from wrist flexion in-

creasing the distance the extensor digitorum

communis (EDC) tendons traverse before insert-ing at the base of the middle phalanx. Great

variability exists in the population as to normal

mobility of these joints, and unless instability

impedes function it need not be addressed.

Therapeutic intervention

Maintenance of full extensibility of tissues is

a primary goal. Function and play activities

that incorporate weightbearing are used to

provide regular stretch to FCU. In the presence

of contracture of the thumb web space, a serialsplint worn during nonfunctional times ad-

dresses the contracture without compromising

function.

Designing functional splints to stabilize the

thumb in a position for opposition is a significant

challenge. To control the thumb joints, splint

components must control the thumb metacarpal

against the forces of spasticity. When the web

space is shortened by skin contracture, the

difficulty in directing the abducting force to the

metacarpal is increased. Although neoprene orLycra are more acceptable splinting materials for

young children, their elasticity and lack of

contour require careful design to ensure appro-

priate application of forces to the thumb. Com-

binations of low temperature thermoplastic

materials and Lycra or neoprene may better

achieve this objective, particularly in older chil-

dren in whom the tissue forces are greater. It is

important to ensure that functional thumb splint-

ing does not impede use of the thumb; no single

splint design has been found that resolves this

problem effectively.

People with this pattern of deformity have

good grasp and release and pinch; however, fine

manipulation is impeded by thumb dysfunction.

Therapy is focused on activities requiring graspand pinch of objects of a wide variety of sizes and

shapes to encourage thumb opposition and hand

manipulation. Placement of objects for manipu-

lation should use a variety of wrist postures, with

vertical play one of the ways to promote wrist

extension.

Pattern 2: moderate wrist flexion in function,

active wrist extension

People with this deformity use a tenodesis-type

action, approaching objects with significant wrist

flexion with extension of the MCP and PIP joints

of the fingers (Fig. 1A). Active flexion of the

fingers is associated with extension of the wrist.

Control of the speed and force of finger flexion is

a common problem. The hypertonicity is located

predominantly in flexor digitorum profundus

(FDP) and flexor digitorum superficialis (FDS),

with mild hypertonicity located in FCU and flexor

carpi radialis (FCR). Strength in the wrist

extensor muscles can overcome the resistance in

the wrist flexors, but EDC cannot extend thefingers with the wrist approaching neutral. EDC is

a critical player in this pattern, as it is compro-

mised by its incapacity to generate tension when

constantly working in a lengthened position, and

by its size and overall smaller capacity to generate

tension as compared with FDS and FDP [67]. The

thumb metacarpal generally is held in an adducted

position by hypertonicity in the AP and first DI

muscles. Extensor pollicis longus (EPL) and

extensor pollicis brevis (EPB) act across the

Fig. 1. Pattern 2 with and without dynamic Lycra splint. (A) Approach to grasp is associated with significant wrist in

flexion with hyperextension of the MCP joint. (B) Dynamic Lycra splint facilitates a balance between wrist and finger

musculature when approaching objects for grasp.



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MCP joint, creating a hyperextension deformity

on reach, while not impairing thumb flexion.

No deficits are evident in the passive range of

motion of the wrist. Shortening may be demon-

strated in FDP and FDS, however, with combined

finger and wrist extension. Daily stretching pro-tocols in association with weightbearing on the

hand with extension of the wrist and fingers may

maintain length without need for splinting or

casting. Contracture of the index thumb web

space is generally present. Persistent extension of

the MCP in combination with adduction of the

CMC joint can lead to instability of the MCP

joint capsule and ineffective force transmission

through the thumb during pinch.

In people with this deformity, grasping is

impaired by reduced thumb web span, limitingthe area of the palm of the hand available for

object contact. In addition, diminished control of

wrist extension in conjunction with flexion of the

fingers often results in failure to secure the object

between the fingers and thumb or the fingers and

palm. Successful grip depends on the size and

shape of objects in relation to the size of the hand.

Transverse volar grip is the most effective because

of the tenodesis action in grasping, with effective-

ness of lateral and two-point pinch dependent on

the size and shape of the object.


The objective of intervention is to gain better

coordination between wrist and finger muscular

action. Treatment is designed to combine re-

educationof movement patterns in functional tasks

that require wrist extensors to work in their mid

range of motion, maximize actionof EDCfor finger

extension, and gain control over speed and force of

contraction of finger flexors during grip. Dynamic

Lycra splints (Fig. 1B) can assist in achieving thisobjective, but rigid splints are incompatible with

functional use of the hand. The Lycra fabric allows

movement but desires to return to its predeter-

mined resting length. Looking like a glove with

inclusion of fingers to prevent migration, the

multiple components across the dorsal and volar

aspects are designed to provide directional pull and

so facilitate movement. The thumb is included with

addition of small thermoplastic components if

additional stability or positioning is required.

Initial splint application should be incorporated

into a therapy program directed toward mastery ofmovement patterns required in specific occupa-

tional tasks. Repetition in ADL provides opportu-

nities to use newly acquired movement patterns and

consolidate gains.

The thumb presents a two-fold challenge.

First, the presence of contracture of the thumb

index web space, and second, diminished active

motion to position the thumb for effectiveopposition. Resolution of contracture requires

serial progressive splinting, preferably at night so

as not to impede performance of functional

activities. Although thumb mobility is desirable,

thumb stability in a position for opposition to the

fingers is more important. Achieving this stability

is not easy in a situation in which spastic muscles

have good moment arms, and splinting levers are

small. Splinting materials must have sufficient

strength to resist the force of AP and extrinsic

extensors to stabilize the CMC and MCP joints.Correction of the wrist position and thus

reduction of the distance over which the EDC

tendons traverse at the wrist resolves much of the

hyperextension deformity at the MCP and PIP

joints of the fingers. Splinting for the PIP joints is

required only if joint instability compromises

function, particularly for switching devices or

computer access. Small splints that restrict PIP

joint extension beyond neutral can be fabricated

and worn for specific functional tasks, but

compliance with long-term wear is problematic.

Pattern 3: wrist flexion >20 in function,

no active wrist extension

In people with this pattern, moderate spasticity

is located in FCU and FCR and the FDP, FDS,

and palmaris longus. Wrist extensor muscles are

weak, constantly working in a position of sig-

nificant wrist flexion. Mid range flexion of the

fingers is possible, but active insufficiency in FDS

and FDP impairs strength of grip. Hyperexten-

sion of the PIP joints is present (Fig. 2). Thispattern is more common in older children and

adults and reflects the impact of growth and tissue

shortening over time.

The significant feature of this pattern is the

deficit in extensibility in the wrist flexor and

extrinsic finger flexor musculature, resulting in

loss of extension ROM. Shortening also may be

present in EDC, limiting full passive finger flexion.

The predominant posture of the thumb is

adduction at the CMC joint and hyperextension

of the MCP joint as described in the previous

classification.People with this deformity grasp objects

between the finger and thumb pads, as it is not



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possible to orientate the palm toward the object

because of significant wrist flexion.


The objective of intervention is to improve

hand function, prevent further wrist contracture

for ease of management, or address pain in the

wrist. As the fingers cannot be flexed tightly, thereis rarely a risk for breakdown of skin in the palm

of the hand.

Rigid splinting or casting are directed to

decreasing hypertonicity and increasing length in

wrist and finger flexors. These are best undertaken

for extended periods or over night. For patients in

whom the contracture of the wrist exceeds

a position of 45 of flexion, a series of two or

three casts over several weeks (Fig. 3) is recom-

mended. With this severe deformity, casting,

maintaining the joint for maximum time at endrange, has advantages over rigid splints that may

be uncomfortable.

A dorsal volar splint (Fig. 4) is used when there

is less contracture of the wrist and shortening of

FDS and FDP. This design is superior to other

splint designs because it uses an effective lever

system to apply an extension force to the wrist

and fingers [68]. Dorsal forearm and volar hand

components are remolded as lengthening occurs in

shortened tissues.

For people with this deformity, functional

goals often are determined by the competence ofthe other hand. For children with hemiplegia, the

goal may be to achieve an efficient gross grasp to

use as an assist/stabilizer to the dominant hand.

For patients in whom bilateral involvement exists,

intervention often is directed at achieving the

hand function requirements for a specific task,

such as wheelchair control or activating commu-

nication devices (Fig. 5). Generally, splinting is

Fig. 2. Examples of pattern 3 deformities. (A) In association with significant wrist flexion tension on EDC contributes to

hyperextension in the PIP joints, while AP and contracture influence the thumb CMC joint and EPL extends the IP joint

of the thumb. (B) The right hand illustrates the resting position of the wrist reinforced by gravity and wrist and fingerhypertonicity. Greater degrees of extension in the resting position of the left wrist and fingers are the outcome following

18 days of serial casting.

Fig. 3. Three plaster casts illustrate progressive increase

in range of passive wrist and finger extension with

successive applications.



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required to assist the wrist in achieving a more

neutral position to resolve the biomechanic

disadvantage for FDS and FDP in grasp, while

not compromising EDC. Functional activities

requiring controlled finger opening and closing

complement the splinting program.

Functional splinting of the wrist may use rigid

thermoplastic materials to immobilize the wrist in

a position that does not compromise the ability toextend the fingers during reach. Alternatively,

materials such as Lycra or neoprene may be used

to make circumferential soft splints, reinforced by

splinting material or flexible boning that restricts

wrist motion andopposes thewrist flexor spasticity.

Lycra or neoprene alone has insufficient strength

to oppose the strong flexion pattern and have no

effect on extension deficits in the wrist or fingers.

Splinting options for the wrist also should in-

corporate components to address the thumb de-

formity as described in the previous classification.

Pattern 4: wrist extension with intrinsic

hypertonicity

Spasticity in this pattern is located primarily in

the wrist extensor muscles, extensor carpi radialis

longus (ECRL) and extensor carpi radialis brevis(ECRB), and hand intrinsic muscles, with adduc-

tion flexion at the thumb CMC and MCP, flexion

and adduction of finger MCP joints, and hyper-

extension deformities of the finger PIP joints.

With flexion of the MCP joints the intrinsic pull

on the lateral bands of the finger extensor

mechanism is facilitated across the dorsal aspect

of PIP joint often restricting flexion motion at this

joint. The thumb metacarpal is held in an ad-

ducted position by contraction in the AP and first

DI muscles, with spasticity in the flexor pollicis

brevis (FPB) contributing to MCP flexion and IPextension.

Contracture can develop in the ECRL and

ECRB musculature, restricting wrist flexion. In-

trinsic muscle contracture is compounded by

decreased extensibility of palmar fascia and skin,

and by the fact EDC function is compromised in

extremes of wrist extension (Fig. 6A). Failure to

manage contracture in the intrinsic muscles and

palmar tissues presents problems for skin care and

hygiene.

The major obstacle to functional use of thehand is the inability to open the hand spontane-

ously. These patients need to disassociate elbow

extension from attempts to grasp, with opening of

the hand requiring a neutral wrist position and

extension of finger MCP joints. In addition, the

thumb must be extended out of the palm of the

hand if any grasp is to be effective. In small

children with this pattern, the thumb MCP flexion

contracture often presents the most significant

problem, as the thumb is trapped constantly

under the flexed fingers.

Fig. 4. The dorsal volar splint has components for

dorsal hand and forearm, volar hand and fingers, and the

thumb. Each component is molded separately to position

joints to address hypertonicity in wrist and finger

musculature.

Fig. 5. (A) In the absence of active wrist extension in pattern 3 deformity, the wrist flexion deformity is reinforced by use

of the wheelchair control. (B) A rigid functional thermoplastic splint immobilizes the wrist to achieve a better

biomechanic position for finger and thumb musculature. A lining sock is worn under the splint.



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Without intervention that has a long-term

perspective, this pattern of deformity can lead to

significant contractures of the thumb and finger

MCP joints. Treatment is directed toward pre-vention of intrinsic muscle contracture with main-

tenance of tissue extensibility and restoration of

the biomechanic balance to the wrist.

In young children who are highly motivated to

use their hand, who can control their elbow

position, and who have no contractures, dynamic

Lycra splints with design components to facilitate

wrist flexion and finger MCP extension can assist

re-education of extrinsicintrinsic muscle func-

tion. Repetitive functional use of the hand is

essential for improved muscle strength. Grossvoluntary opening and closing of the fingers

around objects appropriate to the hand size and

simple thumbindex finger pinch are appropriate

functional goals. Stretching protocols to prevent

contracture must address joint capsular structures,

particularly at the MCP joints and muscle tendon

unit length of the extrinsic finger musculature.

In persons/people for whom tonal patterns are

high and contracture is present, however, a greater

degree of wrist control is required, necessitating

more rigid functional splinting. Materials of choice

depend on whether the person can control wristmovement to neutral or slight flexion. Designs must

incorporate volar and dorsal components (Fig.

6B,C). The volar component is used to position the

thumb in abduction and extension for opposition

to the fingers and to provide counterforce at the

wrist. With appropriate splinting, finger extension

to activate switching or computer devices ispossible, together with a simple gross grip.

Night splinting to address contracture in

shortened musculature and soft tissues requires

the wrist to be positioned in some degrees of

flexion, the MCP joints in extension and abduc-

tion, the IP joints in some flexion, with main-

tenance of the thumb web space and MCP joint

extension. Experience suggests that a reduction in

hypertonicity of the wrist and finger musculature

also improves elbow function.

Pattern 5: fisted hand with wrist flexion or wrist

extension

This is the most severe deformity and reflects

the hypertonicity and secondary contracture of

muscles and associated connective tissues. The

fingers and thumb are maintained in a fisted

position with minimal active motion evident. Skin

maceration and nail care are problems.

Therapeutic interventionThe aim is to maintain sufficient motion so the

hand can be opened to prevent maceration,

Fig. 6. (A) Pattern 4 deformity results in a posture of the hand with significant wrist extension and finger flexion, with

the thumb adducted and flexed across the palm. (B,C) A two-piece splint is required to control wrist and thumb positions

to allow active finger motion.



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infection, and breakdown of the skin of the palm

and thumb. If opening of the fingers and

positioning of the thumb are possible, casting is

the preferred option. The gains are maintained by

bivalving the final cast or applying a splint. If

casting is not an option, prefabricated palmarprotectors and custom made soft rolls can create

an interface between tissue layers; however, they

do little to resolve contracture. This can be

achieved by gradually adding firm components

made of splinting material to the soft rolls to hold

joints more extended, with the circumference

determined by the degree of contracture in the

fingers and web space of the thumb.

Summary

The treatment of hand deformity and associ-

ated dysfunction is a major focus of physical and

occupational therapy for people with CP, as poor

grasp and manipulation has potential to impact

on many aspects of daily life. To assist therapists

in analyzing patterns of movement of the wrist,

finger, and thumb musculature at rest and during

functional activities, five patterns of deformity

commonly seen in the hypertonic hand are

described. Interventions that impact on hyperto-

nicity and associated contracture and that facili-

tate functional use of the hand in the presence of

these deformities are discussed. The paucity of

evidence from clinical trials on intervention

strategies reflects in part the diversity of people

with CP and the highly individual functional

problems they encounter. While further research

is needed on the many possible interventions and

how they contribute to maximizing hand function,

there is increasing evidence of the value of therapy

that is directed to functional outcomes relevant to

the individual.

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