UPPER LIMB ORTHOSIS

- HETVI BHATT

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

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

Categorized :- Upper limb orthosis- Trunk orthosis- Lower limb orthosis

Objectives of upper limb orthosis:1) Protection : - stabilization- Dynamic control2) Correction3) Assistance

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

Nomenclature :

On basis of - joint they cover- the function they provide - condition they treat- by appearance- name of the person who designed

them

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

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

Classification :

On basis of anatomical regions:- Shoulder and arm orthosis- Elbow orthosis- Wrist orthosis- Hand orthosis

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

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

Non-articular splint – gel shell splint

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

Static motion – blocking – swan neck splint

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

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

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

Dynamic traction splints- schenck splint for intraarticular fracture

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

Biomechanics of orthosis

External force + moments on body Internal forces Mainly 4 biomechanical principles:1) Control of moment across a joint2) Control of normal forces across a

joint3) Control of axial forces across a joint 4) Control of action of ground reaction

force

General principles:

1) Uses of force2) Limitation of movements- pain3) Correcting the mobile deformities4) Fixed deformity5) Adjustability6) Pressure reduction7) Heat

8) Weight9) Maintenance and cleaning10) Application11) Sensation12) Gravity 13) Comfort14) Cosmesis

Special principles:

1) Principle of Jordan2) May assist with residual motor

power or substitute for absent motor power

3) Prehension force must be adequate4) Only one action5) Operation of electrically powered

orthosis6) Tactile sensation

Assessment :

Subjective assessment:- Comprehension- Complaints – pain, performance,

appearance- Previous orthotic experiences- Gadget tolerance- The goals- Economic consideration

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

Description of orthoses:

1) Calvicular orthoses: Regional name: shoulder orthosis Common names: figure of four

harness, clavicular brace/ harness

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

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.

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)

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

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.

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.

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

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.

3) Arm abduction orthosis:- Regional name: shoulder elbow wrist

hand orthosis- Common name: airplane splint

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

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

Functional arm orthosis Arm suspension sling – deltoid aid

Balanced forearm orthosis- gun slingerArm supports- wheelchair arm trough

Nonarticular fracture orthosis- humeral fracture brace

4) Elbow- forearm wrist othosis: Regional name : elbow wrist hand

orthosis Common name: sugar-tong splint

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 900 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

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

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

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.

Materials:- Casting- Thermoplastics- Elastics- Neoprene - Metal- Strapping- Velcro- Springs

Contraindications: - Dynamic traction put on muscles with high tone

may increase tone.

Posterior elbow splint Epicondylar straps

Articulated elbow orthosisDynamic supination/pronation splint

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

Dynamic cock up splint

Half cock up splint

Spring cock up splint

Functions Indications

Immobilize to promote tissue healing

CTDCTSFlexor/extensor tendinitisLateral/medial epicondylitisWrist sprain/contusionArthritisForearm/wrist fracturesPost operative extensor tendon repairPost operative wrist fusionPost operative skin grafting

Substitute for weak wrist extension

SCIBPL

Prevent overstretching of wrist extensorsStabilize the wrist for maximal grasp and pinch prehension/strength

ALSRadial nerve lesionPolioGBSArthrogryposisUMN lesion: CVA, TBI, CP,MS

Immobilize wrist / forearm to maintain PROMRestrict 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

Placement:- This orthoses are volar, dorsal,

circumferential, or gutter based, extending from the proximal MP to 2/3rd of the distal forearm.

- If volar based, palmar material should end 1/4th 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.

Materials:- Rigid: metal, thermoplastics, casting,

straping, velcro- Flexible: neoprene leather, plastics,

fabric, strapping, velcro

7) Forearm-wrist- thumb orthosis: Regional name: wrist-hand-forearm

orthosis Common names:- Long opponens splint- Thumb spica

Functions Indications

Immobilize thumb/wrist to promote tissue healing

-CMC/MP synovitis/ arthritis-CTD- de Queryain’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 lesionUMN lesion: CVA, TBI, CP

Maintain thumb prom burns

Restrict motion to prevent harmful thumb positions during activities

CTDArthritisAthletes or performing artists

Elongate soft tissues via low-load, prolonged stretch (serial static splinting)

-Burns-Thumb contractures

• Placement :- The orthotic material usually cover 2/3rd of the distal radial forearm and surrounds the thumb to the IP ( but can extend to tip)

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.

Materials :- rigid: thermoplastics, metal, strapping,

velcro, casting, padding- Flexible: neoprene, elastics, fabric,

leather, strapping, velcro

Bunnell knuckle bender Spider splint

Radial gutter splints

Dynamic finger flexion splint

RIC tenodesis othosis

Resting pan splint

Bobath splint Kleinert flexor tendon repair splint

Short opponens splint Ulnar deviation correction splint

Partial hand opposition splint Finger orthosis

Reverse knuckle bender C-Bar splint web splint

Shock absorbing gloves

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

Swan neck splint

Boutonniere splint

Functions Indications

Block PIP/DIP hyperextension but allow normal IP flexion /extension

ArthritisSwan neck deformityPIP/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

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.

A2 pulley ring: - Fits firmly around the proximal phalanx

from the PIP volar crease to the MP volar crease.

Materials : - Metal- thermoplastics

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

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.

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).

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.

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.

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.

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.

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.

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.

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

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

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.

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.

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

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

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.

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.

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

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