Occupational therapy programs tables of content

GENERAL REFERENCE

GLASCOW COMA SCALE
The Glasgow coma scale is used to reflect changes in a patient’s consciousness. The scale can be used to quantify the degree of coma. Three indicators of consciousness are used: The stimulus needed to elicit eye opening, the type of verbal response, and the type of motor response. A score of 7 or less means that the patient is in coma, whereas a score of 9 or greater excludes the diagnosis of coma.
The scale originally described in 1974 and further discussed in 1979 by Teasdale and his associates, is widely used in assessing head injury patients, both at the time of the injury and as the patient is followed. The score is recorded every 2 to 3 days.
Glasgow Coma Scale

Best Verbal Best Motor

Eye Opening Points Response Points Response Points

Spontaneous 4 ORIENTED 5 Obey Commands 6

Indicates arousal mecha- Patient knows who and Do not classify a grasp

nisms in brain stem are active where he is, and the year, reflex or change in

Season, and month posture as a response

To Sound 3 Confused 4 Localized 5

Eyes open to any sound Responds to questions Moves a limb to attempt

stimulus Indicate varying degree of to remove stimulus

confusion & disorientation

To Pain 2 Inappropriate 3 Flexor: Normal 4

Apply stimulus to limbs, Speech is intelligible but Entire shoulder or arm is

not to face sustained flexed in response to

painful stimuli

Never 1 Conversation is not possible

Incomprehensible 2 Flexion: Abnormal 3

Unintelligible sounds such Slow stereotyped assumption

moans and groans are made of decorticate rigidity posture

in response to painful stimuli
None 1 Extension 2

Abnormal with adduction

and internal rotation of the

shoulder and pronation of the

forearm

None 1

Be certain that a lack of

response is not due to a

spinal cord injury

OCCUPATIONAL THERAPY

PROGRAMS

Section 19

PROGRAM: SPLINTING
DESCRIPTION/PURPOSE:
Splinting is a modality involving the construction of temporary custom orthoses using low temperature plastic materials. In some cases, a premolded form will be utilized and adjusted to meet the individual resident’s needs if indicated. Splints are classified as either static or dynamic.
OBJECTIVES/GOALS:

Prevent deformity caused by muscle tightness or joint contracture by placing the hand in a functional position. Functional position of the hand is 15-30" of wrist dorsiflexion, neutral to slight ulnar deviation of the wrist, partial flexion of the metacarpophalangeal (MCP) and interphalangeal (IP) joints of the fingers and thumb, and thumb abduction and opposition.
Protect weak muscles form over stretching so that maximal efficiency will be obtained when the muscle regains its function.
Prevent increased muscle imbalance by providing assistance to the weaker muscle group. For example, a dynamic splint that uses rubber bands to pull the part through the full ROM. This will enable weak muscles to work and allow active ROM.
Strengthen weak muscles by providing assistive motion first. Assistance is gradually decreased as muscle function improves. The goal is related to C above. The MP extensor assist or opponens assist are examples of splints with these purposes.
Provide temporary support for a painful part while permitting motion of uninvolved segments. An example is the wrist cock-up splint to support an arthritic wrist while allowing some hand motion.
Prepare the hand for future surgery to approximate the position or motions to be gained by surgery and provide the needed ROM and strength, if possible.
Place the hand in the correct or appropriate position after burn, surgery, trauma, or skin grafting.
Aid in the development of a useful tenodesis tightness in the long finger flexors for the wrist-driven flexor hinge splint.

Splinting (cont.)
INDICATIONS:

Static Splints:

Prevent unwanted motion.

Protection of weak muscles (i.e., temporary paralysis) from over stretching and therefore prevent their antagonists from contracting.

Support or immobilization of joint for resting purposes (rheumatoid arthritis, tendon laceration, skin grafting).

Prevention or correction of deformity (ulnar drift deformity).
Dynamic Splints:
Preserve or increase joint motion.

Assist weak muscles or substitute for lost muscle power.

Maintain muscle balance.
CONTRAINDICATIONS:

Prolonged immobility from splinting or positioning can produce limitations in joint ROM and ultimately joint stiffness and immobility.
Joints that do not require splinting should not be limited or immobilized by the splint. All joints proximal and distal to the splinted joint(s) should be used actively or exercised passively if active motion is not possible.
PRECAUTIONS:

Edema

Decreased Sensation

Open lesion

Hypersensitivity

EQUIPMENT:

Towels - to dry the heated material.

An awl or pencil - to scratch the pattern or mark modifications on the splint.

Straight and/or curved scissors.

Ace wrap - to wrap the material around the limb.

Bonding solvent - if required.

Cold spray and/or cold water - to set or cool the splint

Heat gun - for sectional heating

Splinting material

Velcro

Padding

Splinting (cont.)
PROCEDURES:

Choosing the splint design
To determine which splint design will be necessary to achieve the desired result, apply corrective forces manually to the resident’s hand. While applying these forces, note how much force and where the force is needed to put the hand into a functional position, or to assist it to move into functional grasp and prehension patterns. Remember that a relationship exists between the position of the wrist and the position and operation of the fingers due to tenodesis effect. This is an important fact to remember when deciding whether to make a short hand splint or one that crosses and supports the wrist. Both grasp and release should be enhanced, or at least potentially permitted, by the position the wrist will assume in the splinted hand.
Once the design parameters have been chosen, decide which of the following will meet the resident’s needs:

Obtain a prefabricated splint with minor adjustments in necessary.

Utilize a standard pattern and splint design.

Design a new splint for the resident’s unique problem.

Fitting the pattern

The procedure for making a splint pattern varies according to the clinician’s individual preferences. A precut splint blank may be used or the therapist can draw a pattern free-hand.

To draw the pattern on the hand, a soft paper towel is places over the entire surface of the hand and arm that the splint is meant to cover. The pattern is drawn free-hand to fit the contour of the hand which is palpated beneath the paper towel. When the pattern is completed, it is cut out and the paper toweling pattern is dampened with water for final fitting to the contours of the hand,

Splint making.
After the splint design has been selected and the pattern fitted to the resident, a

material is selected that best suits the purpose of the splint and the preferences

and skill of the therapist. Properties to consider in choosing material include

rigidity, work time, conformability, resistance to stretch, self-adherence, and

resistance to fingerprints. The actual splint fabrication varies greatly according

to the type of splint desired and the material being utilized.

Splinting (cont.)
Assemble all tools, equipment and materials near your heat source.

The basic splint shape may be heated in its entirety or sectionally, depending on the situation and the resident. The material must always be heated to a “rubber” state, then wiped dry of all water droplets before application to the resident. When the material needs to be stretched and curved, the therapist can best do this without an ace wrap.

Once the splint is formed, allow the splint to cool and set on the resident before unwrapping the hand and the splint. Handle the splint carefully and submerge it in cold water or use a cold spray. It might be necessary to spring the radial and ulnar sides of the splint for comfort, as the material may shrink slightly in cold water.

Check the fit of the splint on the resident and make minor adjustments as necessary by dipping the splint part in the hot water or using a heat gun.

Checkout of the splint.
The checkout is the process of examining the fit, function, and reliability of the orthosis. The checkout is done prior to establishing a wearing schedule and use training. Periodic re-check of the orthosis may be necessary for those residents who wear the orthosis on a permanent or long term basis.

Criterial for proper fit of a hand splint.

Any splint follows the contours of the hand and arm as closely as possible.

A wrist splint extends 2/3 the length of the forearm for proper leverage. It does not interfere with elbow motion.

A wrist splint holds the wrist in neutral position, or in 15" to 30" of dorsiflexion, depending upon the resident’s condition and purpose of the splint.

The width of the forearm piece of either dorsal or volar wrist splints usually extends to the lateral and medial midlines of the forearm for stability.

Bony prominences are kept free from pressure either by not covering them or by pushing out a space above them.

Except in special circumstances, volar hand splints must allow 90" of metacarpophalangeal flexion and therefore end at or above the distal palmar crease.

Allowance is made in dorsal hand splints for padding over the metacarpal area because of the need to protect superficial bones and tendons.

The arches of the hand are maintained.

The fingers are in a functional position.

Tight encircling parts and straps are avoided.

The thumb is in a position of function: abduction and opposition.

The splint does not restrict either the thenar or hypothenar eminences, which would thereby restrict motion.

There is no indication of reddened pressure areas 20 minutes after removal of the hand splint that has been worn for 30 minutes.

If the splint has a action wrist, does the forearm piece stay in position during wrist extension so that the joint of the splint remains aligned with the wrist joint?
Other considerations:
Does the splint needlessly immobilize a joint?

If the splint or parts of it immobilizes a joint, is the splint removed periodically and the joints moved through passive range of motion?

Does the splint actually accomplish the function for which is was intended?

Does the splint cover the least amount of skin area to permit tactile sensation, but also provide good distribution of force over sufficiently large areas?

Is available passive range of motion permitted at wrist, metacarpophalangeal and interphalangeal joints if desired?

Do all aplint joints approximate their corresponding anotomical joints?

Is the splint comfortable?

How long can the resident wear the splint without discomfort?

Is the splint made for ease of application and removal by resident or staff?

Is the splint cosmetically acceptable to the resident?

Establishing the wearing schedule.
A resident adjusts to a new splint over time by following a wearing schedule that designates the amount of time and the splint is to be worn and the amount of time the splint should remain off. The wearing schedule for a splint designed to correct deformity will start with a very brief wearing period, whereas a supporting splint will start with a wearing schedule of ½ hour or longer on and ½ hour off. The wearing period is gradually increased as tolerated.

The wearing schedule is established by the physician who ordered the orthosis, by the therapist who made it, or preferably by these two professionals in collaboration with each other.

Once a wearing schedule is established, a physician’s order is needed that specifies the type of splint, where it is to be applied, and the wearing schedule. Example: “Apply resting splint to left hand c.d. on 4 hours, off 2 hours.”

Splinting (cont.)

Providing nursing instructions.
Following establishment of a wearing schedule, the nursing staff is to receive instruction regarding the schedule.

Nursing staff is to receive instruction on the application and removal of the splint.

Nursing staff is to receive instruction in precautions and when to contact therapist.
DOCUMENTATION:
Documentation must reflect the need for skilled therapy, support the skilled nature of the splinting program, present objective and measurable progress and the resident’s improvement as related to functional abilities. Also include the resident’s response and tolerance to the treatment procedure; to activity/training provided to family/staff, and post therapy follow-up.

Splinting (cont.)

SPLINT SELECTION/PURPOSE

Type of Splint	Resident Diagnosis	Purpose of Splint
Palmar resting splint	Stroke, arthritis, quadriplegia	Supports the palmar transverse arch. Supports the thumb in abduction and maintains the thumb web space. Maintains functional hand position. Supports flaccid or weak muscles. Prevents flexion contractures.
Dorsal resting splint	Spastic hemiplegia resulting from stroke, head injury, birth defect.	Maintains functional hand position by supporting transverse arch and maintaining thumb web space. Theoretically facilitates extensor muscles to prevent flexion contractures in spastic hand.
Dynamic orthokinetic wrist splint	Spastic hemiplegia resulting from stroke, head injury, birth defect.	Hard hand cone and lipped forearm piece to inhibit spasticity in flexors. Elastic straps theoretically excite extensor to counteract flexor pull. Hinged wrist prevents hand and wrist deformity thereby decreasing pain.
Wrist cock-up splint.	Carpal tunnel syndrome	Places wrist in approximately 20 degrees of extension decreasing pressure on median and ulnar nerves which pass through carpal tunnel.
	Radial nerve palsy, quadriplegia, hemiplegia	Provides wrist stabilization and positioning to prevent over-stretching of extensor muscles and tendons.
Ulnar deviation splint	Arthritis	To retard progress of arthritic joint deformity which pulls fingers into ulnar deviation.
Dynamic finger extension splint	Peripheral nerve injuries, hand injuries.	Assists in finger extension in conditions where little or no muscle strength is present. Provides proper positioning while encouraging active movement of joint.
Dynamic wrist extension splint	Radial nerve palsy.	Assist in wrist extension in conditions where little or no muscle strength is present. Provides proper positioning while encouraging active movement of wrist.
Tenodesis splint	Quadriplegia	Utilizes existing wrist extension to accomplish passive finger flexion. Provides fingertip prehension needed for fine motor tasks.

PROGRAM: INHIBITORY CASTING
DESCRIPTION/PURPOSE:
Inhibitory casting is the use of Plaster of Paris or fiberglass casts for the management of chronic, severe extremity spasticity caused by central nervous system impairment. This procedure is to be completed only by therapists with specific continuing education in inhibitory casting.
OBJECTIVES/GOALS:

Stretch contracted tissue.

Maintain muscle fiber length and decrease its stretch response.

Maintain acquired range of motion.

Progressively correct contractures.

Increase functional independence.

Promote improved hygiene of contracted area and decrease risk of skin breakdown.

INDICATIONS:

Severe spasticity.

Contractures.

Abnormal joint positioning.

Clonus.
CONTRAINDICATIONS:

Edema.

Skin breakdown.

Joint ossification.

Presence of disease processes involving joint or bone (gout, hetereotropic ossification).

PRECAUTIONS:

Prolonged use may cause limitation in ROM.

Cast may slide distally and interfere with palmar crease.

Skin breakdown from pinching between A/P shells.

Improper fit can affect skin integrity and circulation.

Cast cutter should be inspected regularly to ensure proper functioning.

Inhibitory Casting (cont.)

ASSESSMENTS:

Range of Motion

Tone Analysis

Sensory evaluation of involved extremity.
EQUIPMENT:

Cotton cast padding

Tubular stockinette

Foam padding

Plaster rolls

Felt padding

Cast saw

Scissors

Cast trimming knife

Plaster bucket

Tepid water

Cast spreader

Cast bender

PROCEDURES:

An assessment is completed to determine the baseline condition of the extremity as well as the type of cast to be fabricated.
During the casting, consider the following:

Condition of the skin (must be intact).

Joint mobility is intact, ossification has not occurred.

Level of sensory awareness.

Range of motion prior to inhibition.

Position of joint(s) to be casted.

Preparation for cast application.
Gather materials and supplies.

Explain purpose and procedure to the patient.

Position patient in a comfortable position, either sitting, supine or sidelying.

Determine desired angle of cast, usually maximum ROM, before inhibition, minus 10 degrees.

Inhibitory Casting (cont.)
Determine best position for therapist applying splint and person responsible for assisting.

Drape patient with sheets to protect from plaster spillage, leaving involved extremity free.

Application procedure - the application procedure will vary depending on the type of cast and the patient’s condition. The procedure below includes general guidelines for the most commonly used casts: Long arm cast (with conversion to elbow drop out), short arm cast (with conversion to anterior/posterior spling), and elbow drop out.
Long arm cylinder cast with conversion to an elbow drop out cast.

Purpose:

Series of casts applied to progressively correct elbow flexion contractures.

Maintains acquired ROM

Allows for passive and active motion into extension (sensory input).

Weight of cast allows gravity to assist in stretching out elbow flexion contracture.

Approach:

Initial cast is applied at the end of easy passive ROM.

Posterior upper arm portion is cut away along the medial and lateral aspects distal to the olecranon.

Progressive dropout casting is changed weekly until full elbow ROM is accomplished.

Application:

Roll up stockinette into “donut” shape.

Place stockinette over hand and unroll up the arm to the axilla.

Apply cotton cast padding 1" proximal to the styloid process to 2" distal to the axilla, leaving stockinette at each end.

Apply foam strip from humeral condyle, over olecranon, to opposite humeral condyle and incorporate in cotton cast padding; pad bony prominences so that they are no longer prominent.

Moisten plaster bandages in tepid water. Apply plaster from proximal to distal, overlapping by ½ inch. Leave ½ inch of cotton cast padding uncovered at each end.

Pull stockinette over ends to cast and apply 3" x 15" splints to incorporate or apply one more 6" plaster roll if needed.

Make sure there is two finger’s width of space between arm and splint.

Inhibitory Casting (cont.)
Maintain desired position until plaster hardens.

When cast is hard, cut out posterior and upper arm from cast along the medial and lateral aspects distal to the olecranon.

Cut cotton cast padding and foam to the edges and fold over the edges.

Splint the exposed stockinette down the posterior aspect and fold over the edges.

Plaster stockinette in place with 3" x 15" splints, double thickness.

Bend out any impinging edges with a cast bender.

Follow cast application, check for areas of excessive pressure of constriction; note any complaints of discomfort by the patient.]

Check for signs of compromised circulation (skin discoloration, temperature changes, absence of blanching).

Allow the cast to dry completely for 24 hours before the patient resumes activity.

Variations:

Stockinette is not necessary, but makes a neater, complete cast.

Hand and wrist may be included.

Considerations:

Between casts, inspect skin for pressure points.

Clean arm between cast changes.

Provide range of motion between cast changes.

Short arm cast and conversion into an interior-posterior splint.

Purpose:

To maintain acceptable wrist and finger positions.

Follow-up progressive casting program for the wrist and hand.

Splints are removable for bathing, exercising and functional training.

Application:

Place small pieces of cast padding, two or three thicknesses, between fingers.

Provides extra space between fingers, reducing impingement.

Allows for easy subsequent removal.

Wrap fingers, thumb, wrist and forearm with two thicknesses of cast padding.

Inhibitory Casting (cont.)

Will be removed later and allows for greater ease in re-application of finished A/P splint

Compensates for possible shrinkage if splint is dried in oven.

Cut a hole in the stockinette at the appropriate place for the thumb to be inserted.

Apply stockinette to the arm bringing the thumb through the above mentioned hole.

Apply cast padding beginning at the finger tips, incorporate thumb, wrist, and forearm while maintaining optimal position.

Apply foam padding over all bony prominences and other areas requiring additional padding.

Incorporate foam padding with additional cast padding to give a more aesthetic appearance and to aid with east of removal.

Dip plaster rolls in water, folding back 1' of plaster roll to facilitate finding the leading edge of the wet roll.

Apply plaster rolls overlapping by ½ inch, beginning at the finger tips to the MCP joints.

Maintain IP extension, if that is the optimal position, and allow the plaster to set.

Apply another roll of plaster, incorporating the MCP joints and thumb.

Maintain optimal position and allow the plaster to set.

Apply additional plaster to finish the cast up the forearm and allow this portion to set.

Using a cast saw, bivalve the cast at the medial and lateral aspects.

Spread the cast edges apart with a cast spreader just enough to be able to cut underlying cast padding with bandage scissors.

Cut cast padding with bandage scissors on both the lateral and medial sides.

Lift off the anterior portion of the cast with the padding adhering to the plaster.

Remove the posterior portion.

Discard layer of cotton padding from between stockinette and skin.

Discard small pieces of cotton padding from between fingers.

With 2" tape, tape the edges of the cotton padding to the anterior and posterior shells; glue may be necessary to adhere to damp plaster.

Tape the stockinette to the plaster of the anterior and posterior shells making sure the stockinette liner is wrinkle free to prevent skin breakdown.

Apply the splint to the extremity and secure with buckle or velcro straps.

Straps can be plastered, taped or glued to the finished splint.

Inhibitory Casting (cont.)

Variations:

Cast can be allowed to dry on the patient for one or two days prior to being converted to an AP splint.

Frequency:

Once the cast is applied, cast checks should be performed daily to

observe the cast fit and integrity of the cast. The first set of casts

are usually changed at seven to ten days to evaluate skin integrity,

ROM, and further need for serial casting. After the first cast

change, the patient is evaluated for prolonged casting, which may

range from ten to thirty days.
RESOURCES:
Booth, B.J., Dole, M., and Montgomery, J. (1983) Serial Casting for Management Spasticity in the Head Injured Adult. Physical Therapy, 63 (12), 1960-1966.
Brennan, J.B., (1959). Response to Stretch of Hypertonic Muscle Groups in Hemiplegia. British Medical Journal, 1 (5136), 1504-1507.
Cruickshank, D., and O’Neill, D. (1990) Upper Extremity Inhibitive Casing In a Boy with Spastic Quadripletia. AJOT, 44 (6) 552-555.