Continuing our work with Restorative Medical, Inc., below we share a question from an Orthotic Fitter to Karen Bonn of Restorative Medical,
Inc. and the best response:
Question: Do you have a recommendation as to how I can accommodate a
contracture of basically the fifth digit only? Therapist
also wants to treat ulnar drift and "max pain" in bilateral
hands. The picture is below.
Response: I would suggest a prefabricated Prosperity Hand™ (if you cannot do Custom Hand Splints), and mold the 3rd/4th
finger plate down with a heat gun to
apply only mild, comfortable stretch. As the finger’s range improves,
that plate can be gradually remolded
to continue the PROCESS toward full extension.
If the Ulnar Drift is at the wrist, order the Ulnar Drift
Strapping or at the very least the Velcro® on wrist pad. Correcting these deformities will
help relieve the discomfort.
If it is from the MCPs and effects the fingers only, we would
normally recommend the Ulnar Drift Finger Separators, and add the Ulnar Drift Strapping
if needed.
Since the Prosperity Hand™ is recommended for this patient, it might
create a challenge to use finger separators since the base under the fingers is
split between the 3rd and 4th digits. We can make a
Velcro®-on pad the correct size to fit on the lateral side of the little finger
to help correct the Ulnar Drift. The
finger strap that separates the 3rd finger from the 4th
should adequately correct any Ulnar Drift in the 1st and 2nd
fingers. Ulnar Drift tends to be a very painful condition so – as any lost
range of motion condition – we want to provide a gradual comfortable stretch.
Please let this patient’s
clinicians know it takes 6 weeks of prolonged low load passive stretch to
realign the proteins (Actin and Myosin in the Sarcomere "units") in
the muscle to PREPARE the muscle to be relengthened
(not restretched). It is so common for people to look at all patients
as if they were orthopedic patients and perform aggressive stretching for a
length of time, and then assume that is all that can be done when they do not achieve
good results. Instead, if they adjust the correct technology of splint to
only put comfortable, flexible low load passive stretch on the joint(s), then
keep them on caseload just until the therapist is comfortable with the wearing
schedule, the splint is adjusted to comfortable meet their range at that time
with a gentle stretch, and has established a Plan of Care. At that time,
discharge them back to nursing for daily donning and doffing, but put on their therapy
calendar to look at them again in 6-8 weeks to possibly pick them back up on
therapy case load to readjust the splint farther toward normal alignment. At that time, the patient’s tissue should be
ready to begin the relengthening process. If this is continued every few
months throughout the year, at the end of 12 months the therapy staff will be
amazed at the progress, and they have used the patient’s therapy cap wisely.
Carrying out this
process to correct lost range of motion “contractures” can, according to the
joints/body parts affected, prevent Hospitalizations and ReHospitalizations,
wounds, pain, feeding tubes, specialized beds and wheel chairs, dementia
symptoms, falls... and even the need for institutionalization for 24 hour
nursing care. Correcting these deformities also helps to protect caregivers’
backs from injury during turning, repositioning and lifting patients, which
saves medical facilities vast amounts of money on Worker’s Compensation
injuries (and protects family members’ backs at home). Win/win!
Therefore, the key is
to differentiate patients between Orthopedic and Restorative (Neuro) and treat
them accordingly. Neuro patients who
have lost range of motion – whether from tone, shortened tissue or a
combination of both – require Flex Technology Splints™ to allow the body to go
through its process to reach a relaxation through the Central Nervous System by
gentle, flexible tugs on the tissue.
Orthopedic patients
require rigid splints after surgery or injury to hold a body part or joint in a
specific plane to facilitate healing and function. Totally different types of patients
that require totally different treatment measures and totally different
splints.
A general
understanding of the Central Nervous System and also the anatomy and physiology
in the extremities is vital to providing appropriate treatment for these
patients with conditions like: Cerebral Palsy; Traumatic Brain Injury, Acquired
Brain Injury, Strokes and other brain conditions; Multiple Sclerosis;
Parkinson’s; Spinal Cord Injury; Dementia and End Stage Alzheimer’s
disease. When patients suffer an injury
or disease process of the Central Nervous System it is common for that person
to begin to have inappropriate muscle contractions to a certain area of the
body, in the entire body, or in the body below the level of a spinal cord
injury, according to the area of injury and the extent of the injury. These muscle contractions that are not
relaxed because the controlling apparatus is not getting the message from
higher neural centers to tell the muscle to relax is referred to as “tone.”
Unaddressed or
inappropriately addressed tone leads to shortened tissue and any amount of tone
or shortened tissue that prevents full range of motion is a “contracture” and a
contracture is a deformity. We talk
about three types of Restorative, or Neuro contractures: Tone, shortened
tissue, and a combination of both.
Contracture
deformities are an injury, and many times a preventable deformity. Many patients with brain or spinal cord
injuries develop tone the 3rd day after injury when they are still
in the ICU. If we fit them with a Flex
Technology Splint™ and use nonaggressive stretching techniques then and
continually relax the inappropriate muscle contractions (tone), we may see
these patients go through the hospital stay with no deformity – through the
rehab stay with no deformity – and perhaps walk home instead of leaving in a
wheelchair and at times even to a long term care facility. At the very least they will have less far deformity.
Rigid, orthopedic splints
were never designed for neuro patients.
They were available and at some point it was realized that neuro
patients needed splints, so the available ones were used on them. If we watch the effects on patients using
rigid splints versus when a Flex Technology Splint™ is used, the difference is
remarkable. Rigid splints and aggressive
stretching tends to initiate tone in neuro patients, where the Flex splints
will typically relax tone in about 15 minutes as they provide a gentle,
flexible tug on the Golgi Tendon Apparatus.
A highly
respected Kentucky Physical Medicine and Rehab Physician, Kenneth Mook wrote: “I have found that a static, rigid
splint is not effective in controlling spasticity because it provides a
persistence of a spastic event by not allowing the muscle to shorten. A splint
that has static properties with some dynamic “give” during a spastic event
allows the muscle to shorten, thereby the spastic event regresses, and yet the
splint maintains the proper positioning of the joint.
Most RMI products can be found online at our Neuroflex Store.