Splinting for the prevention and
correction of contractures in
adults with neurological
dysfunction
Practice guideline
for
occupational therapists and physiotherapists
Implementation Toolkit/CPD Session
© 2015 College of Occupational Therapists.
This PowerPoint may be copied and adapted for non-commercial use
www.COT.org.uk
Learning outcomes
• To explore aspects of the practice guideline
recommendations in relation to current
practice.
• To develop an understanding of the
importance of using practice guidelines to
inform practice.
• To explore and develop an understanding of
how to use the Audit Form for use with the
evidence-based recommendations.
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2
Practice question:
What is the evidence for
the use of splinting in
adults with neurological
dysfunction
for the prevention and
correction of
contractures?
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Key objective of guideline
To promote best practice in the use of splinting
in adults with neurological dysfunction for the
prevention and correction of contractures.
To assist clinicians with their clinical reasoning,
an exploration of the physiological
background to the development of contracture
has been included in the guideline.
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4
Methodology
1. Guideline development
group established
5. Critically appraise articles
6. Development of practice
guideline recommendations
9. Published by
COT 2015
Implementation Toolkit/CPD Session
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2. Guideline scope defined
involving stakeholders
4. Screen findings
3. Literature search
7. Peer review, stakeholder and
service user consultation
8. Final draft approved by COT
Practice Publications Group
www.COT.org.uk
5
Evidence-based recommendations
Recommendations are based on the evidence
available within 33 critically appraised papers.
Each recommendation is assigned:
• A strength scoring 1 or 2 (Strong or Conditional)
• A quality grading A, B, C or D
(High, Moderate, Low or Very Low)
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Recommendation areas
Lower limb
• Ankle – contracture correction, contracture
prevention
• Knee – contracture correction, contracture prevention
Upper limb
• Wrist and hand – contracture correction,
contracture prevention
• Elbow – contracture correction
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Lower limb
Ankle: Contracture correction
1. It is suggested that ankle casts are used at end range (for people with
ABI and stroke) for improving range of movement at the ankle joint.
2C
(Booth et al 1983 [D] ABI; Carda et al 2011 [B] stroke; Lehmkuhl et al
1990 [D] ABI; Moseley 1993 [C] ABI; Moseley et al 1997 [B] ABI; Pohl
et al 2002 [C] ABI and stroke; Singer et al 2003a [B] stroke and ABI;
Singer et al 2003b [C] stroke and ABI; Verplancke et al 2005 [B] ABI;
Yasar et al 2010 [D] stroke)
2. It is suggested that ankle casts are applied at end range to improve
joint range of movement in conjunction with botulinum toxin A (in people
with stroke and ABI) when presenting with clinically significant spasticity
(see also RCP 2009).
2B
(Carda et al 2011 [B] stroke; Farina et al 2008 [B] stroke; Verplancke et
al 2005 [B] ABI; Yasar et al 2010 [D] stroke)
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Ankle: Contracture correction contd..
3. It is suggested that adjustable ankle splints applied at end range can be
used (in people with stroke and ABI) for improving joint range of
movement.
2C
(Grissom and Blanton 2001 [D] stroke and ABI; Lai et al 2008 [C] ABI
and stroke)
4. It is suggested that caution is exercised when considering the use of
non-custom-made splints for the correction of contractures (at the ankle
in people with stroke and ABI) due to the risk of pressure sores.
2D
(Grissom and Blanton 2001 [D] stroke and ABI)
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Lower limb
Ankle: Contracture prevention
5. It is suggested that ankle casts at end range dorsiflexion (in people with
acute ABI) can prevent loss of range of movement.
2C
(Conine et al 1990 [C] ABI)
6. It is suggested that an ankle splint can be used for preventing
the loss of range of movement at the ankle joint (in people with
stroke) when positioned at plantar grade.
2B
(Robinson et al 2008 [B] stroke)
7. It is suggested that caution is exercised when considering the use of
non-custom-made splints for the prevention of contractures (at the
ankle in people with stroke) due to the risk of pressure sores.
2B
(Robinson et al 2008 [B] stroke)
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Lower limb
Knee: Contracture correction
8. It is suggested that casts may be used for the correction of contracture
(in people with ABI and stroke) with the knee joint positioned at end
range of movement.
2D
(Booth et al 1983 [D] ABI; Lehmkuhl et al 1990 [D] ABI; Pohl et al 2002
[C] ABI and stroke)
9. It is suggested that short-duration cast application (1–4 days) may
produce a lower complication rate than longer-duration cast application
(4–7 days).
2C
(Pohl et al 2002 [C] ABI and stroke)
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Knee: Contracture prevention
10. It is suggested that casts at end range of movement at the knee joint
may be used (in people with stroke and ABI) for the prevention of
contracture.
2C
(Pohl et al 2002 [C] stroke and ABI)
11. It is suggested that caution is used when considering casts for acute
patients (with ABI and stroke) and at lower levels of arousal because of
possible risks of secondary complications (e.g. pressure areas).
2C
(Pohl et al 2002 [C] stroke and ABI)
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Upper limb
Hand and wrist: Contracture correction
12. It is suggested that splints should not be used routinely for the
correction of range of movement but may be beneficial in selected
cases (in people with stroke and ABI).
2B
(Abdolvahab et al 2010 [D] stroke; Amini et al 2009 [D] stroke; Beaty
and Murphy 2013 [C] stroke; Bürge et al 2008 [A] stroke; Charait 1968
[D] stroke; Doucet and Mettler 2013 [C] stroke; Fayez and Sayed; 2013
[C] stroke; Lannin et al 2007a [A] stroke; Lannin et al 2003 [B] stroke
and ABI; Leung et al 2012 [A] stroke and ABI; Shamila et al 2011 [D]
stroke)
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13
Upper limb
Hand and wrist: Contracture prevention
13. It is suggested that splints should not be used routinely to prevent loss
in range of movement at the wrist and hand (people with stroke and
ABI) but may be beneficial in selected cases.
2B
(Basaran et al 2012 [B] stroke; Bürge et al 2008 [A] stroke; Harvey et al
2006 [A] stroke and ABI; Lannin et al 2007a [A] stroke; Lannin et al
2003 [B] stroke and ABI; Shamila et al 2011 [D] stroke)
14. It is suggested that splints in conjunction with botulinum toxin A (in
people with stroke and ABI) may reduce spasticity as a component in
preventing loss of range of movement in selected cases.
2C
(Carda and Molteni 2005 [C] stroke and ABI)
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Hand and wrist: Contracture prevention contd..
15. It is suggested that electrical stimulation of wrist and finger muscles
combined with a custom-made wrist and hand splint should not be used
routinely to prevent loss in range of movement (in people with stroke or
ABI).
2A
(Leung et al 2012 [A] stroke and ABI)
16. It is suggested that a custom-made wrist and hand splint should not be
used routinely to prevent the increase (or worsening) of spasticity (in
people with stroke and ABI).
2B
(Basaran et al 2012 [B] stroke; Bürge et al 2008 [A] stroke; Jung et al
2011 [C] stroke; Leung et al 2012 [A] stroke and ABI; Shamila et al
2011 [D] stroke)
17. It is suggested that a splint in a neutral wrist position may be beneficial
(for people with stroke) for prevention of hand pain associated with joint
malalignment.
2A
(Bürge et al 2008 [A] stroke)
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Key steps for
consideration
when splinting
adults with
contractures
(COT and ACPIN 2015 p40)
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Implementation Toolkit/CPD Session
© 2015 College of Occupational Therapists
www.COT.org.uk (COT and ACPIN 2015 p41)
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(COT and ACPIN 2015 p41)
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Upper limb
Elbow: Contracture correction
18. It is suggested that casts at end range are used (for people with ABI
and stroke) for improving range of movement at the elbow joint.
2C
(Hill 1994 [C] ABI; Lehmkuhl et al 1990 [D] ABI; Moseley et al 2008 [B]
ABI; Pohl et al 2002 [C] ABI and stroke)
19. It is suggested that short-duration cast application (1–4 days) may
produce a lower complication rate than longer-duration cast application
(4–7 days).
2C
(Pohl et al 2002 [C] ABI and stroke)
Implementation Toolkit/CPD Session
© 2015 College of Occupational Therapists
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Impact of practice guideline
for you: the practitioner
• Challenges / affirms your current practice.
• Informs your practice.
• Provides evidence to support your practice
(completion of Audit Form).
• Provides a vehicle for you to justify your
practice.
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Impact of practice guideline
for managers
• Articulates the need for splinting as a useful
adjunct in the therapist’s toolbox in the
prevention and correction of contractures.
• Provides a structure to audit the work of
occupational therapists and physiotherapists
within the service to improve service quality.
• Provides a vehicle for justifying service
provision.
Implementation Toolkit/CPD Session
© 2015 College of Occupational Therapists
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Impact of practice guideline
for commissioners
• Provides evidence of the need for occupational
therapy and physiotherapy for adults who have
or are at risk of contracture from neurological
dysfunction and require splinting as one part of a
comprehensive goal-directed neurological
rehabilitation or management programme.
• Provides guideline recommendations developed
by a NICE Accredited process.
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Impact of practice guideline
for service users
• The recommendations reinforce the fundamental
importance of the service user perspective.
• In being adopted by services and occupational
therapists, the guideline should improve the
consistency and quality of intervention for users
of services.
• Gives assurance that practitioners use the
available evidence to support interventions.
Implementation Toolkit/CPD Session
© 2015 College of Occupational Therapists
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“This one is sporty
looking… put on a pair
of shorts and you look
like you have had a
sports injury”
“. . . in hospital I was
really skinny, when I got
out I put on weight and
the splint was too tight
and had to stop wearing
it.”
“. . . can’t wear nice shoes, having to
buy two pairs, one pair bigger to get
the splint in; it’s expensive and
embarrassing, I wouldn’t want to
take a splint to a shop.”
Implementation Toolkit/CPD Session
© 2015 College of Occupational Therapists
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“Until the serial
casting started,
getting my left
heel down was
always a
struggle”
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Practice guideline resources
• College of Occupational Therapists and Association of Chartered
Physiotherapists in Neurology (2015) Splinting for the prevention
and correction of contractures in adults with neurological
dysfunction: practice guideline for occupational therapists and
physiotherapists. London: COT.
• Audit tool
• Quick Reference Guide
• Feedback form
The full practice guideline together with implementation resources
can be accessed from the College of Occupational Therapists
website: www.cot.org.uk and ACPIN website: www.acpin.net.
Implementation Toolkit/CPD Session
© 2015 College of Occupational Therapists
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