Serial Casting for the Management of Spasticity in the
Head-Injured Adult
B. J. BOOTH,
MARI DOYLE,
and JACQUELINE MONTGOMERY
Soft tissue contractures resulting from spasticity are a frequent sequella of
traumatic head injuries. This article identifies rationale for the use of serial
casting to manage these deformities, provides guidelines for cast fabrication
and application, and reports the results of lower extremity casting on 42 headinjured adults at Rancho Los Amigos Hospital.
Key Words: Contracture, Head injuries, Physical therapy, Plaster casts.
After traumatic head injury, many patients develop
soft tissue contractures as a result of spasticity. Passive
range-of-motion (ROM) exercises, positioning,
stretching, and splinting techniques1 are often inadequate for maintaining joint motion in the head-injured patient. Serial plaster casting is a technique that
has been used effectively for over a decade to manage
spasticity-induced contracture in these patients.2, 3
This technique can also be used in the presence of
potentially deforming spasticity to prevent the development of contractures. The purposes of this article
are to identify the rationale for using serial casting, to
present guidelines for the fabrication and application
of casts, and to report the results of lower extremity
casting on 42 head-injured adults at Rancho Los
Amigos Hospital in Downey, California.
INDICATIONS AND CONSIDERATIONS FOR
SERIAL CASTING
Indications for serial casting are ROM limitations
or presence of potentially deforming spasticity. The
causes of ROM limitations must be assessed carefully.
Serial casting is most effective in managing soft tissue
contractures resulting from spasticity. Range of motion limitations in head-injured patients can also be
the result of heterotopic ossification, fractures, or
ligament injuries. Serial casting may be used in these
conditions but may not be as effective.
Serial casting has been the most effective in our
experience when used within the first six months after
Ms. Booth is a physical therapist and Co-director of The Head
Injury Center at Lewis Bay, 89 Lewis Bay Rd, Hyannis, MA 02601
(USA).
Ms. Doyle is an occupational therapist and Co-director of The
Head Injury Center at Lewis Bay.
Ms. Montgomery is Physical Therapy Supervisor II, Physical
Therapy Department, Rancho Los Amigos Hospital, 7601 E Imperial
Hwy, Downey, CA 90242.
1960
injury and with patients demonstrating ongoing neurological recovery. Patients with long standing and
fixed joint contractures may demonstrate some improvement in ROM after a serial casting program. If
no underlying motor control is unmasked and spasticity is not reduced after the casting procedure, the
probability of maintaining improvement in ROM
without bracing or splinting is poor.
When assessing a patient for serial casting, the
clinician must take several factors into consideration.
In the early acute phase, the initial consideration is
the patient's medical stability. Some physicians believe that casting increases intracranial pressure, but
others do not believe that casting has a direct effect
on intracranial pressure changes. The therapist must
consult the attending physician before initiating a
casting program.
Other medical considerations include unhealed
fractures, poor skin condition because of lacerations
or abrasions, and need for easy accessibility of the
limbs to monitor vital signs and to administer medications. These factors may necessitate postponement
or modification of the casting program.
Another factor to consider with the head-injured
patient is that cognitive impairment often interferes
with the patient's ability to cooperate and relax, and
to interpret and respond to pain. The therapist must
develop skill in assessing the actual easily obtained
ROM and the point at which the limb should be
casted and must not be confused by the patient's
initial response to pain.
GUIDELINES FOR THE APPLICATION
OF CASTS
For patients in a treatment program scheduled for
five days a week, all casts should be applied early in
PHYSICAL THERAPY
the week so that the patients can be closely monitored
for possible complications, such as pressure areas and
swelling. During the cast application, we check for
vasoconstriction or discoloration of the fingers or
toes. Temporary skin discoloration during the actual
cast application is not uncommon, but if the discoloration persists for more than 20 to 30 minutes, the
cast should be removed and a new cast applied.
Special care should be taken to ensure that all areas
that are vulnerable to pressure, such as bony prominences, are well padded to prevent skin breakdown.
Lower extremity casts should be allowed a minimum
of 24 hours to dry before the patient resumes weightbearing activities to ensure the integrity of the cast
and to prevent unwanted indentations that may be a
source of pressure and skin breakdown. All casts used
for weight bearing should be provided with a plantigrade surface. At every cast change, the therapist
should provide passive ROM to maintain full mobility of all immobilized joints. Patients who are agitated
may require extra plaster to prevent breakdown of
the cast from abuse. Fiberglass casting material is not
recommended in these cases because it often splinters,
leaving sharp edges.
GENERAL PROGRESSION OF
SERIAL CASTING
The initial cast in a serial casting program is referred to as the resting cast. It is applied with the limb
positioned at the end of its easily obtainable ROM
and is left on for 7 to 10 days. After the resting cast,
a series of positional or drop-out casts are applied at
weekly intervals. Between cast changes, the therapist
guides the limb through a complete ROM and applies
each new cast in a slightly improved position of
correction. Most often, three to four positioning casts
are used to achieve the desired ROM corrections.
Once the desired or maximally obtainable ROM has
been achieved, the final or holding cast is applied.
The holding cast remains in place for 7 to 10 days to
ensure the maintenance of the newly acquired ROM.
The holding cast is then bivalved and converted into
an anterior-posterior splint. The patient is gradually
weaned from the anterior-posterior splint as he becomes more active. A patient who continues to have
weakness and increased spasticity wears his anteriorposterior splint at night.
Materials for Cast Application
In preparation for initiating a casting program, the
therapist should obtain adequate materials and supplies. Supplies required include the following: bandage scissors; cast saw, trimming knife, spreader, and
bender; plaster bucket; and tepid water. Materials
Volume 63 / Number 12, December 1983
required include the following: 3-in,* 4-in, and 6-in
rolls of cotton cast padding; 2.5-in tubular stockinette
for upper extremity casts and 4-in stockinette for
lower extremity casts; foam padding; felt padding; 4in and 6-in fast-setting or extra fast-setting plaster
rolls; 3-in by 5-in plaster splints for upper extremity
casts and 4-in plaster splints for lower extremity casts.
The procedure is explained to the patient in simple
terms, and if he is nervous or frightened, an attempt
is made to allay the anxiety. The patient is positioned
correctly before beginning. Lower extremity casts are
applied with the patient in the supine position. For
upper-extremity cast application, the patient can be
either supine or sitting. Sheets or plaster drapes are
used to protect against plaster spillage.
Procedures for Cast Application
Tubular stockinette is precut to approximately the
length of the limb receiving the cast and is rolled into
a "doughnut." The stockinette is rolled onto the limb
and smoothed out to eliminate wrinkling. Cotton
padding is applied in a spiral fashion by working in
smoothly overlapping 1.5-in layers. At least two to
three layers are required. Special caution is taken to
prevent wrinkles. Foam padding is applied to all bony
prominences, and an additional roll of cotton padding
is applied over the foam. Plaster rolls are dipped with
the ends up in tepid water for several seconds. The
ends of the role are crimped to avoid a wringing
motion when removing excess water. The plaster is
applied to the limb in the same spiral fashion as the
padding and is smoothed and molded as progress is
made. When the plaster is rolled, the roll is kept as
close to the limb as possible to avoid pulling the
plaster, which causes tension on it. The limb is maintained in the desired position as the plaster sets; care
is taken to avoid indenting the plaster with the fingers
and producing unwanted pressure points. Two rolls
of plaster are usually adequate for upper extremity
casts and three to four rolls for most lower extremity
casts. Larger or stronger patients may require additional plaster. When the plaster sets, the stockinette
is folded over the cast edges and secured with plaster
splints.
Casts can be fabricated without the use of stockinette. However, stockinette is recommended for those
casts that will be bivalved and converted to anteriorposterior splints. The stockinette protects the cotton
padding from fraying and becoming wadded during
frequent splint removal. If the stockinette becomes
stained, it can also be easily replaced.
The procedure for fabricating plaster casts is essentially the same for all casts. Drop-out casts are modifications of cylinder casts. For example, the elbow
* One in equals 2.54 cm.
1961
Fig. 1. Elbow drop-out cast
Fig. 2. Knee drop-out cast with the anterior portion of
cast removed below the knee.
Fig. 6. Short-arm cast.
Fig. 5. Elbow drop-out cast with the hand included.
drop-out cast is fabricated from a long-arm cylinder
cast (Fig. 1). The posterior upper arm is cut out along
the medial and lateral aspects with a cast saw. The
two cuts are connected with a curved cut just distal to
the olecranon process. After the shell is removed, the
cotton padding and foam are cut to the cast edges.
The exposed stockinette is split down the posterior
aspect of the arm, folded over the cast edges, and
affixed to the cast with 3-in by 15-in plaster splints.
The edge of the cast distal to the olecranon process is
bent out slightly with a cast bender to provide a
smooth rounded edge.
The knee drop-out cast is an adaptation of the
long-leg cylinder cast including the foot (Fig. 2).4 The
anterior lower shell of the cast is removed from
anterior to the medial and lateral epicondyles and
femoral condyles to just superior to the patella. The
cotton padding and foam are removed, and the stockinette affixed to the cast in the same manner as
described with the elbow drop-out cast. When the
patient is in the prone position, his knee is permitted
to extend, but not to flex. When he is in the supine or
sitting position, his foot is supported in the posterior
shell of the cast and held in good alignment. If a
patient has a severe equinovarus deformity, the lower
portion of the knee drop-out cast can remain intact
and the anterior thigh portion of the cast can be
1962
removed from anterior to the femoral condyles to just
inferior to the patella (Fig. 3).
Two of the more commonly used casts are applied
as follows:
1. Long-arm cast. The patient's hand is placed
through a precut 2.5-in tubular stockinette
"doughnut," and the stockinette is rolled from the
wrist up to the axilla. The 3-in cotton padding is
applied by working from the wrist, just proximal
to the ulnar styloid process to about 2 in below
the axilla. Foam padding is applied to all bony
prominences at the wrist and elbow. At the elbow,
a foam pad is placed over the olecranon process
and both humeral condyles. An additional roll of
cotton padding is used to cover the foam. A 4-in
roll of plaster is moistened, applied to the arm
starting at the wrist, and smoothed and molded.
The elbow is maintained in the desired position as
the cast sets. The stockinette is folded over the cast
edges and incorporated with 3-in by 15-in plaster
splints.
2. Short-leg cast. A 4-in piece of tubular stockinette
is measured and cut to extend from the knee to
about 1 in distal to the great toe. The stockinette
is placed on the foot and unrolled up to the knee.
The excess stockinette is gathered at the anterior
aspect of the ankle and folded smoothly. The fold
may need to be cut and overlapped to prevent
PHYSICAL THERAPY
Fig. 3. Knee drop-out cast with the anterior portion removed above the knee.
Fig. 4. Elbow drop-out cast with the wrist included.
Fig. 7. Short-arm cast with thumb spica.
Fig. 8. Short-arm cast with the hand included. Note flexion of MCP joints.
wrinkling. A roll of 3-in or 4-in cotton padding is
applied as described before. Use of a figure-eight
wrapping technique around the ankle and heel
helps to prevent gapping. Again, two to three
layers of padding are desired. Foam pad is applied
around the posterior heel and over the medial
malleolus and lateral malleolus. If the tibia is
prominent, a foam pad is placed from the ankle to
the knee. The foam is covered with an additional
roll of cotton padding. A 4-in or 6-in plaster is
moistened and applied, working from the toes to
the knee and avoiding wrinkles at the uneven
surfaces of the foot and ankle. The foot is held in
the desired position by using the palm of the hand
to avoid pressure from the fingers. If additional
cast strength is needed, five 5-in by 30-in plaster
splints are applied along the plantar surface of the
foot and the posterior aspect of the leg and incorporated into the cast with an additional roll of
plaster. The top of the cast is trimmed back to
expose the toes and the stockinette is incorporated
as before.
CLINICAL APPLICATION OF SERIAL
CASTING
The most common problems of the upper extremity
that are managed with serial casting occur at the
Volume 63 / Number 12, December
1983
elbow, wrist, and hand. The most prevalent problem
at the elbow, amenable to serial casting, is limited
elbow extension. A long-arm resting cast is applied at
the end of the easily obtainable passive extension
ROM. Seven to 10 days after application, the cast is
removed and followed by a progression of elbow
drop-out casts. These casts permit passive and active
motion into extension while maintaining the already
acquired extension ROM. The advantage of cutting
out this cast at the proximal end is that the weight of
the cast will act with gravity to provide a passive
stretch when the patient is sitting or upright. Variations of this cast can be made to include the wrist or
hand (Figs. 4, 5). When the cast is applied, the
forearm is placed in a position of neutral supination
and pronation. These casts should be changed weekly.
Once the maximal extension ROM has been obtained with drop-outs, the patient is placed in a
holding cast to ensure maintenance of the final ROM.
This cast is bivalved and removed in 7 to 10 days and
made into an anterior-posterior splint to be used
mainly as a night splint. The straps are attached to
the splint with plaster to prevent them from being
lost. The confused patient may also need the straps
taped down to prevent him from removing the splint.
1963
The most common problems in the wrist and hand,
amenable to serial casting, also relate to limited extension ROM. A series of short arm casts are used to
bring the wrist to a functional position and maintain
it in about 30 degrees to 45 degrees of extension (Fig.
6). Casts are changed every 7 to 10 days. During
application, special attention is given to the web space
and thumb to ensure free mobility of the thumb and
to the volar surface to ensure that the cast is cut back
proximal to the distal palmar crease, which allows the
metacarpophalangeal (MCP) joints to flex and prevent shortening of the collateral ligaments.
Variations of the cast can be used to address more
specific problems. For example, the thumb may be
included through incorporating a thumb spica (Fig.
7). The spica helps maintain the web space and
prevent the thumb from posturing in the palm. Positioning the thumb in abduction and extension has
also been known to decrease flexion tone in the wrist
and hand.5
Another variation is the full-hand cast in which the
fingers as well as the thumb are included (Fig. 8).
This cast is most often used with patients who demonstrate a severe increase in finger flexion and intrinsic muscle tone. Special precautions must be taken
with this type of cast to prevent ROM limitations at
the MCP joints. Therefore, this cast should be applied
with the MCP joints in flexion, changed every five to
seven days, and never used in progression for more
than two weeks.
Any of the above short-arm casts can be bivalved
and made into anterior-posterior splints.
The most common problems of the lower extremity
that respond well to casting occur at the knee and
ankle. At the knee, casting can be used for improvement of knee flexion contractures. Initially, the leg is
positioned in an easily obtained passive knee extension ROM and placed in a long-leg resting cast.
Patients who are unable to assume a prone position
or who have knee flexion contractures of 60 degrees
or more will continue on a progressive serial casting
program until the knee flexion contracture decreases
to less than 60 degrees. At that point, if the patient
can tolerate a prone position, a progression of knee
drop-out casts can be used. The knee drop-out cast
permits free extension but does not allow flexion.
Once optimal knee extension ROM is achieved, a
long-leg holding cast is used to maintain the knee in
its corrected position for two weeks. The holding cast
is converted to an anterior-posterior splint, which the
patient wears full time initially. He is gradually
weaned from the splint as he becomes more active
and eventually uses it as a night splint only.
TABLE 1
Equinovarus deformity is the most common spastic
Changes in ROM and Muscle Tone with Use of Shortdeformity after head injury because it occurs with
Leg Casts in Patients with Cortical Lesions
both decorticate and decerebrate posturing. A progressive short-leg serial casting approach is recomDorsiflexiona ROM (°) Plantar Flexor
b
Tone
mended. After the initial resting cast, a series of shortleg casts are used to correct the equinus and varus
Range
Range
positions gradually. After the foot has been corrected
- 5 0 to0
1.9
1 to 3
Precast
-16
to neutral position, it is maintained in plaster for two
1.4
0to3
Postcast
0.7
- 1 5 to 20
weeks. Once the holding cast has been converted to
0.5
0to2
17
Change
- 5 to 50
an anterior-posterior splint, the splint can be used as
a
Ankle motion measured from right-angle neutral po- a night splint, and foot positioning can be maintained
sition.
during the day in a well-fitting ankle-foot orthosis
b
0 = Normal, 1 = Slightly Increased, 2 = Moderately
Increased, and 3 = Severely Increased, based on resist- with the ankle locked in neutral position.
Adaptations can be made to existing lower extremance to passive motion.
ity casts to address ROM limitations of abduction
TABLE 2
and internal rotation at the hip. Adductor contracChanges in ROM and Tone with Use of Short-Leg Casts tures can be stretched out with the use of a "spreader
in Patients with Brain-Stem Lesions
bar." A predetermined length of wooden slat or doweling is attached to bilateral long-leg casts, between
Plantar
Flexor
a
Dorsiflexion ROM (°)
the thighs, and just superior to the knees. The patient's
Tone5
legs are abducted to their available range and rigidly
Range
Range
maintained by the cut section of doweling, which is
-24
Precast
- 6 0 t o - 5 1.8
1 to 3
affixed to the casts with plaster strips. This method is
2 - 2 5 to 20 1.5
0 to 3
Postcast
successful for patients with severe spasticity of both
26
-2cto2
Change
60 to 10 0.4
lower extremities, but its use is not always practical
a
Ankle motion measured from right-angle neutral po- because the spreader bar creates some difficulty with
sition.
side-lying and wheelchair positioning and makes
b
0 = Normal, 1 = Slightly Increased, 2 = Moderately lower extremity dressing an impossibility. A removIncreased, 3 = Severely Increased, based on resistance
able spreader bar can be made by putting stockinette
to passive motion.
c
over the thigh or heel portion of existing casts and
Indicates increase of tone.
1964
PHYSICAL THERAPY
making a thin plaster mold over the stockinette. The
spreader bar is attached to the plaster mold. Once the
new plaster is dry, it is cut with a cast saw to form a
plaster cup, which can be worn or removed as necessary.
Another common deformity occurring at the hip
that can be alleviated with adaptations to existing
lower extremity casts is external rotation tightness.
The technique used is similar to the one described for
the spreader bar. In this case, a 6- to 8-in piece of
wooden doweling is attached to the lateral aspect of
an existing short-leg or long-leg cast. We refer to this
adaptation as an outrigger or derotation bar. The
doweling is attached with plaster strips to the posterior-lateral aspect of the existing cast, superior to the
lateral malleolus. When the patient is supine in bed,
the outrigger is supported against the mattress and
holds the lower extremity in neutral rotation. When
the patient is sitting in a wheelchair, the outrigger is
supported against the legrest bracket of the wheelchair and once again, holds the limb in neutral rotation. Nonremovable outriggers cause the same problems as nonremovable spreader bars. Removable outriggers can be constructed by attaching the doweling
to removable plaster heel cups.
RANCHO LOS AMIGOS HOSPITAL
CHART REVIEW
Patients by Lesion
PostPrecasting casting
Dorsiflexion Dorsi- Change (°)
ROM (°)
flexion
ROM (°)
Cortical
(n = 5, 8 limbs)
Range
-15
4
- 2 0 to - 5 0 t o 2 0
19
- 5 to 30
9
-15
- 4 5 to - 5 0 t o 2 0
24
10 to 45
Brain Stem
(n - 4, 5 limbs)
Range
a
Ankle motion measured from right-angle neutral position.
TABLE 4
Long-Leg Casts Applied to Increase Knee Extension
ROM and to Decrease Knee Flexor Tone in Patients with
Cortical Insults
Patients
(n = 5)
Precasting
Postcasting
Change
Knee Extension
ROM (°)
Range
-32
-5
- 1 0 to - 9 0 - 2 0 to 0
+ 27
- 1 0 to 90
Tonea
Charts of 201 patients admitted to the Adult Head
Trauma Service at Rancho Los Amigos Hospital from
January 1980 through September 19, 1981 were reviewed to determine the frequency of cast use and to
assess the results of lower extremity serial casting.
Forty-two of the 201 patients (21%) had lower
extremity serial casting for problems of decreased
ROM, increased muscle tone, or both. Patients who
received casts for these problems but had concomitant
limb pathology, such as fracture, heterotopic ossification, and peripheral nerve injuries, were excluded
from the review. For purposes of data analysis, patients were grouped by area of brain injury and
indications for and type of cast applied.
The largest number of patients who had serial
casting were those with cortical lesions. This group
had short-leg casts applied because of decreased dorsiflexion ROM and increased plantar flexor muscle
tone. Twenty-four of the 42 patients (57%) were in
this classification. Ten of these patients had bilateral
short-leg casts. Nineteen of the patients were men, 5
were women, and the average age was 23 years old.
The mean time from injury to the beginning of casting
was 78 days. Mean casting duration was 28 days with
a range of 7 to 88 days. Results are shown in Table 1.
The second highest number of patients who received short-leg casts were those with brain-stem or
Volume 63 / Number 12, December
TABLE 3
Short-Leg Casts Applied to Increase Dorsiflexion ROMa
1983
Range
2.5
2 to 3
2.75
2 to 3
-0.25
-1b to 0
a
0 = Normal, 1 = Slightly Increased, 2 = Moderately
Increased, and 3 = Severely Increased, based on resistance to passive motion.
b
Minus indicates increase of tone.
both cortical and brain-stem lesions. These casts were
applied because of decreased dorsiflexion ROM and
increased plantar flexor muscle tone. Fifteen patients
(36%) received casts; five casts were bilateral. Nine of
these patients were men, six were women, and the
average age was 20 years old. The mean onset of
casting interval was about three months. Mean casting
duration was 39 days with a range of 7 to 92 days.
Results are shown in Table 2. Table 3 shows the
results of patients with cortical or brain-stem lesions
who received short-leg casts to correct decreased dorsiflexion ROM only.
Long-leg casts, incorporating the ankle and foot,
were applied to increase knee extension ROM and to
decrease hamstring muscle tone. During the 20month period reviewed, five patients with cortical
lesions had unilateral long-leg casting. Their average
age was 25 years. Mean casting duration was 22 days
with a range of 8 to 66 days. Their mean onset to
casting interval was 114 days; this period indicates
their acute care was longer than those patients who
had short-leg casts. Results are shown in Table 4.
1965
TABLE 5
Long-Leg Casts Applied to Increase Knee Extension
ROM and to Decrease Knee Flexion Tone in Patients
with Brain-Stem Lesions
Patients
(n=4)
Precasting
Postcasting
Change
-25
- 9 0 to - 5
-10
- 3 0 to 0
15
- 1 5 to 90
1.8
1 to 3
1.6
1 to 3
0.2
0 to 1
Knee Extension
ROM (°)
Range
Serial short-leg casting is an effective technique to
increase dorsiflexion ROM and to decrease plantar
flexor muscle tone in the young adult after head
injury. Serial long-leg casting in itself is not the
answer to reducing knee flexor tone, although casts
prevent further loss of knee extension ROM and, in
fact, increase range.
CONCLUSION
Tone a
Range
„,
a
0 = Normal, 1 = Slightly Increased, 2 = Moderately
Increased, 3 = Severely Increased, based on resistance
to passive motion.
Four men, averaging 24 years old, with brain-stem
lesions received long-leg casts for both decreased
ROM and increased tone. Casting started an average
of 111 days from onset and was continued for an
average of 31 days with a range of 7 to 58 days.
Results are shown in Table 5.
All patients who received casts for decreased dorsiflexion range improved in ROM, All patients, except two, who had casts for decreased ankle ROM
and increased plantar flexor muscle tone improved in
range. The two who did not improve had severely
increased muscle tone both precasting and postcasting.
Thirty-seven percent of the patients who received
casts for decreased ankle ROM and increased plantar
flexor muscle tone had decreased tone postcasting.
Knee flexion tone decreased in only one patient who
had serial long-leg casting. One-half of the limbs in
casts failed to gain full knee extension.
As compared with patients with cortical lesions,
patients with brain-stem lesions who had both decreased ankle ROM and increased plantar flexor
muscle tone started with worse contractures, received
casts later from onset, and took longer to make ROM
gains.
1966
Progressive serial casting is a technique that can be
used for the management of deformity resulting from
spasticity in the head-injured adult. Casting is recommended during the early and acute management
so that immobilization occurs while the patient is at
his lowest level of consciousness. General guidelines
for a casting program have been described as well as
specific clinical applications. Cast application procedures require technical skill to prevent complications.
The results of a chart review of lower extremity
casting of 42 head-injured adults have been described.
Serial casting is an adjunct to treatment and should
be incorporated into an ongoing therapeutic program.
REFERENCES
1. Cherry DB: Review of physical therapy alternatives for reducing muscle contracture. Phys Ther 60:877-881, 1980
2. Booth BJ, Doyle MM, Woodword J: Application of casts for
control of spasticity. In Rehabilitation of the Head Injured
Adult: Comprehensive Management. Downey, CA, Professional Staff Association of Rancho Los Amigos Hospital, Inc,
1980, pp 25-30
3. Garland D, Doyle MM, Booth BJ: Early management of spastic deformities. In Rehabilitation of the Head Injured Adult:
Comprehensive Physical Management. Downey, CA, Professional Staff Association of Rancho Los Amigos Hospital, Inc,
1979, pp 45-51
4. Cherry DB, Weigand GM: Plaster drop-out casts as a dynamic means to reduce muscle contracture. Phys Ther
61:1601-1603, 1981
5. Bobath B: Adult Hemiplegia: Evaluation and Treatment. London, England, Heinemann Medical Books, 1978, p 130
PHYSICAL THERAPY