ORTHOSIS PRACTICUM© F.O.T.A. NOVEMBER 2, 2012 Toni Thompson, MA, OTR/L, C/NDT and Erica N. Goldin, OTR/L Orthosis Practicum: Gearing Up to Meet Client Needs with Efficient Innovation Presentation Details Basic-introductory and Intermediate-experienced levels. This interactive experience incorporates tricks-of-the-trade techniques in the fabrication of a wrist-hand immobilization orthosis and a serpentine orthosis. Participants will learn methods to enhance ergonomics, to improve client collaboration in the fabrication process and to use materials economically. The focus on orthosis fabrication offers opportunities for therapists with a wide range of experience and skill levels to participate. 2. Brief Description The participant will: State the optimal position for the orthosis of the upper extremity in a variety of diagnoses. Make one pattern for one wrist-based orthosis. Demonstrate or state the process to make one orthosis without a physical pattern. Fabricate one wrist immobilization orthosis with one of three hand variation components or one wrist hand immobilization orthosis. Fabricate one serpentine orthosis, either hand-based or forearm-based. Demonstrate three techniques to increase efficiency in orthosis fabrication. Demonstrate three methods of enhanced ergonomics in fabrication process. State three techniques to encourage client collaboration during the fabrication process. Determine essential components of home education to facilitate compliance with orthosis wear. State nine uses for small material scraps. Define five basic infection control standards. Handouts include patterns and designs for wrist immobilization and wrist-hand immobilization orthoses, and bibliography. PARTICIPANTS: Please bring a pair of SCISSORS for use in orthosis construction. Presenters: Toni Thompson, MA, OTR/L, C/NDT and Erica N. Goldin, MS, OTR /L Toni Thompson, MA, OTR/L, C/NDT, fabricated, modified, or fit over 10,000 upper extremity orthoses during her 22 years at Shriners Hospitals for Children in Tampa. She developed and presented 10 two-day pediatric splinting workshops. As a senior instructor for TherapyEd, she has presented over 150 OT Exam Review Courses throughout the US, including Puerto Rico. Publications include over 40 articles in AOTA, OT Practice, ADVANCE for OTs, Journal of Pediatric Orthopaedics, and a variety of physical therapy and orthotic and prosthetic magazines. She authored a chapter in Culture in Rehabilitation: From Competency to Proficiency. Currently, she continues to teach OT Exam Review courses and provide volunteer service to projects in Tampa and in various Latin American countries. Erica N. Goldin, Ms, OTR/L, is a 2011 graduate of the University of Florida Master’s program in Occupational Therapy and holder of the Alice C. Jantzen Fellowship for her class. © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 1 Practicum Outline TERMINOLOGY Volar = palmar Dorsal Wrist flexion, not volar flexion Wrist extension, not dorsiflexion CMC, MP, PIP, DIP, IP Index, middle, ring, small fingers Elbow ROM 0 ° to 125 °- 140 º Radial styloid Ulnar styloid Mechanical Properties ! Force ! influence that changes/directs motion. ! Parameters of force ! Nature: type, either push or pull. ! Magnitude: amount. ! line of angle of application: path. ! point of application: location where force acts. Mechanical Properties ! Torque = moment of force ! The potential for a force to produce: ! rotation of lever around an axis (joint.) ! Torque ! unbalanced force. ! point of application NOT the center of the object. ! resulting in rotation of object around fixed axis. Mechanical Properties ! Torque = moment of force ! Torque = Force X perpendicular distance from the axis of rotation to the point of application. LEVERS CLASSIFICATION SYSTEM American Society of Hand Therapists (ASHT) CLASSIFICATION SYSTEM ARTICULAR = cross joint(s.) NON-ARTICULAR = do not cross joint Support/protect bone/soft tissue. CLASSIFICATION SYSTEM LOCATION = JOINT(S) WHERE orthosis ACTS WRIST = functional orthosis. WRIST/HAND = positional orthosis. THUMB = hand-based thumb orthosis. THUMB CMC/MP = forearm-based, IP free. WRIST/THUMB = forearm-based thumb. ELBOW = elbow orthosis. CLASSIFICATION SYSTEM DIRECTION = DESIRED POSITION © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 2 Flexion Extension Pronation Supination Radial Ulnar Palmar Abduction Opposition Static Orthosis components are essentially immobile. immobilize joint(s.) block one joint for movement elsewhere. facilitate dynamic function. immobilize joint for function later. position for function. Serial Static Orthosis or cast elongate tissue maintain joints, soft tissue, muscle, tendon in lengthened fashion. worn for lengthy periods of time to prevent rebounding. modified periodically by therapist. Static Progressive Orthosis ! low-load force. ! on maximum ROM. ! non-elastic elements for stress. ! variable adjustment to increase ROM. Dynamic Orthosis static base outrigger & elastic components. controlled mobilizing force & elastic component. CLASSIFICATION SYSTEM DESIGN DESCRIPTORS Forearm-based Hand-based Thumb-based Digit-based Arm-based Radial Ulnar Dorsal Posterior Volar Anterior CLASSIFICATION SYSTEM Volar wrist/hand extension immobilization = positional orthosis. Volar wrist extension immobilization = functional volar orthosis. Wrist thumb opposition immobilization = long opponens orthosis. TYPES OF ORTHOSES Functional Enhance current function. Allow thumb/finger movement. Wrist-finger dynamics. TYPES OF ORTHOSES Positional passive-assistive ROM or active-resistive ROM. © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 3 Prevent current functional movement. Continuous low load pressure. Enhance/maintain position. Increase function after orthosis removal. Prevent deformity. Positional or Functional WRIST ORTHOSES???? Wrist-finger dynamics ROM Immobility VS. Mobility Stability & Sleep position Tenodesis, Tone GOALS OF ORTHOSIS USE Facilitate functional movement. Enhance positions of function. Immobilize joint(s) for function. GOALS OF ORTHOSIS USE ! Enhance gains made in therapy. ! Substitute for therapy. GOALS OF ORTHOSIS USE ! Inhibit tone/stiffness. ! Support joint laxity. ! Support low tone. GOALS OF ORTHOSIS USE ! Position pre-operatively. ! Rest/position post-op site. ! Rest post-injury. GOALS OF ORTHOSIS USE ! Prevent/decrease pain. ! Prevent/decrease contractures. ! Prevent/decrease deformities. GOALS OF ORTHOSIS USE ! Decrease inflammation from injury. ! Decrease arthritic inflammation. ! Substitute for muscular weakness. GOALS OF ORTHOSIS USE ! Substitute for motor impairment. ! Substitute for muscular imbalance. ! Substitute for muscular weakness. CONTRAINDICATIONS MOVEMENT IMPAIRMENTS ! Athetosis ! Ataxia ! Dystonia SENSATION LIMITATIONS CONTRAINDICATIONS MEDICAL CONDITIONS ! Temperature regulation © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 4 ! Contact allergies ! Seizures CONTRAINDICATIONS BEHAVIOR/COGNITIVE ! Self-injury ! Injures others ! Eat orthosis ! Cognitive level ! Caregiver situation ORTHOSIS ASSESSMENT INITIAL ELEMENTS Prior to hands-on contact: evaluate PAIN ! ORTHOSIS ASSESSMENT INITIAL ELEMENTS Corporal posture § ORTHOSIS ASSESSMENT INITIAL ELEMENTS Corporal posture ORTHOSIS ASSESSMENT INITIAL ELEMENTS ! Positioning equipment ORTHOSIS ASSESSMENT INITIAL ELEMENTS ! Positioning equipment ORTHOSIS ASSESSMENT INITIAL ELEMENTS Positioning equipment ORTHOSIS ASSESSMENT INITIAL ELEMENTS Prior to hands-on contact: Medical conditions Allergies Nighttime sleeping position ORTHOSIS ASSESSMENT SECONDARY Initial Hands-on Contact: Skin condition Edema Vascularity Bumps Bony prominences ORTHOSIS ASSESSMENT SENSORY-MOTOR Isolated AROM AROM in patterns PROM Joint alignment and position © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 5 Tone/stiffness Static & dynamic contractures Sensation ORTHOSIS ASSESSMENT FUNCTIONAL SKILLS Fine motor skills Self-care skills School activities Leisure activities Chores ORTHOSIS ASSESSMENT COGNITIVE SKILLS Patient cognition Caregiver cognition Ability to carry out PRECAUTIONS don the orthosis maintain time schedule assess for potential injuries HAND/WRIST POSITION Functional Wrist 20°- 30° MPs 35°- 45° PIP/DIPs flexed 45 ° palmar abduction to opposition Safe, Intrinsic-plus, or Anti-deformity Wrist 30°- 40° MPs70 °- 90° PIP/DIPs extended 40°- 45° palmar abduction to opposition The best position and function I can get! Volar orthosis evenly distribute pressure on volar forearm and wrist/hand immobilize wrist free digits for function WRIST EXTENSION IMMOBILIZATION ORTHOSIS options Thumb free ! allow thumb CMC, MP, and IP function Short thumb support ! immobilize thumb CMC and MP ! allow active IP function Long thumb support immobilize thumb CMC, MP, and IP RADIAL or ULNAR IMMOBILIZATION ORTHOSIS “GUTTER ORTHOSIS” © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 6 Functional with elbow free fingers & thumb free for function short thumb post to stabilize MP long thumb post to stabilize MP & IP Positional with elbow included WRIST/HAND IMMOBILIZATION ORTHOSIS Prevent/decrease contractures Enhance function after orthosis removal CUSTOM THERMOPLASTIC WRIST HAND IMMOBILIZATION ORTHOSIS Long thumb post support webspace immobilize CMC, MP, & IP prevent IP hyperextension CUSTOM THERMOPLASTIC ORTHOSIS Fabrication LAB ERGONOMICS Posture. Cutting. Smoothing edges: Use table edge, Use heel of hand, Use leg. THERMOPLASTIC WRIST EXTENSION IMMOBILIZATION ORTHOSIS Key Fabrication Tips distal palmar crease free attention to bony prominences therapy putty bevel padding THERMOPLASTIC WRIST EXTENSION IMMOBILIZATION ORTHOSIS Key Fabrication Tips place damp paper towel on skin use damp paper towel over dressing fit on my wrist first fit on my finger first THERMOPLASTIC WRIST EXTENSION IMMOBILIZATION ORTHOSIS Key Fabrication Tips trough 2/3 length of forearm trough 2/3 width of forearm adequate thenar eminence clearance CUSTOM THERMOPLASTIC WRIST/ HAND IMMOBILIZATION ORTHOSIS Key Fabrication Tips trough 2/3 length of forearm trough 2/3 width of forearm CUSTOM THERMOPLASTIC WRIST/ HAND IMMOBILIZATION ORTHOSIS Key Fabrication Tips fit to wrist first adequate thenar eminence space © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 7 CUSTOM THERMOPLASTIC WRIST HAND IMMOBILIZATION ORTHOSIS Key Fabrication Tips next, fit to forearm stretch webspace and thumb area appropriate thumb position finger pan 1/2 height of fingers CUSTOM THERMOPLASTIC WRIST HAND IMMOBILIZATION ORTHOSIS pan angle MP angle MP bend STRAPS Contour Feather PADDING STRAPS Self-adhesive pads Removable pads Back-to-back adhesive hook Velcro WRIST EXTENSION IMMOBILIZATION ORTHOSIS Thumb & Webspacer options ! Theratube ! Foam Roll Velcro Options Imbed Hook Velcro Imbed Loop Velcro Thermoplastic rivet RED MARKS DO NOT USE PADS OR MOLESKIN TO PAD TIGHT ORTHOSIS OPENING! Make opening larger ! Cut down orthosis around prominences ! Heat & expand orthosis over bony areas Mold with therapy putty on bony areas Cut hole and bevel pad at risk areas SERPENTINE ORTHOSES HAND-BASED SERPENTINE Inhibits thumb-in-palm position Supports MP Long thumb post stabilizes MP stabilizes IP Short thumb post stabilizes MP allows IP function FOREARM-BASED SERPENTINE Rigid webspace support Minimal wrist support Short thumb post stabilizes thumb MP © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 8 allows IP function SERPENTINE ORTHOSIS Fabrication LAB ORTHOSIS EDUCATION Educate Demonstration/Documentation Understanding Contact information Activity checkout Time schedule Issues Other priorities Notice RED FLAGS EDUCATION Educate ! donning ! care ! precautions ! follow-up Demonstrate ! donning & doffing ! return demonstration Document ! strategies EDUCATION Understanding ! printed materials ! demonstration/return demo ! document verbal agreement Contact information ! name, phone Activity Checkout Time wearing schedule EDUCATION Issues & team priorities Other therapists & disciplines: Goals EDUCATION Notice RED FLAGS ! pain -red marks ! rash, irritation -blisters ! limb color -digit color ! hot or cold limb ! written contact information LEFTOVER MATERIALS ? Finger splints Finger dividers Thumb/finger troughs Built-up handles for spoons/combs Makeshift rivets & hinges © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 9 Repair toys/toilets/blinds Splints for stuffed animals and toys CO$T CUTTING TIP$ DON’T RECYCLE SPLINTS between clients. Modify child’s own splints only. Keep scissors sharp and clean. Use separate scissors for velcro. Sew only regular velcro--not adhesive back--on sewing machine. CO$T CUTTING TIP$ Recycle new knee immobilizer pads. Use a fry pan or microwave. Use pure water. Clean splint pans well. Use a high-wattage hair dryer. Have caregivers make cloth splints. Try feasible low-tech options first. INFANT FITTING HINTS Engage the child. Have caregiver hold, cuddle child. Allow child to have a bottle. Sing. Make baby noises. Breathe softly and slowly. Assure caregiver that behavior is normal. TODDLER FITTING HINTS Engage the child. Sing. Dance. Be silly. Make funny faces. “Help me, please!” “Pick the color you want!” Explain each step in simple words. Give positive feedback. OR….. School Age & Adolescent Tips Use team or school colors for straps. Decorate with fabric paint. Add thermoplastic sun, heart, or other design. Apply stickers. Imbed stones or jewels. Decorate with permanent markers. INFECTION CONTROL Determine strategies and policies: Cleaning pans. Changing water. Wearing gloves. Re-dipping thermoplastic splints. Fitting prefab splints. BIBLIOGRAPHY © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 10 American Society of Hand Therapists. (1992). Splint classification system. Garner, NJ: The American Society of Hand Therapists. Banker, B.Q. (1985). Neuropathic aspects of arthrogryposis multiplex congenita. Clinical Orthopedics and Related Research. 194,30-43. Bar, K. (1994). 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Retrieved August 2012. http://occupationaltherapy.advanceweb.com/Article/The-Computer-Access-Splint.aspx © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 14 Thompson, T., & Tobin (Chambers), A.B. (1997). The Modified MacKinnon: A low temperature approach to pedi splinting. ADVANCE for Occupational Therapy Practitioners, Dec. 1, 1997. Retrieved August 2012. http://occupational-therapy.advanceweb.com/Article/The-Modified-MacKinnon-A-LowTemperature-Approach-to-Ped-Splinting.aspx Thompson, T., Smith, S., & Griner, D. Customized Walker Adaptions for a Child with Cerebral Palsy, Pediatric Physical Therapy, Summer 1992. Journal of the Association of Children's Prosthetic Orthotic Clinics, Winter 1992. Thompson-Rangel, T. (September 21, 1991). The mystery of the serpentine splints. OT Forum. (out of print) Trombly, C., & Radomski, M.V. (Eds.). (2002). Occupational therapy for physical dysfunction. (5th ed.). Baltimore: Lippincott, Williams, & Wilkins. Wallen, M., & O’Flaherty, S. (1991). The use of soft splint in the management of spasticity of the upper limb. Australian Journal of Occupational Therapy, 38(15), 227-231. Willey, M.C. (2004). Modification to a pediatric thumb splint. American Journal of Hand Therapy,17(3):379-380. Williams, P.F. (1985). Management of upper limb problems in arthrogryposis. Clinical Orthopedics and Related Research, 194,60-67. Wilson, G. (1997). Custom Neoprene Splints for Upper Extremity Disorders. ADVANCE for occupational therapy practitioners. December 1, 1997. Wilton, J. (2003). Casting, splinting, and physical and occupational therapy of hand deformity and dysfunction in cerebral palsy. Hand Clinics, 19:573-584. Wilton, J.C., (1997). Hand splinting principles of design and fabrication. Philadelphia: W.B. Sanders. Zimmerman, R, Gschwentner,M., Kralinger, F., Arora, R., Gabi,M., Pechla, S. (2004). Long-term results after pediatric distal forearm fractures. Archives of Orthopedic Trauma Surgery 124(3):179-186. Web links: Retrieved August 2012. http://practicalplasticsurgery.org/docs/Practical_28.pdf Tendon Injuries of the Hand. Retrieved August 2012. ffhttp://practicalplasticsurgery.org/docs/Practical_32.pdf © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 15 VOLAR or DORSAL WRIST IMMOBILIZATION SPLINT Small webspacer VOLAR or DORSAL WRIST IMMOBILIZATION SPLINT Three webspacer options © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 16 VOLAR or DORSAL WRIST IMMOBILIZATION SPLINT Long webspacer VOLAR or DORSAL WRIST IMMOBILIZATION SPLINT Velcro webspacer © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 17 VOLAR WRIST IMMOBILIZATION SPLINT Thenar opening VOLAR WRIST IMMOBILIZATION SPLINT Two options: MP IMMOBILIZATION & MP IP IMMOBILIZATION © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 18 WRIST/HAND IMMOBILIZATION SPLINT WRIST/HAND IMMOBILIZATION SPLINT © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 19 WRIST/HAND IMMOBILIZATION SPLINT VOLAR PAN & DORSAL FOREARM Thumb free WRIST/HAND IMMOBILIZATION SPLINT VOLAR PAN & DORSAL FOREARM Two options: MP IMMOBILIZATION & MP IP IMMOBILIZATION © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 20 RADIAL WRIST IMMOBILIZATION SPLINT with thumbpost RADIAL WRIST IMMOBILIZATION SPLINT with thumbhole © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 21 ULNAR WRIST IMMOBILIZATION SPLINT COMPUTER ACCESS SPLINT SPLINT INDEX MP PIP DIP IMMOBILIZATION © 2012, Toni Thompson, MA, OTR/L, C/NDT for personal use only, written permission required for reproduction of these materials. Page 22