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August/September 2002


The Skinny on Splinting

By Ginger Clark, OTR, CHT


Dorsal image of splint with s tatic progressive component in place.

Splinting to promote healing has a long history. The development of low temperature thermoplastics in the late ’60s and early ’70s encouraged therapists to fabricate more elaborate splints that worked many joints in multiple directions. Rubber bands went every which way, often confusing both the patient and the hospital staff. Our clinic resorted to supplying Polaroid pictures of the splint correctly donned for the patient to carry home. Ironically, today’s hand clinic is likely to fabricate a much simpler splint, frequently returning to the use of casting materials and low profile traction.

Therapists over the past 20 years have adjusted their splints to produce low loads over prolonged time. Frequently, rubber band traction has given way to the use of inelastic components that can be easily adjusted by the patient as the fluid is displaced and the muscles relax in the splint. Termed static progressive splinting, the therapist uses straps, strings, turnbuckles, and even click strips1 to position the joint at near end range. Plaster of paris is also making a comeback, and stubborn proximal interphalangeal (PIP) flexion contractures often respond to serial casting when other methods fail.2 We frequently use serial casting in combination with traditional hand therapy to reduce PIP flexion contractures. Therapy is provided as usual, followed by casting of the joint in full available extension. Placed directly on the patient’s skin (if possible), fast-hardening 2-inch casting material is used with edges turned down to provide a smooth edge for the patient. After dipping the casting material in warm water and squeezing out the excess, the bandage is wrapped from proximal to distal in a figure eight pattern for two layers. Unless there is significant flexor digitorum profundus (FDP) tightness, the distal interphalangeal (DIP) joint is left free to encourage pull through of the flexor tendon and mobility of the oblique retinacular ligaments. When the wrapping is complete, gentle tension to end range extension is provided by the therapist until the casting material is set. Care must be taken to spread the pressure out while setting by using the pads of your finger and thumb rather than the tips to distribute pressure over a greater surface.3

The patient should be aware of the danger signs, including vascular checks, and asked to continue use of the cast until seen again by the therapist (approximately every 2-3 days). At the next treatment, the cast is removed, and treatment proceeds as usual, with application of a new cast at the end of the session. This can be continued for as long as progress is seen, and is usually done in our clinic for approximately 3 weeks.

A NEW PROTOCOL

An interesting new concept in splinting is being proposed by Judy Colditz, OTR/L, CHT, FAOTA, and is called casting motion to mobilize stiffness (CMMS). She postulates that the stiff hand has developed poor habits through the use of substitution patterns that promote the body’s use of the loosest joints. For example, when there is significant tightness in the interphalangeal (IP) joints and comparable mobility in the metacarpal phalangeal (MP) joints, the patient is frequently seen substituting lumbrical action for the long flexors, encouraging this imbalance. Conversely, a patient with MP collateral ligament tightness and relative mobility in the IP joints might be seen utilizing only their IP joints in functional activities, avoiding MP flexion, and promoting additional tightness of the MP joints.

In CMMS, the therapist selectively immobilizes joints to promote active motion in the stiffest joints. For example, in a hand that primarily utilizes its intrinsics to flex digits (IP tightness, with relative mobility in the MP joints), the splint or cast is fabricated to immobilize MP joints in extension while placing a dorsal block on the IP joints in flexion. This allows power to be transmitted to the tight joints, and helps to retrain the motor cortex in a more normal pattern. In our clinic, with the chronically stiff hand, we position the MP joints in greater flexion and monitor collateral ligament tightness, with the ultimate goal of positioning the MP joints in extension as profundus action improves.

Similarly, when the patient exhibits relative IP mobility and MP tightness, the cast or splint is fabricated with a dorsal hood distal over the proximal phalanges and MPs in available flexion. The patient is encouraged to flex phalanges away from the splint, promoting MP flexion.4

We have recently been experimenting with a combination of static progressive splinting and CMMS for our patients with severe IP tightness. While we have attempted this procedure with only a few patients who have intractable IP stiffness, the early results are encouraging. In splinting these patients, we place the wrist in approximately 30° of extension, and hold the MP joints in 0° to 45° of flexion, depending on MP tightness. We then add a static progressive component, dynamically pulling the IP joints into flexion. The patient adjusts the static progressive component as appropriate in order to maintain the extensor tissue at a slight stretch. Depending on IP stiffness, the patient is asked to maintain the flexion pull for 2-3 hours at a time. The dynamic component is then removed for 1-3 hours, and the patient is encouraged to actively use the digits within the base splint for functional activities. This sequence is repeated throughout the day, with the base splint kept on throughout the day. In this way, the same splint is used to perform both static progressive splinting and Colditz’s concept of selective immobilization to improve motion. The time schedule is adjusted as IP tightness is reduced, until the patient is using the base splint only to facilitate cortical retraining of the long flexors.

CASE STUDY

An example of how effective this can be was seen in our clinic with MB, a 51-year-old female who is receiving treatment for complex regional pain syndrome (formally known as RSD) with no determined cause. We had treated her for approximately 4 months, and had separately utilized static progressive splinting and CMMS, as well as typical treatment protocols for complex regional pain syndrome with limited success. After 4 days in the splint, there was a notable increase in her active motion as seen in the pictures. It was observed, however, that when we removed her splint in the clinic for active and passive motion, she reverted to an intrinsic flexion pattern, with resultant return of IP stiffness. It became evident that all active motion should be performed in her splint. It has now been 3 weeks, and we are continuing to see improvement in range with the use of this protocol. We anticipate removal of the static progressive component shortly, but plan to continue to retrain the motion through blockage of the MP joints until the patient spontaneously uses a more normal motor pattern with splint removal. Long-term evaluation of this protocol must still be performed. As with all treatment techniques, therapists should use their judgment as to the viability of all splinting regimes with each patient.

SPLINTING AND MEDICARE

Unfortunately, there are some challenges on the horizon that may affect a therapist’s ability to fabricate and be reimbursed for orthoses. The American Society of Hand Therapists (ASHT) has agreed to work with the American Occupational Therapy Association (AOTA) on splinting and Medicare issues over the next few years. Therapists need to be aware of these possible challenges so they can assist their associations in dealing with these issues.

  1. Section 427 of the Medicare, Medicaid, and SCHIP Benefits Improvement Act of 2000 addresses reimbursement and qualifications for providers of orthotics and prosthetics. It contains a mandate to establish a negotiated rulemaking committee to help determine which orthotics and prosthetics will fall under this law, and what the terms of qualifications for those allowed to fabricate them will be. This committee, which will include representatives of orthotic and prosthetic groups and therapy associations, as well as potential beneficiary groups such as the Paralyzed Veterans of America, will meet to assist the Centers for Medicare & Medicaid Services (CMS) in their interpretation of this law. At risk is a therapist’s ability to splint without additional certification requirements.
  2. Medicare is currently running a pilot study in San Antonio, Tex, on a competitive bidding system for durable medical equipment, including prefabricated splints. Therapists in San Antonio are no longer allowed to provide noncustomized orthotics to their patients, but must refer them out to an approved supplier who has won the competitive bidding contract. The project was intended to control noncustomized orthotic distribution; however, it appears that there have been some incidences where fabrication of a custom orthotic was restricted to an approved orthotics and prosthetics supplier. President Bush has voiced support for the competitive bidding system, and there is a significant possibility that CMS will attempt to implement this system nationally in the next year.
  3. One positive aspect of the competitive bidding system challenge is the potential opportunity to begin dialogue with CMS on coding challenges. While therapists are developing new splinting techniques, they continue to try to fit these splints into antiquated or nonexistent insurance codes. For example, there are currently no common procedure coding system (CPCS) codes that cover the fabrication of digital casting. In defense of CMS, it would be impractical to provide a separate code for each of the many and ever changing splints that therapists can imagine. However, it is important in today’s financial climate that therapists are reimbursed for work performed, particularly when it can be so effective. ASHT’s splint classification system, which uses an alternative approach, may be useful in the development of appropriate codes.
It is important for the quality of care of our patients that we continue to evaluate new splinting techniques and theories to ensure that our patients receive optimum care. ASHT and AOTA hope to work together to ensure a therapist’s right to fabricate and be reimbursed for orthotics. Keep posted on these issues through our web sites: www.asht.org and www.aota.org. N Ginger Clark, OTR, CHT, is the 2002 president of the American Society of Hand Therapists. She is the owner of Hand Rehabilitation Services in Bradenton, Fla, and has been in private practice since 1983.

References
  1. Vasquez N. Introduction to a new method for inelastic mobilization. J Hand Ther. 2002;5(2):205-209.
  2. Kolumban SL. The use of dynamic and static splints in straightening contracted proximal interphalangeal joints in leprosy patients: a comparative study. Presented at: 47th Annual Conference of the American Physical Therapy Association; 1960; Washington, DC.
  3. Bell JA. Plaster cylinder casting for contracture of the interphalangeal joints. In: Hunter JM, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand and Upper Extremity. 5th ed. St Louis: Mosby; 2002: 1839-1845.
  4. Colditz JC. Plaster of paris: the forgotten hand splinting material. J Hand Ther. 2002;15(2):144-157.
Ginger Clark, OTR, CHT, is the 2002 president of the American Society of Hand Therapists. She is the owner of Hand Rehabilitation Services in Bradenton, Fla, and has been in private practice since 1983.

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