Today’s post is a response to a question I received. The question in full (slightly modified for grammatical purposes):
What do you think about using wrist and fingers garment in children with CP hemiparesis, do you have a clinical experience? If this product is not fabricated at my place of work, how can I select proper tension/ garment attributes using an overseas order?
In Australia it is standard practice for occupational therapists to provide wrist hand orthoses. In the cerebral palsy clinic I work in, I work alongside occupational therapists who prescribe, order, fit and review a variety or wrist hand orthoses for CP patients with hemiparesis. There are various therapies and approaches to the management of patients with hemiplegic cerebral palsy and some of the most supported approaches include:
- Bimanual training for hemiplegic CP (training a child using two hands through repetitive tasks (Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia. Sakzewski L, Ziviani J, Abbott DF, Macdonell RA, Jackson GD, Boyd RN. Dev Med Child Neurol. 2011 Apr;53(4):313-20.)
- Home based goal-directed OT programs are effective (strong evidence), and intensive -activity based (eg, constraint-induced movement therapy, bimanual training) interventions (moderate evidence) (Efficacy of upper limb therapies for unilateral cerebral palsy: a meta-analysis. Sakzewski L, Ziviani J, Boyd RN. Pediatrics. 2014;133(1):e175.)
- BoNT-A should not be used in as a stand-alone treatment but in conjunction with planned occupational therapy. (Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy. Hoare BJ, Wallen MA, Imms C, Villanueva E, Rawicki HB, Carey L. Cochrane Database Syst Rev. 2010)
In relation to orthotic treatment for the upper limb, various methods could be adopted but it really depends your patient goals – is it more important to increase range or more important to pursue a better grasp pattern to help with writing at school? The orthosis required for your patient may be supplied using an “off the shelf” option (ordered from a company) or perhaps a custom made neoprene or low temperature thermoplastic design is more suitable. Most upper limb orthoses assist function or allow for good grasp and functional positions, some are for contracture prevention and others for protection and pain management. Depending on what your patient’s needs are, off the shelf may be adequate, and if so, a variety of companies like Össur and Otto Bock make a variety of wrist hand orthoses that can simply be measured for and then ordered.
The main three upper limb splinting/ orthotic options include:
- Static splints/ orthoses. As the name suggests these splints/orthoses hold the wrist and hand in a fixed position with the primary goal of stabilizing and immobilizing joints allowing for a better transfer of muscular forces, and/or maintain the current alignment of the hand and wrist and preventing further deformity. (Coppard, & Lohman, 2001; Wilton, 2003; Hsu, Michael, & Fisk, 2008). It has been suggested the changes are minor and over a brief period of time (2 to 3 months) (Jackman, Novak, & Lannin, 2014). Muscular atrophy is also thought to be a consequence of static splinting/ orthotic treatment (Burtner et al., 2008; Bulthaup, Cipriani, & Thomas, 1999).
- Dynamic splints. These have a combination of restriction (preventing contractures) and allowing for movement at particular joints under resistance. (Burtner et al., 2008). Dynamic splints/orthoses often use low temperature thermoplastics with springs and wires that provide resistance.
- Serial casting aims to slowly increase stretch on a muscle group and therefore improve range. (Brouwer, Wheeldon, Stradiotto-Parker, & Allum, 1998).
I hope this information has been helpful for you, please feel free to ask more questions or leave some feedback.
The Supportive Orthotist.