Unit 2
Textbooks
Guide 5: Orthoses
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Deshaies, L. D. (2014). Upper Extremity Orthoses. En Radomski, M. V. &
C. A. Trombly, Latham (eds.) Occupational Therapy for Physical
Dysfunction. Seventh Edition. Buenos Aires: Wolters Kluwer.
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Pre-reading Activities
1- Mire el siguiente título del capítulo. Utilice la técnica de scanning para
identificar los subtítulos y las imágenes en el fragmento a continuación
de la guía. Determine en una o dos oraciones el tema del texto.
2- Preste atención a los dos últimos párrafos de la introducción (The
Occupational Therapist,... must work in close collaboration). Subraye
los cognados que encuentra y mencione los 5 que son claves para
comprender dicha sección.
3- Vuelva a leer los dos últimos párrafos. Trabaje con 4 palabras
desconocidas en dicha sección. Redondee las 4 palabras
seleccionadas, identifique el tipo de palabra, y luego infiera el
significado y corrobore con el traductor.
While reading Activities
4- Arme un punteo de las personas involucradas en el uso exitoso de
ortesis y explique el rol o función de cada una.
5- Diseñe un cuadro sobre los tipos de ortesis que existen según el
texto, y sus características principales.
6- ¿Qué se debe considerar siempre al momento de intervenir con
ortesis, según Amini y Rider (2008) y McKee y Rivard (2011)?
Traduzca la respuesta del texto al español.
7- ¿Qué consideraciones o factores debe tener en cuenta un
terapista al seleccionar una ortesis?
Post-reading Activities
8- Escriba tres oraciones en las que resuma información nueva o útil
derivadas del texto para su futura práctica como terapista
ocupacional.
9- Analice los sintagmas nominales resaltados en amarillo explicando
sus modificadores. Luego, traduzca las frases.
10- Localice los pronombres subrayados en el texto e indique a qué
hacen referencia.
RELACIONES LÓGICAS Y CONECTORES
Las relaciones lógicas son conexiones entre ideas que muestran
cómo se relacionan entre sí, como causa y efecto, comparación,
contraste, o secuencia. Para hacer esas conexiones claras en el texto,
muchas veces usamos conectores.
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A classification system was later developed to describe orthoses
using acronyms based on the major joints or body parts they include.
For example, a thumb carpometacarpal (CMC) support is a hand
orthosis (HO); a wrist cock-up splint is a wrist–hand orthosis (WHO);
an elbow brace is an elbow orthosis (EO); and a complete support
for an arm is a shoulder–elbow–wrist–hand orthosis (SEWHO)
(Condie, 2008). (Deshaies, 2014, p. 429)
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El conector "for example" se utiliza para introducir ejemplos
específicos que ilustran o clarifican una idea general presentada
previamente en el texto. En este caso, después de mencionar que se
desarrolló un sistema de clasificación para describir las ortesis
utilizando siglas basadas en las principales articulaciones o partes del
cuerpo que incluyen, el conector "for example" introduce ejemplos
concretos de cómo se aplican esas siglas.
11- Explique la función que expresa cada conector
resaltado en verde en el texto.
Chapter 15 Upper Extremity Orthoses 429
O
rthoses are often an integral component of oc- commonly used terms for orthoses. One challenge when
cupational therapy for clients with physical discussing orthoses is the lack of uniform terminology in
dysfunction. Orthotics entails prescription, se- the medical literature, which makes it difficult to compare
lection, design, fabrication, testing, and training in the use and contrast features and outcomes when a single ortho-
of these special devices. sis may be known by many names.
Successful use of orthoses is made possible only Before the 1970s, there was no standard system for
through an integrated team approach including the client, classifying orthoses, and orthoses were identified by
his or her significant others, and health care providers. proper names or eponyms based on the place of origin or
Several rehabilitation professionals may bring their exper- the developer. A classification system was later developed
tise to different aspects of the orthotic process. The physi- to describe orthoses using acronyms based on the major
cian typically prescribes the device. The certified orthotist joints or body parts they include. For example, a thumb
is an expert in the design and fabrication of permanent or- carpometacarpal (CMC) support is a hand orthosis (HO);
thoses, especially complicated spinal, lower extremity, and a wrist cock-up splint is a wrist–hand orthosis (WHO); an
upper extremity orthoses used to restore function. The elbow brace is an elbow orthosis (EO); and a complete sup-
rehabilitation engineer is an expert in technical problem port for an arm is a shoulder–elbow–wrist–hand orthosis
solving involving mechanical and/or electrical solutions (SEWHO) (Condie, 2008). Each classification may contain
to unique needs of clients. several types of splints. A wrist cock-up splint and a flexor
The occupational therapist, as an expert in the adaptive hinge hand splint are both WHOs, although they serve
use of the upper extremities in occupational performance different purposes.
tasks, has the major responsibility for the recommenda- To simplify, organize, and describe a standardized pro-
tion of appropriate orthoses, the testing and training in fessional nomenclature, the ASHT developed the ASHT
the use of orthoses for the upper extremities, and the se- Splint Classification System in 1992. It classifies splints in
lection, design, and fabrication of thermoplastic splints. terms of their function and the number of joints they sec-
Occupational therapists often collaborate with orthotists ondarily affect. According to this system, a wrist cock-up
and rehabilitation engineers to solve problems encoun- splint is a wrist extension immobilization, type 0, because
tered by clients in performing their occupations and activ- no other joints are affected. Although the intent was to
ities of daily life. The therapist presents the parameters of serve as a universal language for referral, reimbursement,
the problem to these professionals in terms of the client’s communication, and research, the system has not been
abilities and limitations and the functional and psycho- widely used outside of the hand therapy community.
logical goals that the prescribed device should meet or This chapter uses the traditional or most commonly
allow. The orthotist or engineer then proposes technical used names for the splints it describes.
solutions, and together they apply them to the client and
evaluate the outcome.
Finally, and possibly most importantly, the client and
Basic Types of Orthoses
caregivers bring key physical, psychological, social, and func- Mechanical splint properties fall into three categories: static,
tional characteristics to the orthotic process and should be static progressive, and dynamic (Colditz, 2002/2011). The
considered the primary members of the team. For the ortho- static splint, which has no moving parts, is used primarily
sis to be successful, all team members must work in close to provide support, stabilization, protection, or immobili-
collaboration. zation. Serial static splinting can be used to lengthen tissues
and regain range of motion by placing tissues in an elon-
gated position for prolonged periods (Bell-Krotoski, 2011;
KINDS OF ORTHOSES Colditz, 2011). With this process, splints are remolded as
The numerous kinds of upper extremity orthoses vary range of motion increases. Because immobilization causes
according to the body parts they include, their mechan- such unwanted effects as atrophy and stiffness, a static
ical properties, and whether they are custom-made or splint should never be used longer than physiologically re-
prefabricated. quired and should never unnecessarily include joints other
than those being treated.
Static progressive splints use nondynamic compo-
Classification Systems nents, such as Velcro®, hinges, screws, or turnbuckles, to
An orthosis is an externally applied device used to modify create a mobilizing force to regain motion. This type of
the structural and functional characteristics of the neuro- splinting, termed inelastic mobilization, offers benefits not
muscular and skeletal systems (Condie, 2008). Orthoses available with serial static or dynamic splinting because
may also be called splints; the American Society of Hand the same splint can be used without remolding, and
Therapists (ASHT) (1992) validated that the two terms adjustments can be made more easily as motion improves
may be used interchangeably. Brace and support are other (Fess et al., 2005).
Radomski_Chapter15.indd 429 8/26/13 6:36 PM
430 Section IV Therapeutic Technologies
A B
Figure 15-1 Outriggers directing proper 90° line of pull. A. High profile. B. Low profile. (Adapted with permission
from Hunter, J. M., Mackin, E. J., & Callahan, A. D. [Eds.]. [1995]. Rehabilitation of the hand: Surgery and therapy
[4th ed.]. St. Louis: Mosby.)
Dynamic splints use moving parts to permit, control, Orthotic Selection
or restore movement. They are primarily used to apply
an intermittent, gentle force with the goal of lengthen- Splinting is one of the most useful modalities available
ing tissues to restore motion. Forces may be generated to therapists when used correctly and appropriately. Re-
by springs, spring wires, rubber bands, or elastic cords. member, the end result of splinting should always relate
This type of splinting is termed elastic mobilization to the client’s function (Figs. 15-2–15-5). McKee and
(Fess et al., 2005). Rivard (2004) caution that orthotic intervention may have
With dynamic splinting to increase range of motion, become an end unto itself in the minds of therapists and
two concepts are critical. The first is that the force must clients rather than the means to enable occupational per-
be gentle and applied over a long time (Bell-Krotoski & formance. The outcome of successful splinting is that the
Breger-Stanton, 2011; Fess et al., 2005). Safe force must be splint serves its purpose and that the client accepts and
determined based on tissue tolerances. Excessive force re- wears it. To meet these ends, the therapist must think crit-
sults in tissue trauma, inflammation, and necrosis (Fess & ically and often creatively. Orthotic intervention should
McCollum, 1998). always be individualized with careful consideration of
The second concept is that, to be effective and prevent each client’s unique physical and psychosocial needs, as
skin problems, the line of pull must be at a 90° angle to well as personal factors and contexts (Amini & Rider,
the segment being mobilized (Fess, 2011). To ensure this, 2008; McKee & Rivard, 2011).
forces are directed by an outrigger, a structure extending The therapist’s multifaceted role is to evaluate the
outward from the splint. need for a splint clinically and functionally; to select
Outriggers may be high profile or low profile the most appropriate splint; to provide or fabricate the
(Fig. 15-1). Each design has distinct advantages and dis- splint; to assess the fit of the splint; to teach the client
advantages. Selection of outrigger design must be based and caregivers the purpose, care, and use of the splint;
on the specific client’s needs and abilities. High-profile
outriggers are inherently more stable and mechanically
efficient, require fewer adjustments to maintain a 90° an-
gle of pull, and require less effort for the client to move
against the dynamic force. Low-profile outriggers are less
bulky but require more frequent adjustments and greater
strength to move against the dynamic force (Fess, 2011;
Fess et al., 2005).
By allowing motion in the opposite direction, dynamic
splints reduce the risk of joint stiffness from immobility,
as seen with static splinting. If successful, an increase in
passive joint mobility can be expected within 2 weeks
(Fess & McCollum, 1998).
In addition to gaining motion, dynamic splints can
be used to assist weak or paralyzed muscles. These dy-
namic splints may be intrinsically powered by another
body part or by electrical stimulation of the client’s
muscles. Figure 15-2 Wrist splints enabling gardening.
Radomski_Chapter15.indd 430 8/26/13 6:36 PM
Chapter 15 Upper Extremity Orthoses 431
Figure 15-3 Hand splint enabling keyboarding.
and to provide related training as needed. The therapist
must take a leadership role to ensure that the treatment
team, including the client and caregivers, work collabora-
tively in every phase of the orthotic process. A client-cen-
tered, occupation-based approach empowers the client
and caregivers to participate actively. This also positions
them as the experts in the client’s occupations, lifestyle,
values, image, and activity contexts, which complements
the expertise that the health care professionals bring. The
therapist should clearly explain rationales, make clinically
sound recommendations, and offer choices to the client
whenever possible. This helps establish each team mem-
ber’s accountability and increases the likelihood that the
Figure 15-5 Wrist–hand splint enabling function in the kitchen.
client will actually use the splint.
A problem-solving approach to splinting directs the
therapist to answer several key questions before splinting
● What limitations will the splint impose?
proceeds:
● What evidence is available related to the splint?
● What is the primary clinical or functional problem?
Based on these considerations, the therapist must
● What are the indications for and goals of splint use?
select or design the most appropriate orthosis. In some
● How will the orthosis affect the problem and the
cases, the best choice is no orthosis at all.
client’s overall function?
The growing array of commercial products has led to
● What benefits will the splint provide?
a greater number of choices. The first choice to be made
is whether the orthosis should be custom fabricated or
prefabricated. Materials must also be considered. The
therapist must be familiar with properties, benefits, and
drawbacks of each. Options abound, with rigid, semi-rigid,
and soft materials available (see Chapter 16).
When making a splint selection, several key factors
must be carefully weighed:
● Among the splint-related factors are type, design, pur-
pose, fit, comfort, cosmetic appearance, cost to purchase
or fabricate, weight, ease of care, durability, ease of don-
ning and doffing, effect on unsplinted joints, and effect
on function.
● Client-related factors include clinical and functional
status, attitude, lifestyle, preference, occupational roles,
living and working environments, social support, issues
related to safety and precautions, ability to understand
Figure 15-4 Thumb splints enabling driving. and follow through, and financial or insurance status.
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