Upper Limb Casting in Stroke Rehabilitation: Rationale, Options, and Techniques Sharon R. Flinn, PhD, OTR/L, CHT,1 and Kimberly Craven, MOT1 1
Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus, Ohio Upper limb casts have been recommended for stroke survivors with moderate to severe spasticity. The objective of this article is to (a) review the rationale of 2 theoretical models that address spasticity and its consequences, (b) describe 4 casting options reported in the literature, (c) present the evidence for each cast type, and (d) suggest techniques that ensure safe and efficient fabrication of casts. This review underscores the critical need for high-evidence research on the efficacy of casting and the potential long-term benefits to this population. Current evidence lacks controlled research designs, robust sample sizes, and sensitive outcome measures. However, selective groups of stroke survivors have benefited from each type of casting. Future studies are required to assess the impact of casting on upper limb function, especially for those persons with wrist and hand spasticity, and to evaluate the efficacy of those casts not widely adopted in current practice such as inhibitory and drop-out casts. Key words: casts, hemiplegia, upper limb spasticity
S
troke causes a loss of cortical regulation due to impaired descending motor pathways that control normal subcortical responses.1,2 Abnormal responses include patterned synergistic movements and abnormal reflexes in the form of hypertonicity and flaccidity.2 Spasticity is one form of hypertonicity that occurs from velocity-dependent increases in muscle tone during quick passive movements.3,4 Upper limb spasticity following a stroke may result in pain, muscle contractures and other structural adaptations in soft tissues, weakness, associated reactions, loss of passive functions such as hygiene and donning garments, limited active function, and poor quality of life.1,5-7 Due to the direct influence that spasticity has on upper limb function for persons with stroke, preventing and treating developing spasticity in a timely fashion is essential.6 Best practice for conservative management of upper limb spasticity includes sensorimotor training; avoidance of pain-induced stretches; and motor-learning training such as imagery, electrical stimulation with and without feedback, movement with elevation, and strapping.8 Stretching and orthoses are often used in conjunction with these
Corresponding author: Sharon R. Flinn, 406F Atwell Hall, 453 West 10th Avenue, Columbus, OH 43210; e-mail: [email protected]
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interventions.9 However, conflicting evidence exists on the use of orthoses. Analyses of 4 randomized clinical trials found that orthoses did not significantly affect upper limb function, pain, or range of movement at the wrist, fingers, or thumb.10 However, generalization of these findings is difficult, as subjects had different neurological conditions, orthotic devices, treatment settings, and levels of spasticity. Also of concern is that 65% of all therapists surveyed from a pediatric setting used only 3 of the 12 available types of orthoses recommended in the treatment of neuromuscular disorders.11 More research is needed to evaluate the efficacy of orthoses for stroke survivors, especially in identifying those persons who are the best candidates to benefit from a wide array of orthotic interventions. For persons with moderate to severe spasticity, the National Stroke Foundation recommends evidenced-based strategies including botulinum toxin A, intrathecal baclofen, dynamic splinting, and vibration.12 When contractures are present, persons benefit from positioning their muscles in
Top Stroke Rehabil 2014;21(4):296–302 2014;21(1):296–302 © 2014 Thomas Land Publishers, Inc. www.thomasland.com www.strokejournal.com doi: 10.1310/tsr2104-296 10.1310/tscir2101-296
Upper Limb Casting
a lengthened position, electrical stimulation, and casts.9,13 Several advantages of casting exist.1,4,14,15 Compared to injections, casts are noninvasive. They target specific body parts compared to the systemic effects that result from medications. When properly fabricated, casts provide lowintensity, continuous stretch at the end ranges of joint motion. Casts accommodate gains in range of motion over time and can be used to maintain final improvements. Compared to manual therapies of stretching, casting can reduce pain reflexes and restore the functional length of affected muscles. Joints that are casted allow more focus on therapy of less involved joints. Primitive reflexes such as palmar grasp are inhibited through casts because of reduced transient cutaneous input to the hand.4 Casts are known to draw attention to the involved limb of persons with neglect. Finally, casts require infrequent removal and reapplication by others. This reduces the chance of improper placement, potential for skin breakdown, and poor positioning of the limb.4 With the potential advantages attributed to casts, the purpose of this article is to review 2 treatment models that support upper limb casting for spasticity, to identify the target populations who benefit from this approach, and to discuss various casting options and techniques.
297
In contrast, the biomechanical approach emphasizes the mechanical techniques that correct those deformities that frequently occur secondary to spasticity and prolonged positions of deformity. 11 End-range, low-load, long duration stretches stimulate Golgi tendon organs that activate 1b afferent fibers and inhibit alpha motor neurons.17 This approach also increases the number and length of sarcomeres in the muscle when the limb is immobilized in a lengthened position.4 Changes in the property of the muscle impact the length-tension relationship of cells, grow connective tissue through disorganization of the fibrous matrix, and ultimately increase range of motion.4 When moderate to severe spasticity is present, the length of the muscle fiber shortens and the proportion of collagen to muscle fiber increases.3 The biomechanical approach to handling spasticity is required to make necessary changes in connective tissue. Shorter periods of manual stretches do not change the length of the muscle fiber, and consequently the range of motion obtained is not possible without longer durations of stretch.3 Fortunately, the muscles that become shortened over time due to spasticity maintain their plasticity for lengthening.3 Target populations
Treatment models Two basic treatment models have been identified for managing spasticity in the upper limb.11,15 The neurophysiological approach uses movement and handling techniques that reduce spasticity.11 The goal is to reduce input to the tactile, proprioceptive, and temperature receptors by managing changes in muscle length and decreasing the amount of excitatory input to the muscle fibers.3,4,15 Injured brains can best maximize the sensory-motor input for the upper limb when intrinsic and extrinsic muscles of the hand are at maximal functional lengths.16 Casts also reduce tonus in spastic muscles by offering total contact, pressure, and neutral warmth. These effects hypothetically reduce the excitability of the alpha and gamma motor neurons of the spinal cord and contribute to the inhibition of reflexive muscle contractions.4
An estimated 6.4 million Americans are affected by the long-term effects of stroke.18 Among survivors, 30% to 60% have residual hand and upper limb impairments. Without treatment, they experience high levels of dependence in activities of daily living, poor rehabilitation prognosis, increased costs, and added burden on their caregivers.18-20 Poststroke motor recovery is complicated by the presence of flexor spasticity of the upper limb.7 The prevalence and severity of upper limb spasticity following a stroke differs across time. In a retrospective study of 163 persons 1 year post ischemic stroke, upper limb tone was present in 33% of the cohort at 3 months, 43% at 6 months, and 49% at 12 months.15 The number of persons in this cohort who had severe spasticity (Modified Ashworth Scale [MAS] ≥3) increased from 5% at 3 months, 8% at 6 months, and 18% at 12 months.5
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In longer term follow-up studies of 4 years post stroke, 83% of persons had some amount of abnormal upper limb tone, 41% had moderate tone, and 9% had severe tone.9 Upper limb spasticity affects all the joints of the upper limb and rarely is confined to a single joint.5 The most commonly affected joint is the wrist, and the shoulder is the least affected. However, the wrist and fingers are most frequently affected in those persons with severe levels of spasticity.5 While little is known about the progression of upper limb spasticity 1 year post stroke, these findings suggest that the best population in which to target and monitor intervention across time is persons who develop moderate to severe spasticity by 3 months post stroke.5 Casting of the upper limb, especially the wrist and fingers, is recommended as an important adjunct to therapy for stroke survivors with moderate to severe upper limb tone.4 Early clinical predictors of moderate to severe spasticity are low neurological scores on the National Institutes of Health Stroke Scale (NIHSS), poor upper limb muscle strength on the Upper Extremity Motricity Index (UEMI), and limited self-care skills on the Modified Barthel Index (MBI).5 Casting Options Less evidence is reported on the use of casts in stroke survivors compared to persons with traumatic brain injuries. Furthermore, lack of level I evidence neither supports nor refutes the effectiveness of upper limb casting in stroke survivors.21 However, targeted recommendations have been useful in selective patients during their rehabilitation. Therefore, a review of 4 casting options will be discussed in the management of upper limb spasticity. Descriptions of each type will be provided along with existing evidence and recommended protocols for use. Serial casts are applied and removed multiple times with progressively increased range of motion for each application.4 Subjects had greater improvements in passive range of motion and lower complications in casting with more frequent cast changes of 1 to 4 days.22,23 A minimum of overnight use and 2 to 4 hours per day has been recommended to maintain stretch and to prevent
contractures.21,24 Casting is recommended 2 to 3 weeks post injection of botulinum toxins when the best effect can be achieved.25 The elbow was the most frequently targeted joint for stroke survivors. An average of 35° improvement in passive extension was reported in 21 subjects with severe spasticity when serial casting was done in conjunction with multimodal treatments. These gains were maintained for 6 to 9 months post discharge.26 An additional 3 subjects with moderate to severe spasticity (MAS ≥3) and extension deficits averaging 117° had similar outcomes with an average improvement of 95° following 4 weeks of serial casting.27 Finally, 7 subjects post stroke had significant increases in elbow and wrist extension when casts placed affected joints in positions of submaximal rest approximately 5° to 10° less than full passive range of motion.28 No changes in electromyographic activity were present during the casting procedures. Inhibitory casts maintain a position that reduces spasticity in a reflex-inhibiting position (4Stoekmann). For the upper limb, these positions include shoulder abduction, elbow extension, forearm supination, neutral wrist extension, and finger and thumb extension/abduction.29 The frequency of cast changes should reflect the pace that the individual is making, but recommendations are every 2 to 28 days.21 Decreased motor neuron excitability has been measured in the elbows and wrists of adults with upper limb spasticity who receive inhibitory casts.28,30,31 Drop out casts allow a spastic joint to move in a desired position (ie, elbow extension) but prevent it from returning to a contracted position (ie, elbow flexion).4 In this example of a drop out cast for flexor tonicity of the elbow, a posterior portion of the upper part of the cast is removed. This design allows access to the triceps muscle for electrical stimulation and gives the wearer a chance to extend the arm into more extension while preventing elbow flexion beyond the casted position. Precautions are needed to monitor rotation of the cast due to less contact by the wearer. Unfortunately, studies on drop out casts are limited. One subject with left hemiparesis was reported to have gained 75° in passive elbow range of motion following 16 days of casting in addition to traditional therapy.32
Upper Limb Casting
Bivalve casts are used to maintain the range of motion gained through therapy and other casting options. As a supportive strategy, bivalve casts are less effective for increasing passive movement and individuals should be casted in maximum range.21,25 However, the main benefit of this design is that the cast is easy to remove because it is cut in halves. This provides an ability to inspect the skin, provide hygiene, and engage the limb in active movement.4 Bivalve casts can also be useful in constraint-induced therapy where the functional limb needs to be immobilized to facilitate the use of the more involved limb. A study of 15 stroke survivors showed that more improvement occurs in passive range of motion when using bivalve casts compared to the use of manual stretching and splinting.33 These gains were present in a 1 month follow-up, but alone they did not translate into improved upper limb function. Fabrication Several considerations are needed in the fabrication of a cast. Prior to casting, an assessment of upper limb function is essential. Leahy provides a precasting worksheet to guide the assessment of passive range of motion, tone, voluntary movement, inspection, and palpation.34 An in-depth analysis of adaptive tissue shortening in the extrinsic and intrinsic muscles is highly recommended. 16 Recognition of tissues with adaptive shortening suggests the joints and their position for the cast. Table 1 provides the positions of the upper limb that maximize the functional length of the extrinsic flexors by layers, extensors, and intrinsic muscles. Also inherent in the precasting process is the establishment of a Table 1.
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clear goal to reduce pain or tone, gain passive range of motion, or identify purposeful movements.21 Finally, a clinical outcome should be selected based on the desired outcome. Common measures include the Visual Analogue or the Wong-Baker Face Scales for pain, the MAS for spasticity, torque range of motion for extrinsic flexor musculature extensibility, and the Fugl-Meyer for physical performance. Once the goals and treatment plan are established, the cast material is selected. Plaster casts are generally cheaper, dry quickly, are strong, and can be reinforced easily.4 However, plaster casts are heavier when dry and are messier to apply. Due to the disadvantages associated with plaster, fiberglass materials are attractive to use because they are lighter, resilient, and durable; dry quickly; and require the use of less equipment such as cast saws and spreaders.4 The procedures for fabricating casts on spastic upper limbs have been described for serial and inhibitory types.22 Therefore, instructions will be provided for bivalve casts of the wrist and hand. Figures of the process are provided to improve clarity. • Have supplies ready, including stockinette, Coban, padding, 2 rolls of fiberglass, gloves, bandage scissors, and bucket with room temperature water (Figure 1). • Ensure client is comfortably seated and positioned for easy access to casting. • Position Coban cutting track on lateral border of the arm (Figure 2). • Measure stockinette lengths for arm and just extending beyond fingertips and thumb nail. • Apply stockinette and padding over bony prominences such as the ulnar head (Figure 3).
Tests for adaptive shortening of upper limb muscles
Structure
PROM composite tests
Composite extrinsic flexors Layer 1 (superficial) extrinsic flexors Level 2 extrinsic flexors Level 3 (deep) extrinsic flexors Extrinsic extensors Intrinsic
Elbow extension, supination, wrist and finger extension Wrist extension Wrist and finger MP and PIP extension Wrist and finger MP, PIP, and DIP extension Elbow extension, pronation, wrist and finger flexion Finger MP extension, PIP, and DIP flexion
Note: DIP = distal interphalangeal; MP = metacarpophalangeal; PIP = proximal interphalangeal; PROM = passive range of motion.
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Figure 1. Supplies needed for bivalve casting.
Figure 3. Placement of stockinette and padding.
Figure 2. Position of cutting track.
Figure 4. Application of figure-of-8 roll of material.
• Use gloves when applying fiberglass material. • Open package, submerge material in water as suggested (10-20 seconds), and remove excess water. The length of time in the water will affect the material set-up and the time you have to apply the cast. • Roll material in figure-of-8 motions starting at fingers, then thumb, wrist, and forearm. Avoid tension, keep the roll short and flowing, overlap by half the length of material, minimize layers, pull to one side, and make small cuts around curves such as the thumb (Figure 4). • Cover the edges with the stockinette as you go to prevent sharp edges, and ensure finger tips
•
•
• • •
are visible in the cast to inspect circulation (Figure 5). If roll starts to harden during application, wet material. Use a second person to assist with patient positioning and cast application as needed. Once the cast material is applied, ensure hand arches are made and uncasted joints have complete range of motion (Figure 6). Use bandage scissors to split cast over the cutting track (Figure 7). Remove cast and pad opening (Figure 8). Check for reddened areas, review instructions for bathing, elevation, scratching, and follow-up.
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Figure 5. Coverage of edges.
Figure 7. Split cast along cutting track.
Figure 6. Creation of arches and uncasted range of motion.
Figure 8. Final bivalve cast.
The final, yet important, phase of casting is the follow-up. The cast should be monitored every 2 hours for the first 24 hours. Concerns include changes in pain, edema, skin integrity, severe itching, sensibility, circulation, or movement in the cast. 25 Closer attention should occur with clients with tendencies toward pressure sores, compartment syndromes, or peripheral neuropathies and those with difficulty expressing pain or personal concerns.4
patients, it is important to complete a thorough assessment of the upper extremity, determine the therapist’s and patient’s goals for casting, and determine the most appropriate casting type and strategy to use. Frequency of cast changes and duration will be determined by monitoring individual patient progress. Although evidence exists regarding the benefits of casting for stroke patients, further studies are needed to gather highlevel evidence on the long-term impact of casting on upper limb function for poststroke individuals.
Conclusion Casts are used in conjunction with other therapeutic modalities to assist patients with increasing range of motion and function of involved extremities post stroke. Before casting
Acknowledgments We want to acknowledge Autumn Appis for her contribution to this manuscript. We have no conflicts of interest to report.
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REFERENCES 1. Bovend’Eerdt TJ, Newman M, Barker K, Dawes H, Minelli C, Wade DT. The effects of stretching in spasticity: A systematic review. Arch Phys Med Rehabil. 2008;89:1395-1406. 2. Abrams M. Upper extremity problems in clients with central nervous system dysfunction. In: Cooper C, ed. Fundamentals of Hand Therapy, Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity. Philadelphia: Elsevier; 2006. 3. Preissner K. The effects of serial casting on spasticity: A literature review. Occ Ther Health Care. 2001;14(2):99-106. 4. Stoeckmann T. Casting for the person with spasticity. Top Stroke Rehabil. 2001;8(1):27-35. 5. Kong K, Lee J, Chua K. Occurrence and temporal evolution of upper limb spasticity in stroke patients admitted to a rehabilitation unit. Arch Phys Med Rehabil. 2012;93:143-148. 6. Pizzi A, Carlucci G, Falsini C, Verdesca S, Grippo A. Evaluation of upper-limb spasticity after stroke: A clinical and neurophysiological study. Arch Phys Med Rehabil. 2005;86:410-415. 7. Doucet B, Mettler J. Effects of dynamic progressive orthotic intervention for chronic hemiplegia: A case series. J Hand Ther. 2013;26:139-146. 8. Barreca S, Wolf S, Fasoli S, Bohannon R. Treatment interventions for the paretic upper limb of stroke survivors: A critical review. Neurorehabil Neural Repair. 2003;17:220-226. 9. Marciniak C. Poststroke hypertonicity: Upper limb assessment and treatment. Top Stroke Rehabil. 2011;18(3):179-194. 10. Tyson S, Kent R. The effect of upper limb orthotics after stroke: A systematic review. Neurorehabilitation. 2011;28:29-36. 11. Fess E, Gettle K, Phillips C, Janson R. Splinting for patients with upper extremity spasticity. In: Fess E, Gettle K, Phillips C, Janson R, eds. Hand and Upper Extremity Splinting, Principles and Methods. 3rd ed. Philadelphia: Mosby; 2004. 12. National Stroke Foundation. Clinical guidelines for stroke management 2010. http://strokefoundation. com.au/health-professionals/tools-and-resources/ clinical-guidelines-for-stroke-prevention-andmanagement/. Accessed May 2, 2014. 13. Gustafsson L, Yates K. Are we applying interventions with research evidence when targeting secondary complications of the stroke-affected upper limb. Aust Occup Ther J. 2008;56:428-435. 14. Gracies J, Renton R, Sandanam J, Gandevia S, Burke D. Short-term effects of dynamic Lycra splints on upper limb in hemiplegia patients. Arch Phys Med Rehabil. 2008;81:1547-1555. 15. Suat E, Engin S, Nilgun B, Yavuz Y, Fatma U. Short and long term effects of an inhibitor hand splint in poststroke patients: A randomized controlled trial. Top Stroke Rehabil. 2011;18(3):231-237. 16. Pitts D, O’Brien S. Splinting the hand to enhance motor control and brain plasticity. Top Stroke Rehabil. 2008;15(5):436-466. 17. Mortenson P, Eng J. The use of casts in the management of joint mobility and hypertonia
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32. 33. 34.
following brain injury in adults: A systematic review. Phys Ther. 2003;83:648-658. Butler A, Shuster M, O’Hara E, Hurley K, Middlebrooks D, Guilkey K. A meta-analysis of the efficacy of anodal transcranial direct current stimulation for upper limb motor recovery in stroke survivors. J Hand Ther. 2013;26:162-171. Bear-Lehman J, Duff S. Innovations in neurological upper extremity rehabilitation. J Hand Ther. 2013;26:85-86. Veerbeek J, Kwakkel G, van Wegen E, Ket J, Heymans M. Early prediction of outcome of activities of daily living after stroke: A systematic review. Stroke. 2011;42:1482-1488. Lannin N, Novak I, Cusick C. A systematic review of upper extremity casting for children and adults with central nervous system disorders. Clin Rehabil. 2007;21:963-976. Pohl M, Ruckreim S, Mehrholz J, Ritschel C, Strik H, Pause M. Effectiveness of serial casting in patients with severe cerebral spasticity: A comparison study. Arch Phys Med Rehabil. 2002;83:784-90. Pohl M, Mehrholz J, Ruckriem S. The influence of illness duration and level of consciousness on the treatment effect and complication rate of serial casting in patients with severe cerebral spasticity. Clin Rehabil. 2003;17:373-379. Bhakta B. Management of spasticity in stroke. Br Med Bull. 2000:56(2):476-485. Logan L. Rehabilitation techniques to maximize spasticity reduction. Top Stroke Rehabil. 2011;18(3):203-211. Lehmkuhl L, Thoi L, Baize C, Kelly C, Kawczyk L, Bontke C. Multimodal treatment of joint contractures in patients with severe brain injury: Cast, effectiveness, and integration of therapies in the application of serial and inhibitive casts. J Head Trauma Rehabil. 1990;5:23-42. Pohl M, Ruckriem S, Strik H, Hurtinger B, Meifiner D, Mehrhotz J, Pause M. Treatment of pressure ulcers by serial casting in patients with severe spasticity of cerebral origin. Arch Phys Med Rehabil. 2002;83:35-39. Mills V. Electromyographic results of inhibitory splinting. Phys Ther. 1984; 64:190-93. Bobath B. Adult Hemiplegia: Evaluation and Treatment. 3rd ed. London: Heinemann; 1990. Childers M, Biswas S, Petroski G, Merveille O. Inhibitory casting decreases a vibratory inhibition index of the H-reflex in the spastic upper limb. Arch Phys Med Rehabil. 1999;80(6):714-716. Pizzi A, Carlucci G, Falsini C, Verdesca S, Grippo A. Application of a volar static splint in post-stroke spasticity of the upper limb. Arch Phys Med Rehabil. 2005;86:1855-1859. King T. Plaster splinting as a means of reducing elbow flexor spasticity: A case study. Am J Occup Ther. 1982;36:671-673. Hill J. The effects of casting on upper extremity motor disorders after brain injury. Am J Occup Ther. 1994;48:219-224. Leahy P. Pre-casting worksheet, an assessment tool. Phys Ther. 1988;68(1):72-74.
Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus, Ohio Upper limb casts have been recommended for stroke survivors with moderate to severe spasticity. The objective of this article is to (a) review the rationale of 2 theoretical models that address spasticity and its consequences, (b) describe 4 casting options reported in the literature, (c) present the evidence for each cast type, and (d) suggest techniques that ensure safe and efficient fabrication of casts. This review underscores the critical need for high-evidence research on the efficacy of casting and the potential long-term benefits to this population. Current evidence lacks controlled research designs, robust sample sizes, and sensitive outcome measures. However, selective groups of stroke survivors have benefited from each type of casting. Future studies are required to assess the impact of casting on upper limb function, especially for those persons with wrist and hand spasticity, and to evaluate the efficacy of those casts not widely adopted in current practice such as inhibitory and drop-out casts. Key words: casts, hemiplegia, upper limb spasticity
S
troke causes a loss of cortical regulation due to impaired descending motor pathways that control normal subcortical responses.1,2 Abnormal responses include patterned synergistic movements and abnormal reflexes in the form of hypertonicity and flaccidity.2 Spasticity is one form of hypertonicity that occurs from velocity-dependent increases in muscle tone during quick passive movements.3,4 Upper limb spasticity following a stroke may result in pain, muscle contractures and other structural adaptations in soft tissues, weakness, associated reactions, loss of passive functions such as hygiene and donning garments, limited active function, and poor quality of life.1,5-7 Due to the direct influence that spasticity has on upper limb function for persons with stroke, preventing and treating developing spasticity in a timely fashion is essential.6 Best practice for conservative management of upper limb spasticity includes sensorimotor training; avoidance of pain-induced stretches; and motor-learning training such as imagery, electrical stimulation with and without feedback, movement with elevation, and strapping.8 Stretching and orthoses are often used in conjunction with these
Corresponding author: Sharon R. Flinn, 406F Atwell Hall, 453 West 10th Avenue, Columbus, OH 43210; e-mail: [email protected]
296
interventions.9 However, conflicting evidence exists on the use of orthoses. Analyses of 4 randomized clinical trials found that orthoses did not significantly affect upper limb function, pain, or range of movement at the wrist, fingers, or thumb.10 However, generalization of these findings is difficult, as subjects had different neurological conditions, orthotic devices, treatment settings, and levels of spasticity. Also of concern is that 65% of all therapists surveyed from a pediatric setting used only 3 of the 12 available types of orthoses recommended in the treatment of neuromuscular disorders.11 More research is needed to evaluate the efficacy of orthoses for stroke survivors, especially in identifying those persons who are the best candidates to benefit from a wide array of orthotic interventions. For persons with moderate to severe spasticity, the National Stroke Foundation recommends evidenced-based strategies including botulinum toxin A, intrathecal baclofen, dynamic splinting, and vibration.12 When contractures are present, persons benefit from positioning their muscles in
Top Stroke Rehabil 2014;21(4):296–302 2014;21(1):296–302 © 2014 Thomas Land Publishers, Inc. www.thomasland.com www.strokejournal.com doi: 10.1310/tsr2104-296 10.1310/tscir2101-296
Upper Limb Casting
a lengthened position, electrical stimulation, and casts.9,13 Several advantages of casting exist.1,4,14,15 Compared to injections, casts are noninvasive. They target specific body parts compared to the systemic effects that result from medications. When properly fabricated, casts provide lowintensity, continuous stretch at the end ranges of joint motion. Casts accommodate gains in range of motion over time and can be used to maintain final improvements. Compared to manual therapies of stretching, casting can reduce pain reflexes and restore the functional length of affected muscles. Joints that are casted allow more focus on therapy of less involved joints. Primitive reflexes such as palmar grasp are inhibited through casts because of reduced transient cutaneous input to the hand.4 Casts are known to draw attention to the involved limb of persons with neglect. Finally, casts require infrequent removal and reapplication by others. This reduces the chance of improper placement, potential for skin breakdown, and poor positioning of the limb.4 With the potential advantages attributed to casts, the purpose of this article is to review 2 treatment models that support upper limb casting for spasticity, to identify the target populations who benefit from this approach, and to discuss various casting options and techniques.
297
In contrast, the biomechanical approach emphasizes the mechanical techniques that correct those deformities that frequently occur secondary to spasticity and prolonged positions of deformity. 11 End-range, low-load, long duration stretches stimulate Golgi tendon organs that activate 1b afferent fibers and inhibit alpha motor neurons.17 This approach also increases the number and length of sarcomeres in the muscle when the limb is immobilized in a lengthened position.4 Changes in the property of the muscle impact the length-tension relationship of cells, grow connective tissue through disorganization of the fibrous matrix, and ultimately increase range of motion.4 When moderate to severe spasticity is present, the length of the muscle fiber shortens and the proportion of collagen to muscle fiber increases.3 The biomechanical approach to handling spasticity is required to make necessary changes in connective tissue. Shorter periods of manual stretches do not change the length of the muscle fiber, and consequently the range of motion obtained is not possible without longer durations of stretch.3 Fortunately, the muscles that become shortened over time due to spasticity maintain their plasticity for lengthening.3 Target populations
Treatment models Two basic treatment models have been identified for managing spasticity in the upper limb.11,15 The neurophysiological approach uses movement and handling techniques that reduce spasticity.11 The goal is to reduce input to the tactile, proprioceptive, and temperature receptors by managing changes in muscle length and decreasing the amount of excitatory input to the muscle fibers.3,4,15 Injured brains can best maximize the sensory-motor input for the upper limb when intrinsic and extrinsic muscles of the hand are at maximal functional lengths.16 Casts also reduce tonus in spastic muscles by offering total contact, pressure, and neutral warmth. These effects hypothetically reduce the excitability of the alpha and gamma motor neurons of the spinal cord and contribute to the inhibition of reflexive muscle contractions.4
An estimated 6.4 million Americans are affected by the long-term effects of stroke.18 Among survivors, 30% to 60% have residual hand and upper limb impairments. Without treatment, they experience high levels of dependence in activities of daily living, poor rehabilitation prognosis, increased costs, and added burden on their caregivers.18-20 Poststroke motor recovery is complicated by the presence of flexor spasticity of the upper limb.7 The prevalence and severity of upper limb spasticity following a stroke differs across time. In a retrospective study of 163 persons 1 year post ischemic stroke, upper limb tone was present in 33% of the cohort at 3 months, 43% at 6 months, and 49% at 12 months.15 The number of persons in this cohort who had severe spasticity (Modified Ashworth Scale [MAS] ≥3) increased from 5% at 3 months, 8% at 6 months, and 18% at 12 months.5
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In longer term follow-up studies of 4 years post stroke, 83% of persons had some amount of abnormal upper limb tone, 41% had moderate tone, and 9% had severe tone.9 Upper limb spasticity affects all the joints of the upper limb and rarely is confined to a single joint.5 The most commonly affected joint is the wrist, and the shoulder is the least affected. However, the wrist and fingers are most frequently affected in those persons with severe levels of spasticity.5 While little is known about the progression of upper limb spasticity 1 year post stroke, these findings suggest that the best population in which to target and monitor intervention across time is persons who develop moderate to severe spasticity by 3 months post stroke.5 Casting of the upper limb, especially the wrist and fingers, is recommended as an important adjunct to therapy for stroke survivors with moderate to severe upper limb tone.4 Early clinical predictors of moderate to severe spasticity are low neurological scores on the National Institutes of Health Stroke Scale (NIHSS), poor upper limb muscle strength on the Upper Extremity Motricity Index (UEMI), and limited self-care skills on the Modified Barthel Index (MBI).5 Casting Options Less evidence is reported on the use of casts in stroke survivors compared to persons with traumatic brain injuries. Furthermore, lack of level I evidence neither supports nor refutes the effectiveness of upper limb casting in stroke survivors.21 However, targeted recommendations have been useful in selective patients during their rehabilitation. Therefore, a review of 4 casting options will be discussed in the management of upper limb spasticity. Descriptions of each type will be provided along with existing evidence and recommended protocols for use. Serial casts are applied and removed multiple times with progressively increased range of motion for each application.4 Subjects had greater improvements in passive range of motion and lower complications in casting with more frequent cast changes of 1 to 4 days.22,23 A minimum of overnight use and 2 to 4 hours per day has been recommended to maintain stretch and to prevent
contractures.21,24 Casting is recommended 2 to 3 weeks post injection of botulinum toxins when the best effect can be achieved.25 The elbow was the most frequently targeted joint for stroke survivors. An average of 35° improvement in passive extension was reported in 21 subjects with severe spasticity when serial casting was done in conjunction with multimodal treatments. These gains were maintained for 6 to 9 months post discharge.26 An additional 3 subjects with moderate to severe spasticity (MAS ≥3) and extension deficits averaging 117° had similar outcomes with an average improvement of 95° following 4 weeks of serial casting.27 Finally, 7 subjects post stroke had significant increases in elbow and wrist extension when casts placed affected joints in positions of submaximal rest approximately 5° to 10° less than full passive range of motion.28 No changes in electromyographic activity were present during the casting procedures. Inhibitory casts maintain a position that reduces spasticity in a reflex-inhibiting position (4Stoekmann). For the upper limb, these positions include shoulder abduction, elbow extension, forearm supination, neutral wrist extension, and finger and thumb extension/abduction.29 The frequency of cast changes should reflect the pace that the individual is making, but recommendations are every 2 to 28 days.21 Decreased motor neuron excitability has been measured in the elbows and wrists of adults with upper limb spasticity who receive inhibitory casts.28,30,31 Drop out casts allow a spastic joint to move in a desired position (ie, elbow extension) but prevent it from returning to a contracted position (ie, elbow flexion).4 In this example of a drop out cast for flexor tonicity of the elbow, a posterior portion of the upper part of the cast is removed. This design allows access to the triceps muscle for electrical stimulation and gives the wearer a chance to extend the arm into more extension while preventing elbow flexion beyond the casted position. Precautions are needed to monitor rotation of the cast due to less contact by the wearer. Unfortunately, studies on drop out casts are limited. One subject with left hemiparesis was reported to have gained 75° in passive elbow range of motion following 16 days of casting in addition to traditional therapy.32
Upper Limb Casting
Bivalve casts are used to maintain the range of motion gained through therapy and other casting options. As a supportive strategy, bivalve casts are less effective for increasing passive movement and individuals should be casted in maximum range.21,25 However, the main benefit of this design is that the cast is easy to remove because it is cut in halves. This provides an ability to inspect the skin, provide hygiene, and engage the limb in active movement.4 Bivalve casts can also be useful in constraint-induced therapy where the functional limb needs to be immobilized to facilitate the use of the more involved limb. A study of 15 stroke survivors showed that more improvement occurs in passive range of motion when using bivalve casts compared to the use of manual stretching and splinting.33 These gains were present in a 1 month follow-up, but alone they did not translate into improved upper limb function. Fabrication Several considerations are needed in the fabrication of a cast. Prior to casting, an assessment of upper limb function is essential. Leahy provides a precasting worksheet to guide the assessment of passive range of motion, tone, voluntary movement, inspection, and palpation.34 An in-depth analysis of adaptive tissue shortening in the extrinsic and intrinsic muscles is highly recommended. 16 Recognition of tissues with adaptive shortening suggests the joints and their position for the cast. Table 1 provides the positions of the upper limb that maximize the functional length of the extrinsic flexors by layers, extensors, and intrinsic muscles. Also inherent in the precasting process is the establishment of a Table 1.
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clear goal to reduce pain or tone, gain passive range of motion, or identify purposeful movements.21 Finally, a clinical outcome should be selected based on the desired outcome. Common measures include the Visual Analogue or the Wong-Baker Face Scales for pain, the MAS for spasticity, torque range of motion for extrinsic flexor musculature extensibility, and the Fugl-Meyer for physical performance. Once the goals and treatment plan are established, the cast material is selected. Plaster casts are generally cheaper, dry quickly, are strong, and can be reinforced easily.4 However, plaster casts are heavier when dry and are messier to apply. Due to the disadvantages associated with plaster, fiberglass materials are attractive to use because they are lighter, resilient, and durable; dry quickly; and require the use of less equipment such as cast saws and spreaders.4 The procedures for fabricating casts on spastic upper limbs have been described for serial and inhibitory types.22 Therefore, instructions will be provided for bivalve casts of the wrist and hand. Figures of the process are provided to improve clarity. • Have supplies ready, including stockinette, Coban, padding, 2 rolls of fiberglass, gloves, bandage scissors, and bucket with room temperature water (Figure 1). • Ensure client is comfortably seated and positioned for easy access to casting. • Position Coban cutting track on lateral border of the arm (Figure 2). • Measure stockinette lengths for arm and just extending beyond fingertips and thumb nail. • Apply stockinette and padding over bony prominences such as the ulnar head (Figure 3).
Tests for adaptive shortening of upper limb muscles
Structure
PROM composite tests
Composite extrinsic flexors Layer 1 (superficial) extrinsic flexors Level 2 extrinsic flexors Level 3 (deep) extrinsic flexors Extrinsic extensors Intrinsic
Elbow extension, supination, wrist and finger extension Wrist extension Wrist and finger MP and PIP extension Wrist and finger MP, PIP, and DIP extension Elbow extension, pronation, wrist and finger flexion Finger MP extension, PIP, and DIP flexion
Note: DIP = distal interphalangeal; MP = metacarpophalangeal; PIP = proximal interphalangeal; PROM = passive range of motion.
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Figure 1. Supplies needed for bivalve casting.
Figure 3. Placement of stockinette and padding.
Figure 2. Position of cutting track.
Figure 4. Application of figure-of-8 roll of material.
• Use gloves when applying fiberglass material. • Open package, submerge material in water as suggested (10-20 seconds), and remove excess water. The length of time in the water will affect the material set-up and the time you have to apply the cast. • Roll material in figure-of-8 motions starting at fingers, then thumb, wrist, and forearm. Avoid tension, keep the roll short and flowing, overlap by half the length of material, minimize layers, pull to one side, and make small cuts around curves such as the thumb (Figure 4). • Cover the edges with the stockinette as you go to prevent sharp edges, and ensure finger tips
•
•
• • •
are visible in the cast to inspect circulation (Figure 5). If roll starts to harden during application, wet material. Use a second person to assist with patient positioning and cast application as needed. Once the cast material is applied, ensure hand arches are made and uncasted joints have complete range of motion (Figure 6). Use bandage scissors to split cast over the cutting track (Figure 7). Remove cast and pad opening (Figure 8). Check for reddened areas, review instructions for bathing, elevation, scratching, and follow-up.
Upper Limb Casting
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Figure 5. Coverage of edges.
Figure 7. Split cast along cutting track.
Figure 6. Creation of arches and uncasted range of motion.
Figure 8. Final bivalve cast.
The final, yet important, phase of casting is the follow-up. The cast should be monitored every 2 hours for the first 24 hours. Concerns include changes in pain, edema, skin integrity, severe itching, sensibility, circulation, or movement in the cast. 25 Closer attention should occur with clients with tendencies toward pressure sores, compartment syndromes, or peripheral neuropathies and those with difficulty expressing pain or personal concerns.4
patients, it is important to complete a thorough assessment of the upper extremity, determine the therapist’s and patient’s goals for casting, and determine the most appropriate casting type and strategy to use. Frequency of cast changes and duration will be determined by monitoring individual patient progress. Although evidence exists regarding the benefits of casting for stroke patients, further studies are needed to gather highlevel evidence on the long-term impact of casting on upper limb function for poststroke individuals.
Conclusion Casts are used in conjunction with other therapeutic modalities to assist patients with increasing range of motion and function of involved extremities post stroke. Before casting
Acknowledgments We want to acknowledge Autumn Appis for her contribution to this manuscript. We have no conflicts of interest to report.
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