Splints for stroke and children
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Non-Sterile Therapeutic Air Splints an Aid to Rehabilitation

Splints Available For Therapeutic Use
	The long arm splint single chamber two lengths: --> 70 cm	REF 70 002 0
	--> 80 cm	REF 70 001 0
	Leg splint for resting Single chamber splint standard size (adult)	REF 71 002 0
	Leg splint for standing Single chamber splint with non-inflatable sole standard size (adult)	REF 70 012 0
	The leg gaiter two lengths: --> 70 cm	REF 70 006 0
	--> 60 cm to fit shorter leg	REF 70 007 0
	The foot splint double chamber	REF 70 108 0

Precautions

1. The splints must be orally inflated. - warm air from the lungs ensures a perfect fit, moulding the splint to the patients limb to give all-over even pressure. Pressure should never exceed 40 mm Hg. (see page 5). Pressure should be read when the limb is at rest.
2. A thin cotton sleeve should cover the patients limb while splint is in use as a protection against sweat rash.
3. The splint should not be worn in direct sunlight. Strong sunlight through the plastic can produce burns of the skin.
4. No splint should be left on for more than one hour but should be taken off and reapplied during a full morning treatment session. Splints should never be used for overnight positioning.
5. Sometimes a patient may have broken skin or a sore on a part to be covered by the splint. Splints may still be applied but if wound dressings are bulky, reduce the size leaving a smaller sterile dressing covering the affected area. After use the splint should be cleaned as described on page 4. In this event, patients must have their own personal splint, clearly named and not used on other patients.
6. Dispose of splints by normal household rubbish bin. Do not burn on domestic fire or an electric incinerator.

Care of Splints

1. Before using for the first time, new splints should be inflated with the zip fastener open to ensure the two layers of plastic separate. After fully inflating the splint, the valve should be opened and the splint rolled up to force all the air out. The splint is then straightened and is ready for use.
2. When not in use, the splint should be unfolded and kept lying flat, or hung up so that the inflation tube hangs downwards, ensuring that there is no strain where the tube joins the splint. DO NOT USE THIS JUNCTION AS A HANDLE WHEN FITTING THE SPLINT.
3. The splints may be wiped over with a mild disinfectant to clean them, and then dried with a towel. If necessary the valve may be disconnected and washed and the inflation tube cleaned with a test tube brush dipped in a mild disinfectant, allowed to dry and then reassembled. DO NOT let fluid run inside the splints as you cannot drain out.
4. Splints SHOULD NOT be stored in sub-zero temperatures. The recommended storage temperature is + 10^oC. For best results, splints should be allowed to achieve treatment room temperature before use.
5. Many patients prefer to have their own splints and when appropriate, carers and family members may be taught to use the splints by the therapist.
6. A personal detachable mouthpiece for inflation, easily fitted to the inflation tube, is recommended (see Page 5).

Inflation of Splints

The splints must be orally inflated - warm moist air from the lungs ensure a perfect mould of the splint to the patient's limb, giving all-over even pressure.

Inflation pressures should not exceed 40mm Hg. If in doubt then check the pressure of the splint with a manometer, using a 10cm connection between valve on splint and manometer. Pressures should be read when the limb is at rest. ** See below. Pressures comfortable for the patient should always be used. Therapists quickly become accustomed to the feel of correct pressure. A personal detachable mouth piece for inflation, easily fitted to the inflation tube and carried in the user's pocket, is recommended. * See below.

Mouth Pieces for Inflation
1. mouth Piece		REF 75 000 0
2. filter bottle		REF 75 011 0

1. MOUTH PIECE - a personal detachable mouth piece, easily fitted and carried in the user's pocket. May be washed and cleaned for frequent use.
2. DISPOSABLE FILTER BOTTLE - contains crystals which absorb excess moisture. Easily fitted to the inflation tube and when detached carried in the user's pocket. The colour of the granules turn from orange to white (clear) when saturated. Should be discarded when the crystals become white.

 ** Manometer for Checking Inflation Pressure

To monitor oral inflation pressures, use the Air Splint Manometer 300mm Hg, Product code 038q, obtainable from:
A.C. Cossor & Son (Surgical) Ltd., Accoson Works, Vale Road, London N4 1 PS, UK.
Telephone: +44  (0) l 81 800 1172 Fax 0l 81 809 5170

Notes on the Arm Splint and the Leg Splint for Resting

Urias Splints are made of a double layer of clear plastic, they are applied to a patient's limb and then inflated by mouth. During inflation the inner lining moulds exactly to the patient's limb giving an all-over, even pressure when inflation has been completed.

When the problem is one of excessive flexor tone splints will help to maintain the limbs, for rest periods, in desired inhibitory patterns of extension.
Care must be taken before and during inflation to ensure correct positioning of the limb within the splint.
Total tonal patterns should also be considered and positions of rest used during the patient's treatment time should be chosen to inhibit unwanted tone throughout the body as well as the affected limbs.
Flexion contractures, which lead to deformities, are found to develop in the limbs of some patients with neurological disorders.
The splints may be used to help prevent the development of contractures in upper and lower limbs. Where the signs of developing contractures are recognized early, the regular use of the splints will inhibit the development of contractual deformities.
Where the contractural deformity has already developed, the splints may be used to stretch the contracture and gradually reduce the deformity.
When the problem develops bilaterally it is usual to apply splints to two limbs simultaneously during the treatment session.

Use for the Arm splint and the Leg Splint for Resting

Regular use of the splints will inhibit developing flexor spasticity, daily resting periods wearing the splints with body and limbs carefully positioned in patterns of inhibition are recommended.
The splints give limb stability and facilitate passive movements to shoulder and hip joints. Passive movements may be performed on the wrist while the arm splint is worn.
The splints will help to stabilize ataxia.
The splints give a sensory boost where there is loss of function associated with sensory deterioration.
A firm inflation will give a stronger stretch and more support to the limb, but give the inflation that is appropriate for each patient.

The Arm Splint

Applied with the patient supine and comfortably supported.

The splint should be applied so that the arm is held in the correct position to inhibit flexor spasticity.

1. A cotton sleeve is put on the patient's am.
2. Head pillows are removed or reduced to a comfortable minimum. The patient's head is placed with the neck in extension and the face turned towards the affected arm. The therapist eloses the zip-fastener on the splint and pulls it onto her own arm. Then, taking a hand-shake grasp with the patient, turns the patient's arm to outwardly rotate the shoulder while extending the elbow. The splint is then drawn up the patients's arm.
3. Using the hand that is outside the splint the therapist abducts the patient's thumb and applies pressure to the thenar eminence. As the splint is inflated the therapist gradually withdraws her hand from the inside of the splint.
4. The splint is firmly inflated.

The zip-fastener is on the side of the patient's small finger.
The elbow, wrist and fingers are now held in extension and the thumb in mild abduction. The fingers are well back from the end of the splint.
Resting periods wearing the splint should be followed by passive/active range of shoulder movements.
Wrist flexors may be comfortably stretched before removing the splint.

Note: There are many other uses for the Arm splints, they are essential tools in any motor retraining programme for the neurologically impaired patient, when following the Johnstone Concept of neuro-rebabilitation.
For example in the treatment of the patient after Stroke.
The splint gives the arm support and stability and aids the control of limb extension while re-education takes place.
The splint may be used to stabilise weight bearing through the arm with the patient in a crawling position (or sitting) leaning on the palm of the hand with extended wrist and elbow and the shoulder outwardly rotated.
Active exercises in these carefully chosen positions will bring an overflow of tone into the splinted arm thus increasing extensor tone and reducing flexor spasticity, leading on to balance training with stability and control of shoulder, upper trunk and head.
When this has been achieved further progression to regaining lost arm and hand function may follow.

The Leg Splint for Resting

A single chamber splint designed to support the lower limb in extension.
Applied with the patient supine and comfortably supported as necessary.
A cotton stocking is put on the patient's leg before the leg is placed in the open splint. The zip-fastener is then closed and the splint inflated. Make sure that the limb is cushioned all round with air and the zip-fastener is not pressing on the anterior surface of the knee joint.

If the leg has already developed a flexion contracture, then proceed as follows:

1. Place the patient's leg in the open splint, gradually close the zip-fastener as the splint is eased up the leg.
2. The fabric of the splint and the zip-fastener are held away from the front of the knee joint as the splint is inflated.
3. As inflation takes place the knee is forced gently into extension. There must be a cushion of air over the front of the knee joint.

The toes must be well back from the end of the splint.

Uses: To stretch/prevent flexion contractures daily resting periods wearing the splints are recommended. The patient should lie supine with pillows between legs to maintain hip abduction and under the pelvis to increase hip extension.
Good results have been achieved when splints were applied twice a day for one hour (morning and afternoon).
It is hoped that with improvement the patient may progress to standing with splint support as described in the following pages.
Resting with splint support has also been found to benefit some patients with severe ataxia, bringing temporary relief from constant involuntary movements.

NOTE: Splints should not be left on for more than one hour. If more time is required, remove the splint, roll it up to remove the air, then reapply.

The Leg Splint for Standing

This single chamber splint has a non-inflatable weight bearing sole.

Applied to one or both legs with the patient standing supported as necessary. The splint encloses the whole leg, including the ankle and foot, and when inflated gives extra stability to the limb.
The patient should wear full-length cotton stockings or lightweight trousers and properly fitting shoes with flat heels.
For application of the splint start with the patient in a sitting position, the leg is then placed in the open splint with the heel of the shoe well back in the heel section of the splint and firmly on the floor. The splint should then be eased up round the patient's leg and the zip fastener closed. The patient is then required to stand - assisted and supported as necessary. The splint should now be inflated, during inflation the upper edge of the splint should be held high on the patient's leg and the zip-fastener held forward from the front of the knee joint and the front of the ankle.
When fully inflated the limb is cushioned. All round with air.
The zip-fastener should not press on the anterior surface of the knee joint.

Shoes to be worn within splints must be chosen with care to ensure there are no sharp parts that would damage the splints.

Uses: A treatment aid for patients who will benefit from standing.
Increased ankle and foot stability combined with knee support allows for re-education of standing balance.
Extensor tone is increased while inhibiting excessive flexor tone.
In the severely disabled will help to maintain length and pliability of muscles and ligaments and prevent flexion contracture.
Poor standing balance may be improved.
Standing exercises may be performed - trunk and pelvic stabilisations and gait retraining.
Preliminary step-taking when retraining walking.

Note 1: The splint is designed to bring the patient's centre of gravity over the forefoot and so stimulate leg extension.

Note 2: When ankle and foot are stable the training for standing balance and control of trunk and pelvis may best be done with support from the leg gaiter. (See next page.)

The Leg gaiter

A double chamber splint used to support the leg in standing.
The patient should wear full length cotton stockings or light-weight trousers and properly fitting shoes with flat heels.
Applied to one or both legs as necessary, there are two different methods of application each producing a different response.

Method 1 - for the patient with excessive extensor tone.

For application the patient should be standing and suitably supported, the feet carefully positioned straight forward and slightly apart.

The open splint is then wrapped around the patient's leg with the zip-fastener positioned down the lateral side of the leg. When closing the zip make sure that the upper edge of the splint fits right under the ischial tuberosity. The posterior chamber of the splint is then firmly inflated. It is important that the patient is weight bearing through the leg as inflation takes place. This ensures mild flexion of the knee and firm contact between the heel and the floor. This desired standing position reduces extensor tone at the hip.
The anterior chamber is then inflated with a small amount of air - enough to stabilise the knee joint and make the splint comfortable. This is the purpose for which the splint was originally designed.

Method 2 - if the problem is that of excessive flexor tone.

With the patient standing with suitable help and support the gaiter should be applied as before with the upper edge of the posterior chamber under the ischial tuberosity and the zip fastener down the outside of the leg. But, the procedure for inflation should be reversed, the anterior chamber should be inflated first with a firm inflation to extend the knee, the posterior chamber should then be inflated to stabilise the limb. Body weight through the already extended knee to the fore part of the foot will bring a further increase in extensor tone.

Note: If the flexor tone is greatly increased and the foot and ankle are unstable and need support for standing a better result will be achieved by using the leg splints for standing as described on pages II and 12. This single chamber splint with all over even pressure has a greater inhibiting effect on spasticity and was designed for this purpose.

Uses: On application it is important that the gaiter fits high on the leg so that the ischial tuberosity is weight bearing on the upper edge of the splint.
It is often better to apply two gaiters so that the pelvis is fully supported and level allowing for re-education of balance and weight shifts and stabilisations of lower trunk and pelvis while the lower limbs are maintained in required inhibiting patterns.
Standing exercises may be performed, preparation for weight transfers etc...
Practice of knee bending and stretching wearing the gaiter/gaiters will strengthen the supported muscles round the knee and also strengthen the foot muscles and stretch the Tendo Achillis.>
Stabilise the limb in standing when retraining in post-operative rehabilitation.

Note: If the patient is too disabled to allow application of leg splints or gaiters when standing supported then the patient may lie supine on a tilt-table while the splints are carefully applied. The tilt-table may then be used to bring the patient, by easy stages, from the horizontal to the vertical position.

The Double Chamber Foot Splint

This splint has a non-inflatable sole to allow for standing and walking.

There are two separate chambers, one on each side of the foot. The splint is designed to be worn over the patient's shoe. (Trainer type shoe is suitable).
Shoes to be worn within the splints must be chosen with care to ensure there are no sharp parts that would damage the splints.
Applied as an aid to stabilise the foot and ankle when retraining walking.
There are two different methods of application each producing a different response.

Method 1 - where the recovery of a proper walking gait is made difficult by a dragging inverted foot.

The patient, wearing properly fitting shoes, should be seated while the splint is applied. The zip-fastener on the splint is opened and the patient's foot placed in the splint with the heel of the shoe well back into the heel section of the splint. The zip-fastener is then closed and the splint inflated. The chamber on the outer aspect of the ankle is inflated first, with a firm inflation to bring eversion into the foot at the ankle. Some air is then blown into the chamber on the inner side of the ankle - a small amount of air, enough to make the splint comfortable.

Method 2 - if the problem is one of excessive eversion of the foot then the splint should be fitted over the patient's shoe as before but the procedure for inflation should be reversed. The chamber on the inner side of the ankle to be inflated first with the stronger inflation to bring the foot into inversion at the ankle, a small amount of air should then be blown into the outer chamber to stabilise the ankle and make it comfortable.

Uses: To stabilise the foot and ankle in positions that allow re-education of foot function while training control of balance in sitting and standing.
Progressing to training correct walking - the splint aids the recovery of the swing phase followed by heel strike in the affected leg.

Note 1: When fitting the splint the toe of the shoe may not be fully enclosed in the splint, this is not thought to be a problem as the shoe protects the toes from any small change in pressure.
Always use an inflation that is comfortable for the patient.

Note 2: This splint should only be worn indoors for a training session of half an hour. If more time is required the splint should be taken off and may then be re-applied.

This splint should not be worn out of doors.

Summary

Comfortable in use the Orally Inflated Therapeutic Splints are an important aid in the rehabilitation and management of patients with neurological damage. Splints must be applied using correct neurological principles, therein lies the skill of the therapist.

The use of the splints is now spreading into other branches of physical therapy such as orthopaedics and rheumatology. A specific series of splints have been developed for use with the Margaret Johnstone Concept of Stroke Rehabilitation.* Some splints from the Stroke Programme are suitable for use when treating other conditions. For example the leg gaiters may be applied to one or both legs to aid early weight bearing and mobilisation in many orthopaedic conditions involving spine, hip or leg. The hand splint may be used when mobilising hands after injury or surgery.

Small splints are now being manufactured for use with paediatric patients.

Three instruction booklets with information on URIAS air splints are available:

1. Therapeutic Air Splints - an aid to rehabilitation (Adult).
2. Stroke Pressure Splints (Adult).
3. Therapeutic Air Splints for Children - an aid to rehabilitation.

Publications

• Johnstone M. - Restoration of Normal Movement after Stroke, 1995, Churchill Livingstone.
• Johnstone M. - Home Care for the Stroke Patient, 1996, Churchill Livingstone.
• Johnstone M. - Home Care for the Stroke Patient, (CLIP-Ex software).

CONTACT: Churchill Livingstone

(in UK, Europe)

Harcourt Brace Customer Services

Footscray High Street, Sidcup, Kent DA14 5HP, UK

Tel. +44 (0) 181 308 5700 Fax, 0181 309 9353

(in USA)

WB Saunders Customer Services

6277 Sea Harbour Drive, Orlando, Florida 32887

Tel. 001407 345 2000 Fax. 001407 352 3395