Splints for stroke and neurorehab
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Therapeutic Air Splints for Children - an aid to rehabilitation

Splints available for children
	The child below knee splint Single chamber 20 cm	REF 74 120 0
	The child leg extension single chamber splint three lengths: --> 40 cm	REF 74 140 0
	--> 50 cm	REF 74 150 0
	--> 60 cm	REF 74 160 0
	The child leg gaiter double chamber splint three lengths: --> 30 cm	REF 74 230 0
	--> 40 cm	REF 74 240 0
	--> 50 cm	REF 74 250 0
	The baby arm single chamber splint four lengths No zip fastener on this 14 cm (Not being made at present time)	REF ??
	--> 20 cm	REF 73 020 0
	--> 30 cm	REF 73 030 0
	--> 40 cm	REF 73 040 0
	The baby leg extension single chamber splint Three lengths 25 cm	REF 73 125 0
	--> 35 cm	REF 73 135 0
	--> 45 cm	REF 73 145 0
	The child arm single chamber splint four lengths --> 20 cm	REF 74 020 0
	--> 30 cm	REF 74 030 0
	--> 40 cm	REF 74 040 0
	--> 50 cm	REF 74 050 0
	The child hand splint double chamber 14 cm No zip fastener (Not being made at present time)	REF ??

Introduction

Therapeutic pressure splints for children have now been developed in response to the large number of requests from therapists in various parts of the world who are currently working with children.
This interest was aroused when therapists found that patients with post stroke disabilities could achieve a high level of rehabilitation when following a concept of treatment pioneered by Margaret Johnstone* involving the use of orally inflated splints.
More recently the use of these air splints has increased and spread to other neurological conditions with the development of adult therapeutic splints. Now the latest development has considered children's needs.

How or why do these splints work?

1. They are made of a unique and specially developed PVC-sheeting, were pioneered by Margaret Johnstone, and have been developed by URIAS. The PVC-sheeting moulds readily to the shape of the limb.
2. The splints are orally inflated - warm air from the human lungs ensures a perfect fit, softening and so assisting the moulding of the inner sheath to the patient's limb to give all over even pressure.
3. A thin cotton sleeve is applied to the patient's limb to be worn while the splint is in use as a protection against sweat rash.
4. The all over even pressure offered to limbs when the splints are correctly applied will maintain inhibiting patterns and may be used to control tonal flow and associated reactions.
5. The stability offered to a limb in this way is sufficient where appropriate to allow weight bearing on a correctly positioned base and movement within the splint.
6. The all over even pressure, supplied by the splint plus its stabilising effect on a limb which allows for early weight bearing makes a valuable contribution to recovery by stepping up sensory input.

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 Soft Ware).

Contact: Churchill Livingstone Publisher

(in UK, Europe)

Harcourt BracL Customer Services

Footscray High Street, Sideup, Kent DA 14 5HP, UK

Tel. +44 (0) 18 1 308 5700 Fax: +44 (0) 181 309 9353

 

(in USA)

W B Saunders Customer Services

6277 Sea Harbour Drive, Orlando, Florida 32887

Tel. 001 407 345 2000 Fax. 001 407 352 3395

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.  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 it 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.

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+44 (0) l 81 809 5170

* NOTE: As illustrated here the fingertips are too near the end of the splint. They must be well back from the end of the splint.

If a shorter splint is used to stabilise an elbow with the hand extending beyond the splint during an exercise session, care must be taken to ensure that the splint is only left on for a maximum time of twenty minutes. This also applies to any splint used to stabilise the knee with the foot protruding. Should longer time be required in this situation the splint should be taken off and then re-applied.

Therapeutic Arm Splint

Applied most usually with the patient supine and comfortably supported. The splint should be applied so that the limb is held in the correct position to inhibit excessive tone.

1. A thin cotton sleeve is first put on the patient's limb.
2. Pictures A, B and C  illustrate the easiest method used to apply an arm splint.
3. The splint is then inflated by mouth. It should be firmly inflated but must not be overinflated. The pressure offered to the limb must never exceed 40 mm. Hg. See note below.

Leg Extension Splints

Special Feature: These splints have a non-inflatable weight bearing sole.

Applied to one or both legs with the patient standing or lying supine and comfortably supported as necessary. The patient should wear full-length cotton stockings or light weight trousers. Properly fitting shoes or boots should be put on the patient before the leg is placed in the open splint. The heel of the shoe or boot is then placed firmly into the heel section of the splint and held there while the zip fastener is closed and the splint inflated. While inflating, the zip fastener should be held forward from the front of the knee joint so that with full inflation the knee is cushioned all round with air.

Uses: A treatment aid for patients who will benefit from standing. The resulting ankle and foot stability, combined with knee support, allows for the training of standing balance and stabilisation of the trunk. In the severely disabled will help to maintain length and pliability of muscles and ligaments and prevent flexion contracture. Correct standing will inhibit developing spasticity.

Note: When fitting the Leg Extension Splint and the Below Knee Splint the toe of the shoe or boot may not be fully enclosed in the splint, this is not thought to be a problem as the shoe protects the toes from any change in pressure. Use an inflation pressure that is comfortable for the patient and never exceed 40 mm. Hg. If in doubt check pressures with a manometer, using a 10cm connection between valve on splint and manometer. Pressures should be read when the limb is at rest. Therapists quickly become accustomed to the feel of correct pressure.

These splints are intended for training sessions only and should not be used for more than thirty minutes at a time. If more time is required the splints may be taken off and then reapplied.

When the ankle and foot are stable the training for standing balance and the control of trunk and pelvis may best be done with support from the Leg Gaiter. This double chamber splint fits high on the leg and supports the pelvis under the ischial tuberosity. A gaiter may be applied to each leg when the pelvis needs to be fully supported.

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

The Below Knee Splint

This is the shortest of the leg extension splints. It is intended for use on the lower leg and therefore is termed the Below Knee Splint.

Applied to the lower leg below the knee and the method of application is illustrated in Fig. A above. This shows the patient's heel, in a properly fitting boot, placed well back into the heel section of the splint. Before inflation takes place the therapist grasps the fabric of the splint, as shown in the illustration, and lets this grasp go gradually as air is blown into the splint. This ensures a firm cushion of air over the anterior aspect of the ankle and dorsum of the foot, thus maintaining the necessary stable foot position.

Uses: Mainly to stabilise the ankle and foot giving a suitably firm base. I while training of sitting balance is undertaken and 2, while advancing into the next stage of rehabilitation and standing balance is beginning

The Leg Gaiter

This is the second two-chamber splint, again designed to bring in a specific response. It should be understood that single chamber splints were designed to give all over even pressure which is used to maintain inhibiting patterns with stability. It is necessary for the therapist to understand the response he/she requires in the individual patient if he/she is to use the splints correctly to assist in the required exercise routines if progress is to be made. Therein lies the skill of the therapist. Three gaiters of different lengths are available. 'The smaller sizes are straight sided but the larger size is tapered towards the foot. When applied to a leg the top of the splint must be up under the ischial tuberosity. If the child is too tall for the 50cm length, the longer length of 60cm may be ordered from the adult range of splints. Adult splints also offer a gaiter length of 70cm.

The patient should wear full-length cotton stockings or light-weight trousers. Properly fitting shoes are optional. There are two distinctly different ways in which the leg gaiter can be applied and each method gives a different response. These are as follows:

1. Where legs lack stability in extension.
   As already described the leg gaiter is a double chamber splint which will be applied to one or both legs with the patient lying comfortably supported on his/her back. Applied with the zip fastener down the lateral side of the leg. The splint is wrapped round the leg and the zip is closed. The splint is positioned well up the leg so that the top is just under the ischial tuberosity. The anterior section of the splint is inflated first to give firm support with the knee in extension. The posterior section is inflated next to give all-round stability. The foot protrudes at the foot of the splint. Depending on the need of the patient a second splint is applied to the second leg in the same way. Most useful where feet are already stable enough to allow for weight bearing. The patient is lifted into a standing position.
2. Where excessive extensor tone is found in one or both legs.
   Here it is easier to obtain the required response from the splint application if it is put on while the patient is standing suitably supported. Applied as before with the zip fastener running down the middle of the lateral side of the leg so that, when inflated, the two sections give clearly defined anterior and posterior pressures on the limb. This time the posterior section must be inflated first. Where the patient is standing the position of the foot is extremely important and should not be allowed to turn outwards. It must have the great toe pointing straight forwards or slightly inwards to ensure that the weight bearing leg above is correctly positioned to maintain the position which will inhibit extensor tone. As the splint is inflated the patient's weight is transferred over this correctly positioned foot and the knee is encouraged (by the therapist if necessary) TO BEND into mild flexion. With a firm pressure in the posterior section of the splint, the anterior section is inflated minimally to stabilise the knee in the semi-flexed position and to give comfort.

Note: that applications 1 or 2 may be done in lying or standing as long as the therapist obtains the specific required response. As illustrated earlier, leg A is using the gaiter on a leg that lacks stability in extension while leg B is using a gaiter on a leg where it is necessary to inhibit excessive extensor tone.

Uses: dictate the method of application. Some of the uses suggested:

1. For practice in weight transfers from side to side.
2. In training trunk stability in e.g. Cerebral Palsy.
3. To give necessary support to practise side stepping.
4. To give necessary support to stand firmly on both feet and practise knee bending and stretching within the splints.
5. To give limb stability in standing while training standing balance in post-operative rehabilitation e.g. derotational osteotomy.
6. Gaiters may also be used when the tone in the hip abductor and leg flexor muscles is so great that standing is impossible. The gaiters are then applied to the supine patient. The anterior chamber inflated first, then the posterior chamber to give all round stability. This induced relaxation will free the hip for passive/active range of movement, thus maintaining length and pliability of muscles and soft tissues. Hopefully the child may then progress to standing.

Treatment time with the splints on is limited to an exercise session of twenty to thirty minutes.

As the foot is not included within the splint but protrudes beyond, the splint should not be left for longer. If more time is required the splints may be taken off and then reapplied.

Summary

The URIAS Orally Inflated Therapeutic Splints for Children

These splints are now seen by many therapists as a valuable aid to rehabilitation in neurological damage both in adults and in children e.g. brain damage resulting from direct violence, stroke, or the neurological damage associated with M.S., C.P., etc. They have also been found to be useful in some orthopaedic conditions, e.g. for preventing or stretching contractures, stabilising joints, mobilising hands etc. They have proved their worth because of their ability to hold limbs in recovery patterns, maintaining stability, controlling spasticity and allowing a motor retraining programme to develop along the same lines as the motor development of the infant. They increase sensory input and are particularly valuable to the mentally handicapped and children with visual impairment who have little or no body image or spatial awareness. This increase in sensory input is frequently necessary if rehabilitation is to progress. Also, the extra stability offered by the splint assists weight bearing techniques to give a positive sensory input through joint proprioceptors.

The infant rolls before he crawls, crawls before he kneels and kneels before he stands; he also, rolls before he sits and sits before he stands. This represents the developmental sequence used in balance training and the whole sequence, or some part of the sequence, will be included in the rehabilitation of neurological damage. It is generally agreed that trunk stability must be the initial aim as limbs cannot be rehabilitated on an unstable trunk. To work on the trunk where there is no limb stability will usually increase abnormal tonal patterns in the limbs and, in many cases, standing remains impossible on unstable limbs. URIAS splints can deal very effectively with this problem.

The splints act as a valuable rehabilitation tool which is offered to the skilled therapist. The success of the treatment frequently depends on the skill of the therapist. She/he must base work routines on sound neurological principles and splints must be correctly applied, combining carefully corrective positioning with an advancing exercise programme.

These splints are now marketed in various sizes from infant (baby) up to adult but this booklet is concerned with sizes from infant up to teenage. Pages 1 to 2 illustrate the whole range of splints available and they are marketed under the headings of BABY or CHILD. When ordering state BABY or CHILD and the length required. All measurements shown on Pages 1 & 2 are in centimetres and refer to the length of the splint. Select the appropriate size for your patient. The smallest CHILD splint (Arm) can be used also as a hand splint (single chamber) or an elbow support splint depending upon the size of the child. Large children may require small splints from the ADULT range. The total range of splints can accommodate a wide variety of sizes.

NOTE: For sound neurological reasons, some of these splints are not designed or suitable for the treatment of stroke disability, in particular the CHILD extension splints. Therapeutic splints should not be confused with those which are specifically offered as an aid to stroke rehabilitation. Therapists may apply to Maersk Medical for the separate instruction booklets, on Adult Therapeutic Splints and on Stroke Rehabilitation Splints.

Summary of Points to Remember

1. For the debilitated patient a very soft inflation may be all that is required for a splint to control a limb position. The first priority must always be to use an inflation pressure that is comfortable for the patient.
2. If a short arm splint is being used to stabilise an elbow with the wrist and hand protruding beyond the splint, care must be taken to ensure that the splint is not left on for an extended period, In this situation the splint should only be left on while active exercise is carried out. In the clinical field this has been safely used for periods of up to 20 minutes. Should longer time be required the splint should be taken off and reapplicd.
3. The Leg Gaiter
   a) Standing: The purpose of the gaiter is to fit high on the leg so that the ischial tuberosity is weight bearing on the upper edge of the splint (or splints if two gaiters are applied). This support to the pelvis facilitates pelvic and trunk stabilisations and allows re~education (or, in the very young patient, first time learning) of weight transfers and balance control in preparation for walking.
   b) Lying: Gaiters may also be applied to the supine patient (see earlier, Note 6). The resulting relaxation means that free hip movements will be facilitated as will rolling. Rolling may be spontaneous or assisted allowing progression through the developmental patterns that are so often denied to the disabled child. With increasing ability the child may progress to standing.
4. The Leg Extension Splint.
   a) Standing: The extension splint will support the legs and give stability where knee, ankle and foot control is lacking and the trunk is weak. The patient is supported in standing. Extension of the limb maintained and body weight, directed by posture within the splint, is directed through the foot which will in turn reinforce the reflex extensor thrust. Standing balance may be trained and the patient will hopefully progress to walking.
   b) Lying: When the patient is unable to stand the extensor splint may be used to inhibit spasticity in hip abductor and leg flexor museles to prevent the development of contractural deformities. May also be used as an aid to rolling as an alternative to the Leg Gaiter (see Note 3b above).
5. Provided the therapist applies the splints using correet neurological principles many ways may be found to achieve a high standard of rehabilitation for the patient.
6. Splints are comfortable in use and treatment sessions are welcomed by the patients.

Note: For further information on URIAS Air Splints, similar booklets to this are available from Maersk Medical:

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